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Choudhry HS, Patel AM, Zhu A, Guttikonda S, Shaikh A, Sadek HS, Seery CW, Dastjerdi MH. Interspecialty Opioid Prescribing Patterns in Ophthalmology Following Declaration of a Public Health Emergency. J Ocul Pharmacol Ther 2024; 40:34-47. [PMID: 37878373 DOI: 10.1089/jop.2023.0078] [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: 10/26/2023] Open
Abstract
Purpose: Previous literature has investigated opioid prescription trends in ophthalmology at large, however, little has been done looking at differences between subspecialties. We evaluate if significant trends exist among subspecialties in opioid prescribing patterns. This study aims to illuminate potential over-usage of opioids in ophthalmology that could compromise patient quality of life. Methods: Medicare data and "National Plan and Provider Enumeration System (NPPES) Downloadable File" were queried for cases of ophthalmologists with nonsuppressed opioid prescription data from 2014 to 2019. Ophthalmologists with no subspecialty code or missing regional, gender, degree, or graduation information were excluded. Chi-squared analysis, analysis of variance, t-tests, and multivariate logistic regression were utilized. Results: Five thousand one hundred forty-three physician records were included in analysis, 450 of which were by cornea subspecialists. Most cornea cases were male, graduated before 2005, and practiced in the South. All subspecialties had a significantly increased likelihood of making opioid claims and higher prescription rates compared with cornea (P < 0.050) besides glaucoma (P = 0.357). Only oculoplastics had significantly increased likelihood of greater total supply of opioids compared with cornea (odds ratio [OR] = 22.195, 95% confidence interval [CI] = 12.209-40.350, P < 0.001), while pediatrics (OR = 4.036, 95% CI = 1.377-11.831, P = 0.011) and neuro-ophthalmology (OR = 4.158, 95% CI = 1.237-13.975, P = 0.021) in addition to oculoplastics (OR = 64.380, 95% CI = 26.306-157.560, P < 0.001) were predicted to have significantly greater opioid beneficiaries. Males, the South/Midwest, and graduating before 2005, all were generally associated with increased likelihood of greater total opioid claims, supply, beneficiaries, and prescription rate (P < 0.050). Conclusion: Subspecialty, demographic, chronological, and regional trends exist for opioid prescribing patterns in ophthalmology.
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Affiliation(s)
- Hassaam S Choudhry
- Department of Ophthalmology and Visual Science at Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Aman M Patel
- Department of Ophthalmology and Visual Science at Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Aretha Zhu
- Department of Ophthalmology and Visual Science at Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Sri Guttikonda
- Rutgers The State University of New Jersey, Piscataway, New Jersey, USA
| | - Anam Shaikh
- Department of Ophthalmology and Visual Science at Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Hadeel S Sadek
- Department of Ophthalmology and Visual Science at Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Christopher W Seery
- Department of Ophthalmology and Visual Science at Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Bascom Palmer Eye Institute at the University of Miami, Coral Gables, Florida, USA
| | - Mohammad H Dastjerdi
- Department of Ophthalmology and Visual Science at Rutgers New Jersey Medical School, Newark, New Jersey, USA
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2
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Chen TC, Wettermark B, Steinke D, Caughey GE, Tadrous M, Wirtz VJ, Chen LC. Feasibility and validity of using healthcare databases to conduct cross-national comparative studies of opioid use, its determinants and consequences. Pharmacoepidemiol Drug Saf 2023; 32:1021-1031. [PMID: 36942801 DOI: 10.1002/pds.5618] [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: 05/31/2022] [Revised: 02/28/2023] [Accepted: 03/16/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE A cross-national comparative (CNC) study about opioid utilization would allow the identification of strategies to improve pain management and mitigate risk. However, little is known about the accessibility and validity of information in healthcare databases internationally. This study aimed to identify the feasibility of using healthcare databases to conduct a CNC study of opioid utilization and its associated consequences. METHODS A cross-sectional survey was launched in March 2018, including experts interested in CNC studies comparing opioid utilization by purposeful sampling. An electronic survey was used to collect database characteristics, medicine information, and linkage information of each aggregate-level dataset (AD) and individual patient-level dataset (IPD). RESULTS Overall, participants from 21 geographical regions reported 18 ADs and 19 IPDs. Information on dispensed medications is available from 17 ADs and 17 IPDs. Of the 16 ADs that include primary care settings, only 9 ADs can obtain information from secondary care settings. Fourteen IPDs included patients' characteristics or could be retrieved from linkage databases. Although most ADs are publicly accessible (n = 13), only five IPDs can be accessed without extra cost. CONCLUSION Most ADs could be used to report opioid utilization in a primary care setting. IPDs with linkage databases should be applied to identify potential determinants, clinical outcomes, and policy impact. Data access restrictions and governance policies across jurisdictions can be challenging for timely analysis and require further collaboration.
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Affiliation(s)
- Teng-Chou Chen
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Björn Wettermark
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
- Pharmacy Center, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Douglas Steinke
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Gillian E Caughey
- Registry of Senior Australians, South Australian Health and Medical Research Institute and Division of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Veronika J Wirtz
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Li-Chia Chen
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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3
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Levy HA, Karamian BA, Larwa J, Henstenburg J, Canseco JA, Haislup B, Chang M, Patel P, Woods BI, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Is Patient Geography a Risk Factor for Chronic Opioid Use After ACDF? Am J Med Qual 2022; 37:464-471. [PMID: 35951341 DOI: 10.1097/jmq.0000000000000077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The social and medical implications intrinsic to patient zip codes with high opioid fatality may reveal residence in these locations to be a risk factor predicting chronic opioid use after anterior cervical discectomy and fusion (ACDF). The purpose of this study is to determine if residence in Pennsylvania zip codes with high incidence of opioid overdose deaths is a risk factor for chronic postoperative opioid use after ACDF. Preoperative opioid usage did not vary meaningfully between high- and low-risk zip code groups. Patients in high-risk opioid overdose zip codes were significantly more likely to exhibit chronic postoperative opioid use. The Kaplan-Meier curve demonstrated that opioid discontinuation was less probable at any postoperative time for patients residing in high opioid fatality zip codes. Logistic regression found opioid tolerance, smoking, and depression to predict extended opioid use.
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Affiliation(s)
- Hannah A Levy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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4
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Naumann RB, Austin AE, Wang L, Roberts AW. Impacts of a Medicaid "lock-in" program on opioid use disorder treatment and services and naloxone dispensing. Drug Alcohol Depend 2022; 233:109385. [PMID: 35276627 DOI: 10.1016/j.drugalcdep.2022.109385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/25/2022] [Accepted: 02/26/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND "Lock-in" programs are used by health insurers to reduce the risk of adverse outcomes that can result from overutilization of opioids and other controlled substances. We estimated the association between North Carolina's Medicaid lock-in program and use of opioid use disorder treatment-related services and naloxone dispensing. METHODS A cohort study of individuals who became eligible for a Medicaid lock-in program between December 2016 and December 2019 (n = 21,220). We compared those enrolled in the program to those eligible but not enrolled. Outcomes included rate of medication for opioid use disorder (MOUD); rate of other substance use disorder treatment (e.g., detoxification); and naloxone dispensing. RESULTS The majority of beneficiaries enrolled in the program had recently received MOUD or other treatment prior to enrollment (59%). After controlling for several potential confounders, the program was associated with slight increases in MOUD use, compared to those eligible but not enrolled (adjusted rate ratio: 1.09, 95% CI: 1.04,1.14). Those enrolled in the program received, on average, 5.4 more days of MOUD per person per year than those eligible but not enrolled (adjusted risk difference: 5.43, 95% CI: 2.49,8.36). Naloxone dispensing was similar and low among those enrolled and not enrolled in the program (7-8%). CONCLUSIONS Enrollment in a Medicaid lock-in program was associated with a small increase in the number of days with substance use disorder treatment. However, given the high prevalence of opioid use disorder among beneficiaries in the program, findings highlighted considerable opportunity for improvement in treatment utilization and retention and a need for increased naloxone dispensing.
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Affiliation(s)
- Rebecca B Naumann
- Gillings School of Global Public Health and Injury Prevention Research Center, University of North Carolina at Chapel Hill, USA.
| | - Anna E Austin
- Gillings School of Global Public Health and Injury Prevention Research Center, University of North Carolina at Chapel Hill, USA
| | - Lily Wang
- Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, USA
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5
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Crane HM, Nance R, Whitney BM, Ruderman S, Tsui JI, Chander G, McCaul ME, Lau B, Mayer KH, Batey DS, Safren SA, Moore RD, Eron JJ, Napravnik S, Mathews WC, Fredericksen RJ, Hahn AW, Mugavero MJ, Lober WB, Saag MS, Kitahata MM, Delaney JAC. Drug and alcohol use among people living with HIV in care in the United States by geographic region. AIDS Care 2021; 33:1569-1576. [PMID: 33486978 PMCID: PMC9104760 DOI: 10.1080/09540121.2021.1874274] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
Substance use in the U.S. varies by geographic region. Opioid prescribing practices and marijuana, heroin, and methamphetamine availability are evolving differently across regions. We examined self-reported substance use among people living with HIV (PLWH) in care at seven sites from 2017-2019 to understand current regional substance use patterns. We calculated the percentage and standardized percentage of PLWH reporting current drug use and at-risk and binge alcohol use by U.S. Census Bureau geographic region and examined associations in adjusted logistic regression analyses. Among 7,686 PLWH, marijuana use was the most prevalent drug (30%), followed by methamphetamine/crystal (8%), cocaine/crack (7%), and illicit opioids (3%). One-third reported binge alcohol use (32%). Differences in percent of current use by region were seen for marijuana (24-41%) and methamphetamine/crystal (2-15%), with more use in the West and Northeast, and binge alcohol use (26-40%). In adjusted analyses, PLWH in the Midwest were significantly less likely to use methamphetamine/crystal (aOR: 0.13;0.06-0.25) or illicit opioids (aOR:0.16;0.05-0.53), and PLWH in the Northeast were more likely to use cocaine/crack (aOR:1.59;1.16-2.17), compared to PLWH in the West. Understanding differences in substance use patterns in the current era, as policies continue to evolve, will enable more targeted interventions in clinical settings among PLWH.
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Affiliation(s)
- Heidi M Crane
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Robin Nance
- Department of Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Judith I. Tsui
- Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Mary E McCaul
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Kenneth H. Mayer
- Fenway Institute and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - D Scott Batey
- Department of Social Work, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Steven A Safren
- Department of Psychology, University of Miami, Miami FL, USA
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Joseph J Eron
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - W Chris Mathews
- Department of Medicine, University of California at San Diego, San Diego, CA, USA
| | | | - Andrew W Hahn
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Michael J Mugavero
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - William B Lober
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Michael S Saag
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mari M Kitahata
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Joseph AC Delaney
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Manitoba, Manitoba, Canada
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6
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Kurdi A. Opioids and Gabapentinoids Utilisation and Their Related-Mortality Trends in the United Kingdom Primary Care Setting, 2010-2019: A Cross-National, Population-Based Comparison Study. Front Pharmacol 2021; 12:732345. [PMID: 34594223 PMCID: PMC8476961 DOI: 10.3389/fphar.2021.732345] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/02/2021] [Indexed: 01/02/2023] Open
Abstract
Background: There is growing concern over the increasing utilisation trends of opioids and gabapentinoids across but there is lack of data assessing and comparing the utilisation trends across the four United Kingdom countries. We assessed/compared opioids and gabapentinoids utilisation trends across the four United Kingdom countries then evaluated the correlation between their utilisation with related mortality. Methods: This repeated cross-national study used Prescription Cost Analysis (PCA) datasets (2010–2019). Opioids and gabapentinoids utilisation were measured using number of items dispensed/1,000 inhabitants and defined daily doses (DDDs)/1,000 inhabitant/day. Number of Opioids and gabapentinoids-related mortality were extracted from the United Kingdom Office for National Statistics (2010–2018). Data were analysed using descriptive statistics including linear trend analysis; correlation between the Opioids and gabapentinoids utilisation and their related mortality using Pearson correlation coefficient. Results: The results illustrated an overall significant increasing trend in the utilisation of opioids (12.5–14%) and gabapentinoids (205–207%) with substantial variations among the four United Kingdom countries. For opioids, Scotland had the highest level of number of items dispensed/1,000 inhabitant (156.6% higher compared to the lowest level in England), whereas in terms of DDD/1,000 inhabitant/day, NI had the highest level. Utilisation trends increased significantly across the four countries ranging from 7.7% in Scotland to 20.5% in NI (p < 0.001). Similarly, for gabapentinoids, there were significant increasing trends ranging from 126.5 to 114.9% in NI to 285.8–299.6% in Wales (p < 0.001) for number of items/1,000 inhabitants and DDD/1,000 inhabitant/day, respectively. Although the utilisation trends levelled off after 2016, this was not translated into comparable reduction in opioids and gabapentinoids-related mortality as the latter continued to increase with the highest level in Scotland (3.5 times more deaths in 2018 compared to England- 280.1 vs. 79.3 deaths/million inhabitants). There were significant moderate-strong positive correlations between opioids and gabapentinoids utilisation trends and their related mortality. Conclusion: The utilisation trends of opioids and gabapentinoids have increased significantly with substantial variations among the four United Kingdom countries. This coincided with significant increase in their related mortality. Our findings support the call for immediate actions including radical changes in official United Kingdom policies on drug use and effective strategies to promote best clinical practice in opioids and gabapentinoids prescribing.
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Affiliation(s)
- Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Science, University of Strathclyde, Glasgow, United Kingdom.,Department of Pharmacology and Toxicology, College of Pharmacy, Hawler Medical University, Erbil, Iraq.,Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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7
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Neelamegam M, Zgibor J, Chen H, O’rourke K, Bakour C, Rajaram L, Anstey KJ. The effect of opioids on the cognitive function of older adults: results from the Personality and Total Health through life study. Age Ageing 2021; 50:1699-1708. [PMID: 33755047 PMCID: PMC8437064 DOI: 10.1093/ageing/afab048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND chronic pain, a common complaint among older adults, affects physical and mental well-being. While opioid use for pain management has increased over the years, pain management in older adults remains challenging, due to potential severe adverse effects of opioids in this population. OBJECTIVE we examined the association between opioid use, and changes in cognitive function of older adults. DESIGN prospective study. SETTING community dwelling older adults. SUBJECTS study population consisted of 2,222 individuals aged 65-69 years at baseline from the Personality and Total Health Through Life Study in Australia. METHODS medication data were obtained from the Pharmaceutical Benefits Scheme. Cognitive measures were obtained from neuropsychological battery assessment. Opioid exposure was quantified as Total Morphine Equivalent Dose (MED). The association between change in cognitive function between Wave 2 and Wave 3, and cumulative opioid use was assessed through generalized linear models. RESULTS cumulative opioid exposure exceeding total MED of 2,940 was significantly associated with poorer performance in the Mini Mental State Examination (MMSE). Compared with those not on opioids, individuals exposed to opioids resulting in cumulative total MED of greater than 2,940 had significantly lower scores in the MMSE (Model 1: β = -0.34, Model 2: β = -0.35 and Model 3: β = -0.39, P < 0.01). Performance in other cognitive assessments was not associated with opioid use. CONCLUSION prolonged opioid use in older adults can affect cognitive function, further encouraging the need for alternative pain management strategies in this population. Pain management options should not adversely affect healthy ageing trajectories and cognitive health.
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Affiliation(s)
- Malinee Neelamegam
- Yale School of Public Health, Yale University, New Haven, CT, USA
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Janice Zgibor
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Henian Chen
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Kathleen O’rourke
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Chighaf Bakour
- College of Public Health, University of South Florida, Tampa, FL, USA
| | | | - Kaarin J Anstey
- Centre for Research on Ageing, Health and Wellbeing, Australian National University, Canberra, Australia
- School of Psychology, University of New South Wales, Sydney, Australia
- Neuroscience Research Australia, Sydney, Australia
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8
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Lehti TE, Rinkinen MO, Aalto U, Roitto HM, Knuutila M, Öhman H, Kautiainen H, Karppinen H, Tilvis R, Strandberg T, Pitkälä KH. Prevalence of Musculoskeletal Pain and Analgesic Treatment Among Community-Dwelling Older Adults: Changes from 1999 to 2019. Drugs Aging 2021; 38:931-937. [PMID: 34386937 PMCID: PMC8484214 DOI: 10.1007/s40266-021-00888-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/28/2022]
Abstract
Background Pain is undertreated in older populations. At the same time, increased use of opioids is of concern in the Western world. Aims We sought to analyze temporal trends in musculoskeletal pain and prescribed analgesic treatment among community-dwelling people aged 75–95 years using cross-sectional cohort data spanning 20 years. Methods The Helsinki Aging Study recruited random samples of people aged 75, 80, 85, 90, and 95 years in 1999, 2009, and 2019. In total, 5707 community-dwelling persons participated in the study. The participants reported their medical diagnoses, regular prescription medications, and the presence of back pain or joint pain within the last 2 weeks (never, sometimes, or daily). We compared analgesic use among participants reporting and not reporting musculoskeletal pain in 1999, 2009, and 2019. Results Of the participants, 57–61% reported intermittent or daily musculoskeletal pain. The percentage receiving a prescribed daily analgesic increased from 9% in 1999 to 16% in 2019. The use of non-steroidal anti-inflammatory drugs (NSAIDs) decreased from 1999 to 2019, while the use of paracetamol increased from 2 to 11%. Opioids were taken by 2% in 1999 and 3% in 2019. Of those reporting daily musculoskeletal pain, 20%, 35%, and 32% received regular pain medication in 1999, 2009, and 2019, respectively. Conclusions Pain remains undertreated in the community-dwelling older population, although the use of regular prescribed analgesics increased between 1999 and 2019. The use of NSAIDs has decreased, while the use of paracetamol has increased. Daily opioid use has remained modest.
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Affiliation(s)
- Tuuli Elina Lehti
- Primary Health Care Unit, Helsinki University Hospital, Ilkantie 10 B 22, 00400, Helsinki, Finland. .,Social Services and Health Care Division, City of Helsinki, Helsinki, Finland. .,Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland.
| | - M-O Rinkinen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - U Aalto
- Social Services and Health Care Division, City of Helsinki, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - H M Roitto
- Social Services and Health Care Division, City of Helsinki, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - M Knuutila
- Social Services and Health Care Division, City of Helsinki, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - H Öhman
- Geriatric Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Kautiainen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - H Karppinen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - R Tilvis
- Geriatric Unit, Department of Internal Medicine, University of Helsinki, Helsinki, Finland
| | - T Strandberg
- Geriatric Unit, Department of Internal Medicine, University of Helsinki, Helsinki, Finland.,Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - K H Pitkälä
- Primary Health Care Unit, Helsinki University Hospital, Ilkantie 10 B 22, 00400, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
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9
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Drendel AL, Brousseau DC, Casper TC, Bajaj L, Alessandrini EA, Grundmeier RW, Chamberlain JM, Goyal MK, Olsen CS, Alpern ER. Opioid Prescription Patterns at Emergency Department Discharge for Children with Fractures. PAIN MEDICINE 2021; 21:1947-1954. [PMID: 32022894 DOI: 10.1093/pm/pnz348] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To measure the variability in discharge opioid prescription practices for children discharged from the emergency department (ED) with a long-bone fracture. DESIGN A retrospective cohort study of pediatric ED visits in 2015. SETTING Four pediatric EDs. SUBJECTS Children aged four to 18 years with a long-bone fracture discharged from the ED. METHODS A multisite registry of electronic health record data (PECARN Registry) was analyzed to determine the proportion of children receiving an opioid prescription on ED discharge. Multivariable logistic regression was performed to determine characteristics associated with receipt of an opioid prescription. RESULTS There were 5,916 visits with long-bone fractures; 79% involved the upper extremity, and 27% required reduction. Overall, 15% of children were prescribed an opioid at discharge, with variation between the four EDs: A = 8.2% (95% confidence interval [CI] = 6.9-9.7%), B = 12.1% (95% CI = 10.5-14.0%), C = 16.9% (95% CI = 15.2-18.8%), D = 23.8% (95% CI = 21.7-26.1%). Oxycodone was the most frequently prescribed opioid. In the regression analysis, in addition to variation by ED site of care, age 12-18 years, white non-Hispanic, private insurance status, reduced fracture, and severe pain documented during the ED visit were associated with increased opioid prescribing. CONCLUSIONS For children with a long-bone fracture, discharge opioid prescription varied widely by ED site of care. In addition, black patients, Hispanic patients, and patients with government insurance were less likely to be prescribed opioids. This variability in opioid prescribing was not accounted for by patient- or injury-related factors that are associated with increased pain. Therefore, opioid prescribing may be modifiable, but evidence to support improved outcomes with specific treatment regimens is lacking.
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Affiliation(s)
| | | | | | - Lalit Bajaj
- University of Colorado, Children's Hospital Colorado, Colorado
| | | | - Robert W Grundmeier
- University of Pennsylvania, Children's Hospital of Philadelphia, Pennsylvania
| | - James M Chamberlain
- Children's National Medical Center, The George Washington University, Washington, DC
| | - Monika K Goyal
- Children's National Medical Center, The George Washington University, Washington, DC
| | | | - Elizabeth R Alpern
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago for The Pediatric Emergency Care Applied Research Network (PECARN), Chicago, Illinois, USA
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10
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Morgan CL, Jenkins-Jones S, Knaggs R, Currie C, Conway P, Poole CD, Berni E. Characterization and Associated Costs of Constipation Relating to Exposure to Strong Opioids in England: An Observational Study. Clin Ther 2021; 43:968-989. [PMID: 33931241 DOI: 10.1016/j.clinthera.2021.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/10/2021] [Accepted: 03/29/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Opioid use is associated with gastrointestinal adverse events, including nausea and constipation. We used a real-world dataset to characterize the health care burden associated with opioid-induced constipation (OIC) with particular emphasis on strong opioids. METHODS This retrospective cohort study was conducted using the Clinical Practice Research Datalink, a large UK primary care dataset linked to hospital data. Patients prescribed opioids during 2016 were selected and episodes of opioid therapy constructed. Episodes with ≥84 days of exposure were classified as chronic, with date of first prescription as the index date. The main analysis focused on patients prescribed strong opioids who were laxative naive. Constipation was defined by ≥2 laxative prescriptions during the opioid episode. Patients for whom initial laxative therapy escalated by switch, augmentation, or dose were defined as OIC unstable, and the first 3 lines of OIC escalation were classified. Health care costs accrued in the first 12 months of the opioid episode were aggregated and compared. FINDINGS A total of 27,629 opioid episodes were identified; 5916 (21.4%) involved a strong opioid for patients who were previously laxative naive. Of these patients, 2886 (48.8%) were defined as the OIC population; 941 (33.26%) were classified as stable. Of the 1945 (67.4%) episodes classified as unstable, 849 (43.7%), 360 (18.5%), and 736 (37.8%) had 1, 2, and ≥3 changes of laxative prescription, respectively. Patients without OIC had lower costs per patient year (£3822 [US$5160/€4242]) compared with OIC (£4786 [US$6461/€5312]). Costs increased as patients had multiple changes in therapy: £4696 (US$6340/€5213), £4749 (US$6411/€5271), and £4981 (US$6724/€5529) for 1, 2, and ≥3 changes, respectively. The adjusted cost ratio relative to non-OIC was 1.14 (95% CI, 1.09-1.32) for those classified as stable and 1.19 (95% CI, 1.09-1.32) for those with ≥3 laxative changes. Similar patterns were observed for patients taking anyopioid, with costs increased for those classified as having OIC (£3727 [US$5031/€4137] vs £2379 [US$3212 /€2641),and for those patients classified as unstable versus stable (£3931 [US$5307/€4363] vs £3432 [US$4633/€3810). Costs increased with each additional line of therapy from £3701 (US$4996/€4108), £3916 (US$5287/€4347), and £4318 (US$5829/€4793). IMPLICATIONS OIC was a common adverse event of opioid treatment and was poorly controlled for a large number of patients. Poor control was associated with increased health care costs. The impact of OIC should be considered when prescribing opioids. These results should be interpreted with consideration of the caveats associated with the analysis of routine data.
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Affiliation(s)
| | | | - Roger Knaggs
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom; Pain Centre Versus Arthritis, University of Nottingham, Nottingham, United Kingdom
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11
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Staples JA, Erdelyi S, Moe J, Khan M, Chan H, Brubacher JR. Prescription opioid use among drivers in British Columbia, 1997–2016. Inj Prev 2021; 27:527-534. [DOI: 10.1136/injuryprev-2020-043989] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 11/03/2022]
Abstract
BackgroundOpioids increase the risk of traffic crash by limiting coordination, slowing reflexes, impairing concentration and producing drowsiness. The epidemiology of prescription opioid use among drivers remains uncertain. We aimed to examine population-based trends and geographical variation in drivers’ prescription opioid consumption.MethodsWe linked 20 years of province-wide driving records to comprehensive population-based prescription data for all drivers in British Columbia (Canada). We calculated age- and sex-standardised rates of prescription opioid consumption. We assessed temporal trends using segmented linear regression and examined regional variation in prescription opioid use using maps and graphical techniques.ResultsA total of 46 million opioid prescriptions were filled by 3.0 million licensed drivers between 1997 and 2016. In 2016 alone, 14.7% of all drivers filled at least one opioid prescription. Prescription opioid use increased from 238 morphine milligram equivalents per driver year (MMEs/DY) in 1997 to a peak of 834 MMEs/DY in 2011. Increases in MMEs/DY were greatest for higher potency and long-acting prescription opioids. The interquartile range of prescription opioid dispensation by geographical region increased from 97 (Q1=220, Q3=317) to 416 (Q1=591, Q3=1007) MMEs/DY over the study interval.ImplicationsPatterns of prescription opioid consumption among drivers demonstrate substantial temporal and geographical variation, suggesting they may be modified by clinical and policy interventions. Interventions to curtail use of potentially impairing prescription medications might prevent impaired driving.
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12
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Cobert J, Lantos PM, Janko MM, Williams DGA, Raghunathan K, Krishnamoorthy V, JohnBull EA, Barbeito A, Gulur P. Geospatial Variations and Neighborhood Deprivation in Drug-Related Admissions and Overdoses. J Urban Health 2020; 97:814-822. [PMID: 32367203 PMCID: PMC7704893 DOI: 10.1007/s11524-020-00436-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Drug overdoses are a national and global epidemic. However, while overdoses are inextricably linked to social, demographic, and geographical determinants, geospatial patterns of drug-related admissions and overdoses at the neighborhood level remain poorly studied. The objective of this paper is to investigate spatial distributions of patients admitted for drug-related admissions and overdoses from a large, urban, tertiary care center using electronic health record data. Additionally, these spatial distributions were adjusted for a validated socioeconomic index called the Area Deprivation Index (ADI). We showed spatial heterogeneity in patients admitted for opioid, amphetamine, and psychostimulant-related diagnoses and overdoses. While ADI was associated with drug-related admissions, it did not correct for spatial variations and could not account alone for this spatial heterogeneity.
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Affiliation(s)
- Julien Cobert
- Department of Anesthesia, Critical Care Medicine division, University of California at San Francisco, 505 Parnassus Ave, Room M917, Box 0624, San Francisco, CA, 94143, USA.
| | - Paul M Lantos
- Department of Internal Medicine, Duke University Medical Center, Durham, NC, 27710, USA
- Duke University Global Health Institute, Durham, NC, 27710, USA
| | - Mark M Janko
- Duke University Global Health Institute, Durham, NC, 27710, USA
| | - David G A Williams
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Durham Veterans Affairs Hospital, Durham, NC, 27710, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Eric A JohnBull
- Department of Anesthesiology, Durham Veterans Affairs Hospital, Durham, NC, 27710, USA
| | - Atilio Barbeito
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, 27710, USA
- Department of Anesthesiology, Durham Veterans Affairs Hospital, Durham, NC, 27710, USA
| | - Padma Gulur
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, 27710, USA
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Marrache M, Best MJ, Raad M, Mikula JD, Amin RM, Wilckens JH. Opioid Prescribing Trends and Geographic Variation After Anterior Cruciate Ligament Reconstruction. Sports Health 2020; 12:528-533. [PMID: 32966157 PMCID: PMC7785898 DOI: 10.1177/1941738120954432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Opioid prescribing patterns play an important role in the opioid epidemic in the United States. The purpose of this study is to examine the trends and geographic variation in opioid prescribing patterns after anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS Regional differences in opioid prescribing patterns after ACL reconstruction are present. STUDY DESIGN Descriptive epidemiology study. LEVEL OF EVIDENCE Level 4. METHODS The Truven Health MarketScan Commercial Claims database was used to analyze all patients with perioperative private insurance coverage who underwent ACL reconstruction from January 1, 2010, to November 31, 2017. Total number and morphine milligram equivalents per day (MMED) of opioid prescriptions were examined, and regional and statewide variation was assessed. RESULTS A total of 90,068 ACL reconstruction patients who underwent surgery between 2010 and 2017 were included in the study. Overall, 67% received an opioid prescription within 30 days of surgery and 17% received an opioid prescription ≥90 MMED. The West (20%) had the highest proportion of patients with an opioid prescription ≥90 MMED and the Northeast had the lowest (12%), P < 0.001. The number of opioid prescriptions as well as proportion of opioid prescriptions ≥90 MMED varied significantly by state, P < 0.001. There was a significant increase in number of opioid prescriptions from 2010 to 2017 (62% in 2010 and 83% in 2017; P < 0.001). A significant change in the proportion of patients being prescribed ≥90 MMED was also present (P = 0.04; 15% in 2010, 17% in 2011, 17% 2012, 17% in 2013, 15% in 2014, 20% in 2015, 18% in 2016, and 15% in 2017). CONCLUSION This study shows a trend of increasing opioid prescriptions and geographic variations in the amount and MMED of opioid prescriptions for patients undergoing ACL reconstruction. These data highlight several areas of improvement that state officials and national entities can use to help curb the opioid epidemic and underscore the importance of national guidelines for opioid prescribing. CLINICAL RELEVANCE Knowledge of prescribing patterns after specific procedures may help provide more direct insight and guidance to surgeons and patients regarding postoperative pain management.
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Affiliation(s)
- Majd Marrache
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Matthew J. Best
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Micheal Raad
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jacob D. Mikula
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Raj M. Amin
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - John H. Wilckens
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
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Matthias MS, Talib TL, Huffman MA. Managing Chronic Pain in an Opioid Crisis: What Is the Role of Shared Decision-Making? HEALTH COMMUNICATION 2020; 35:1239-1247. [PMID: 31179769 PMCID: PMC6901808 DOI: 10.1080/10410236.2019.1625000] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Shared decision-making (SDM) is a widely-advocated practice that has been linked to improved patient adherence, satisfaction, and clinical outcomes. SDM is a process in which patients and providers share information, express opinions, and build consensus toward a treatment decision. Chronic pain and its treatment present unique challenges for SDM, especially in the current environment in which opioids are viewed as harmful and a national opioid crisis has been declared. The purpose of this qualitative study is to understand treatment decision-making with patients taking opioids for chronic pain. Ninety-five clinic visits and 31 interviews with patients and primary care providers (PCPs) were analyzed using the constant comparison method. Results revealed that 1) PCPs desire patient participation in treatment decisions, but with caveats where opioids are concerned; 2) Disagreements about opioids, including perceptions of lack of listening, presented challenges to SDM; and 3) PCPs described engaging in persuasion or negotiation to convince patients to try alternatives to opioids, or appeasing patients requesting opioids with very small amounts in an effort to maintain the patient-provider relationship. Results are discussed through the lens of Charles, Gafni, and Whelan's SDM model, and implications of the role of the patient-provider relationship in SDM and chronic pain treatment are discussed.
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Affiliation(s)
- Marianne S Matthias
- Department of Veterans Affairs, Center for Health Information and Communication
- Department of Communication Studies, Indiana University-Purdue University
- Regenstrief Institute
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine
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Huang Z, Su X, Diao Y, Liu S, Zhi M, Geng S, Sun J, Liu Y. Clinical Consumption of Opioid Analgesics in China: A Retrospective Analysis of the National and Regional Data 2006-2016. J Pain Symptom Manage 2020; 59:829-835.e1. [PMID: 31759032 DOI: 10.1016/j.jpainsymman.2019.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/04/2019] [Accepted: 11/04/2019] [Indexed: 01/05/2023]
Abstract
CONTEXT The annual consumption of opioid analgesics in the U.S. was more than 10 times the world average, whereas that in China was at a moderate level within Asia but much lower than the worldwide average. The opposite situations of opioid use in the U.S. and China revealed totally different problems in the developed versus developing world, that is, overuse versus underuse of opioids. OBJECTIVES This study analyzed the clinical consumption, estimated the needs of pain treatment, and evaluated the adequacy of opioid analgesic consumption in mainland China and its seven regions. METHODS A retrospective analysis of the national and regional consumption of opioid analgesics in mainland China during 2006-2016 was conducted. The adequacy of consumption measure was used to gauge the overall adequacy of opioid analgesic consumption in morphine equivalents (MEs) for the treatment of moderate-to-severe pain in mainland China and compared with international data. Annual per capita consumption was adopted to measure the clinical consumption of opioid analgesics in MEs at a national level and across seven regions of mainland China. Needs of morphine for cancer pain treatment in mainland China and in its seven regions were estimated and compared with the clinical consumption of opioid analgesics in MEs. RESULTS The adequacy of consumption measure of mainland China ranged from 0.0041 to 0.0088 during 2006-2016, which was less than 1% of that in the reference countries. The poor North East region had only 10.85% of the cancer pain morphine needs fulfilled. The highest fulfillment rate was 36.02% in rich Southern China, which was 25.9% at the national level. CONCLUSION The clinical consumption of opioid analgesics for the treatment of moderate-to-severe pain in mainland China was far below the international level. The annual per capita of clinical consumption was lower, and the adequacy of cancer pain treatment was poorer in less developed areas. All these findings call for actions to strengthen pain management.
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Affiliation(s)
- Zhiran Huang
- School of Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | - Xiawen Su
- Scientific Research Section, Research Department, Peking University Shenzhen Hospital, Shenzhen, PR China
| | - Yifan Diao
- School of Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | - Shiyang Liu
- School of Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | - Mengjia Zhi
- School of Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
| | | | - Jing Sun
- School of Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China.
| | - Yuanli Liu
- School of Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
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Kesten JM, Thomas K, Scott LJ, Bache K, Hickman M, Campbell R, Pickering AE, Redwood S. Acceptability of a primary care-based opioid and pain review service: a mixed-methods evaluation in England. Br J Gen Pract 2020; 70:e120-e129. [PMID: 31594772 PMCID: PMC6783137 DOI: 10.3399/bjgp19x706097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 05/22/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Primary care opioid prescribing to treat chronic non-cancer pain (CNCP) has progressively increased despite a lack of evidence for long-term safety and effectiveness. Developing primary care interventions to reduce opioid dependence in patients with CNCP is a public health priority. AIM To report the acceptability of the South Gloucestershire pain and opioid review service for patients with CNCP, which aimed to help patients understand their relationship with prescribed opioids and support non-drug-based pain management strategies. DESIGN AND SETTING A mixed-methods evaluation was performed on the service, which was based in two GP practices in South Gloucestershire, England, and delivered by project workers. METHOD Descriptive data were collected on delivered-within-service and community-based interventions. Twenty-five semi-structured interviews (n = 18 patients, n = 7 service providers) explored experiences of the service. RESULTS The enrolment process, person-centred primary care-based delivery, and service content focused on psychological issues underlying CNCP were found to be acceptable to patients and service providers. Patients welcomed having time to discuss their pain, its management, and related psychological issues. Maintaining a long-term approach was desired as CNCP is a complex issue that takes time to address. GPs recommended that funding was needed to ensure they have dedicated time to support a similar service and to ensure that project workers received adequate clinical supervision. CONCLUSION This service model was acceptable and may be a useful means to manage patients with CNCP who develop opioid dependence after long-term use of opioids. A randomised controlled trial is needed to formally test the effectiveness of the service.
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Affiliation(s)
- Joanna M Kesten
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West, University Hospitals Bristol NHS Foundation Trust; NIHR Health Protection Research Unit in Evaluation of Interventions, University of Bristol, Bristol
| | - Kyla Thomas
- Population Health Sciences, Bristol Medical School, University of Bristol; South Gloucestershire Council, Bristol
| | - Lauren J Scott
- NIHR CLAHRC West, University Hospitals Bristol NHS Foundation Trust; Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | | | - Matthew Hickman
- Population Health Sciences, Bristol Medical School; NIHR Health Protection Research Unit in Evaluation of Interventions, University of Bristol, Bristol
| | - Rona Campbell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | - Anthony E Pickering
- Department of Anaesthesia, University Hospitals Bristol NHS Foundation Trust; School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol
| | - Sabi Redwood
- NIHR CLAHRC West, University Hospitals Bristol NHS Foundation Trust; Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
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Epidemiology of pediatric buprenorphine and methadone exposures reported to the poison centers. Ann Epidemiol 2020; 42:50-57.e2. [PMID: 31992493 DOI: 10.1016/j.annepidem.2019.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 10/24/2019] [Accepted: 12/30/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Buprenorphine prescriptions have increased dramatically within the United States, whereas methadone continues to be used widely. We investigated the trends and characteristics of buprenorphine and methadone exposures in the pediatric population. METHODS We identified pediatric exposures to buprenorphine and methadone using the National Poison Data System from 2013 to 2016. We descriptively assessed characteristics of the exposures. Trends in exposures were evaluated using generalized linear mixed models. RESULTS Pediatric buprenorphine exposures increased from 2013 (1097) to 2016 (1226) while methadone calls decreased (486 to 396). After adjusting for the random effects of the geographical region, the mean number of pediatric buprenorphine exposures (per 100,000 pediatric population) increased from 1.3 to 1.5 (P = .05). Conversely, the mean number of methadone exposures decreased from 0.6 to 0.4 (P = .03). Children aged ≤3 years constituted the highest percentage of both exposures. Unintentional exposures accounted for most of the buprenorphine (86.9%) and methadone (62.4%) exposures. Major clinical effects were demonstrated in 2.3% of buprenorphine exposures and were more frequent with methadone (13%). West Virginia and Maryland demonstrated the highest incidence of buprenorphine and methadone exposures, respectively. CONCLUSIONS Pediatric buprenorphine exposures increased but demonstrated less severe effects compared to methadone exposures, which decreased during the study period.
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Evaluation of a primary care-based opioid and pain review service: a mixed-methods evaluation in two GP practices in England. Br J Gen Pract 2020; 70:e111-e119. [PMID: 31791939 PMCID: PMC6890470 DOI: 10.3399/bjgp19x707237] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/23/2019] [Indexed: 12/31/2022] Open
Abstract
Background Opioid prescribing to treat chronic non-cancer pain has rapidly increased, despite a lack of evidence for long-term safety and effectiveness. A pain review service was developed to work with patients taking opioids long-term to explore opioid use, encourage non-drug-based alternatives, and, where appropriate, support dose reduction. Aim To evaluate the service and its potential impact on opioid use, health and wellbeing outcomes, and quality of life (QoL). Design and setting Mixed-methods evaluation of a one-to-one service based in two GP practices in South Gloucestershire, England, which took place from September 2016 to December 2017. Method Quantitative data were collected on baseline demographics; data on opioid use, misuse, and dose, health, wellbeing, QoL, and pain and interference with life measures were collected at baseline and follow-up. Twenty-five semi-structured interviews (n = 18 service users, n = 7 service providers) explored experiences of the service including perceived impacts and benefits. Results Of 59 patients who were invited, 34 (57.6%) enrolled in the service. The median prescribed opioid dose reduced from 90 mg (average daily morphine equivalent; interquartile range [IQR] 60 to 240) at baseline to 72 mg (IQR 30 to 160) at follow-up (P<0.001); three service users stopped using opioids altogether. On average, service users showed improvement on most health, wellbeing, and QoL outcomes. Perceived benefits were related to wellbeing, for example, improved confidence and self-esteem, use of pain management strategies, changes in medication use, and reductions in dose. Conclusion The service was well received, and health and wellbeing outcomes suggest a potential benefit. Following further service development, a randomised controlled trial to test this type of care pathway is warranted.
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Colloca L, Lee SE, Luhowy MN, Haycock N, Okusogu C, Yim S, Raghuraman N, Goodfellow R, Murray RS, Casper P, Lee M, Scalea T, Fouche Y, Murthi S. Relieving acute pain (RAP) study: a proof-of-concept protocol for a randomised, double-blind, placebo-controlled trial. BMJ Open 2019; 9:e030623. [PMID: 31719077 PMCID: PMC6858101 DOI: 10.1136/bmjopen-2019-030623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/26/2019] [Accepted: 10/17/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Physicians and other prescribing clinicians use opioids as the primary method of pain management after traumatic injury, despite growing recognition of the major risks associated with usage for chronic pain. Placebos given after repeated administration of active treatments can acquire medication-like effects based on learning mechanisms. This study hypothesises that dose-extending placebos can be an effective treatment in relieving clinical acute pain in trauma patients who take opioids. METHODS AND ANALYSIS The relieving acute pain is a proof-of-concept randomised, placebo-controlled, double-blinded, single-site study enrolling 159 participants aged from 18 to 65 years with one or more traumatic injuries treated with opioids. Participants will be randomly assigned to three different arms. Arm 1 will receive the full dose of opioids with non-steroidal anti-inflammatory drugs (NSAIDs). Arm 2 will receive the 50% overall reduction in opioid dosage, dose-extending placebos and NSAIDs. Arm 3 (control) will receive NSAIDs and placebos. The trial length will be 3 days of hospitalisation (phase I) and 2-week, 1-month, 3-month and 6-month follow-ups (exploratory phase II). Primary and secondary outcomes include feasibility and acceptability of the study. Pain intensity, functional pain, emotional distress, rates of rescue therapy requests and patient-initiated medication denials will be collected. ETHICS AND DISSEMINATION All activities associated with this protocol are conducted in full compliance with the Institutional Review Board policies and federal regulations. Publishing this study protocol will enable researchers and funding bodies to stay up to date in their fields by providing exposure to research activity that may not otherwise be widely publicised. DATE AND PROTOCOL VERSION IDENTIFIER 3/6/2019 (HP-00078742). TRIAL REGISTRATION NUMBER NCT03426137.
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Affiliation(s)
- Luana Colloca
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Se Eun Lee
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Meghan Nichole Luhowy
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Nathaniel Haycock
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Chika Okusogu
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Soojin Yim
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Nandini Raghuraman
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Robert Goodfellow
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Robert Scott Murray
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Patricia Casper
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Myounghee Lee
- Investigational Drug Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Thomas Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Yvette Fouche
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sarah Murthi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
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Nejim B, Alshwaily W, Faateh M, Locham S, Dakour-Aridi H, Malas M. Trend and Economic Burden of Intravenous Narcotic Analgesic Utilization in Major Vascular Interventions in the United States. Ann Vasc Surg 2019; 66:289-300.e2. [PMID: 31678548 DOI: 10.1016/j.avsg.2019.10.076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 10/08/2019] [Accepted: 10/15/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of IV narcotic analgesics (IVNA) within the context of vascular procedures is not fully described. We sought to evaluate the burden of IVNA including narcotic analgesia-related adverse drug events (NARADE), associated mortality and hospitalization cost in open and endovascular vascular procedures, and to compare it with nonnarcotic analgesia (IVNNA). METHODS Retrospective cross-sectional study in hospitals participating in Premier database (2009-2015). Logistic regression analysis was implemented to report the risks of NARADE and in-hospital mortality. Negative binomial regression was used to assess length of stay and generalized linear modeling was used to estimate the hospitalization cost. RESULTS A total of 171,473 patients were identified. NARADE occurred in 6.2% of the cohort. NARADE group was similar in gender and race but was slightly older (median age 71 vs. 70; P < 0.001). After risk-adjustment, NARADE risk was higher in patients who received IVNA-alone in carotid and lower extremity revascularization (LER) [OR (odds ratio) (95% confidence interval [CI]): 1.17 (1.02-1.34) and 1.31 (1.14-1.50)] or combined with IVNNA [OR (95% CI): 1.34 (1.13-1.59) and 1.81 (1.54-2.13)], respectively. Patients receiving aortic repair benefited from the use of IVNA + IVNNA [OR (95% CI): 0.82 (0.69-0.98)]. Occurrence of NARADE doubled the LOS, amplified mortality risk and increased cost in all domains. NARADE increased the odds of mortality by 24.3, 6.5 (4.9-8.68) and 16.6 times and added $5,368, $12,737 and $11,349 to the cost of carotid, aortic and LER interventions, respectively. In contrast, IVNNA was not associated with NARADE risk, increased LOS or cost and showed a survival benefit in patients undergoing open aortic repair [aOR (95% CI): 0.52 (0.36-0.75)]. CONCLUSIONS AND RELEVANCE The use of opioid-based narcotics had increased the risk of NARADE, resources utilization and NARADE-related mortality. Yet the use of nonopioid-based analgesic was safe, did not increase the cost and reduced mortality in open AA repair. This entices shifting the paradigm toward exploring nonopioid-based analgesia options in order to replace or minimize opioid requirements.
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Affiliation(s)
- Besma Nejim
- Department of Vascular Surgery, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA
| | | | - Muhammad Faateh
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | | | | | - Mahmoud Malas
- Department of Surgery, UC San Diego School of Medicine, La Jolla, CA.
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Tardelli VS, Fidalgo TM, Santaella J, Martins SS. Medical use, non-medical use and use disorders of benzodiazepines and prescription opioids in adults: Differences by insurance status. Drug Alcohol Depend 2019; 204:107573. [PMID: 31568936 PMCID: PMC6938257 DOI: 10.1016/j.drugalcdep.2019.107573] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/16/2019] [Accepted: 08/21/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To report and analyze prevalence's of Benzodiazepines (BZDs) and Prescription Opioids (POs) use by insurance status and to investigate associations between insurance status and BZDs, POs and concurrent medical/non-medical use and use disorders. METHODS This study included 81,133 adults ages 18 and older from 2015 and 2016 National Survey on Drug Use and Health. Participants' self-reported past- year medical use, non-medical use and use disorders of BZDs and POs were assessed, along with their insurance status (Private/Military, Medicare, Medicaid, and Uninsured) and demographic characteristics. RESULTS In 2015-2016, 12.6% of adults reported using BZDs and 36.9% reported using POs in the past year. Among adults, 8.3% reported past-year use of both BZDs and POs; also, 1.9% and 3.8% reported non-medical use of BZDs and POs, respectively, and 0.9% reported non-medical use of both BZDs and POs. Medicaid-covered respondents had higher risk of BZDs (aRRR = 1.59, 95%CI = [1.45, 1.74]), POs (aRRR = 1.66, 95%CI = [1.54, 1.79]) and concurrent past-year medical use (aRRR = 2.11, 95%CI = [1.87, 2.38]), higher risk of BZDs non-medical use (aRRR = 1.40, 95%CI = [1.17, 1.68]) and BZD Use Disorders (aRRR = 2.60, 95%CI = [1.82, 3.72]), POs non-medical use (aRRR = 1.67, 95%CI = [1.45, 1.92]), PO use Disorders (aRRR = 4.12, 95%CI = [3.33, 5.11]) and concurrent non-medical use (aRRR = 1.52, 95%CI = [1.20, 1.92]) and Use Disorders (aRRR = 3.68, 95%CI = [1.93, 6.78]), compared to those with private insurance. CONCLUSIONS Future health policies should focus on reducing individual and co-prescription of BZDs and POs and providing different strategies of pain management.
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Affiliation(s)
- Vítor Soares Tardelli
- Departamento de Psiquiatria, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil; Department of Epidemiology - Columbia University Mailman School of Public Health, New York, NY, United States.
| | - Thiago Marques Fidalgo
- Departamento de Psiquiatria, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.
| | - Julian Santaella
- Department of Epidemiology - Columbia University Mailman School of Public Health, New York, NY, United States.
| | - Silvia S. Martins
- Department of Epidemiology - Columbia University Mailman School of Public Health, New York, NY, United States
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Philpot LM, Schumann ME, Ebbert JO. Social Relationship Quality Among Patients With Chronic Pain: A Population-Based Sample. J Patient Exp 2019; 7:316-323. [PMID: 32821790 PMCID: PMC7410145 DOI: 10.1177/2374373519862934] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective Chronic daily pain is experienced by 11.2% of United States adults and psychosocial factors have significant impact on self-reported pain. Most research in this area has focused on pain-related conditions, not the general population. This study sought to understand the associations between clinically significant chronic pain and multiple dimensions of social relationship quality in a general population. Methods A cross-sectional survey was deployed and adjusted logistic regression models were constructed for chronic pain against independent social support domains. The moderating effect of self-rated health on social support quality was explored. Results Of all, 26.1% of surveys were completed (3920/15 000) and 18.8% reported clinically significant chronic pain. Patients with chronic pain had lower friendship quality (aOR = 0.78; 0.64-0.94) and higher perceived rejection (aOR = 1.26; 1.04-1.53) and perceived hostility (aOR = 1.26; 1.05-1.52). Within our moderation analysis, chronic pain patients with low self-rated health had higher odds of low friendship quality, high loneliness, and high perceived rejection. Conclusions Chronic pain patients experience social relationships differently than those without, and self-rated health differentially impacts these perceptions.
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Affiliation(s)
- Lindsey M Philpot
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Matthew E Schumann
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Jon O Ebbert
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, Rochester, MN, USA.,Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
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Han Y, Saran R, Erickson SR, Hirth RA, He K, Balkrishnan R. Environmental and individual predictors of medication adherence among elderly patients with hypertension and chronic kidney disease: A geospatial approach. Res Social Adm Pharm 2019; 16:422-430. [PMID: 31253498 DOI: 10.1016/j.sapharm.2019.06.011] [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: 01/12/2019] [Revised: 06/19/2019] [Accepted: 06/19/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Few studies have examined how adherence to antihypertensive medications varies across different regions or how neighborhood-level factors were related to individuals' medication-taking behaviors in patients. OBJECTIVE To explore local variation in medication adherence and examine environmental and individual influences on adherence to angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) among elderly hypertensive patients with chronic kidney disease (CKD) in the United States. METHODS The Medicare 5% sample claim data (2006-2013), American Community Survey 5-Year Data (2005-2009) and the Health Resources and Services Administration Primary Care Service Area data (2007). The primary outcome was medication adherence, measured by Proportion of Days Covered (PDC). Geographically weighted regression (GWR) and linear mixed-effects models were used to investigate the relationship between environmental factors, individual risk factors and medication adherence. RESULTS A total of 70,201 hypertensive CKD patients residing in 2,981 counties of the US were selected. Significant spatial autocorrelation was observed in ACEIs/ARBs PDC. The West North Central and New England regions demonstrated higher adherence compared to the East South Central and West South Central regions. Residing in Medically Underserved Areas, counties with high deprivation scores, and not receiving Part D Low-income Subsidy were associated with poor medication adherence. CONCLUSIONS Medication adherence is geographically differentiated across the US. Environmental and individual factors identified may be helpful in the design of local interventions focused on improving patient outcomes from a population perspective.
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Affiliation(s)
- Yun Han
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Richard A Hirth
- Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Kevin He
- Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Rajesh Balkrishnan
- University of Virginia School of Medicine, Department of Public Health Sciences, USA.
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Lund BC, Ohl ME, Hadlandsmyth K, Mosher HJ. Regional and Rural–Urban Variation in Opioid Prescribing in the Veterans Health Administration. Mil Med 2019; 184:894-900. [DOI: 10.1093/milmed/usz104] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/13/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Opioid prescribing is heterogenous across the US, where 3- to 5-fold variation has been observed across states or other geographical units. Residents of rural areas appear to be at greater risk for opioid misuse, mortality, and high-risk prescribing. The Veterans Health Administration (VHA) provides a unique setting for examining regional and rural–urban differences in opioid prescribing, as a complement and contrast to extant literature. The objective of this study was to characterize regional variation in opioid prescribing across Veterans Health Administration (VHA) and examine differences between rural and urban veterans.
Materials and Methods
Following IRB approval, this retrospective observational study used national administrative VHA data from 2016 to assess regional variation and rural–urban differences in schedule II opioid prescribing. The primary measure of opioid prescribing volume was morphine milligram equivalents (MME) dispensed per capita. Secondary measures included incidence, prevalence of any use, and prevalence of long-term use.
Results
Among 4,928,195 patients, national VHA per capita opioid utilization in 2016 was 1,038 MME. Utilization was lowest in the Northeast (894 MME), highest in the West (1,368 MME), and higher among rural (1,306 MME) than urban (988 MME) residents (p < 0.001). Most of the difference between rural and urban veterans (318 MME) was attributable to differences in long-term opioid use (312 MME), with similar rates of short-term use.
Conclusion
There is substantial regional and rural–urban variation in opioid prescribing in VHA. Rural veterans receive over 30% more opioids than their urban counterparts. Further research is needed to identify and address underlying causes of these differences, which could include access barriers for non-pharmacologic treatments for chronic pain.
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Affiliation(s)
- Brian C Lund
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA
- Veterans Rural Health Resource Center, Iowa City VA Healthcare System, Iowa City, IA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Michael E Ohl
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA
- Veterans Rural Health Resource Center, Iowa City VA Healthcare System, Iowa City, IA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Katherine Hadlandsmyth
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Hilary J Mosher
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA
- Veterans Rural Health Resource Center, Iowa City VA Healthcare System, Iowa City, IA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
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Desai RJ, Jin Y, Franklin PD, Lee YC, Bateman BT, Lii J, Solomon DH, Katz JN, Kim SC. Association of Geography and Access to Health Care Providers With Long-Term Prescription Opioid Use in Medicare Patients With Severe Osteoarthritis: A Cohort Study. Arthritis Rheumatol 2019; 71:712-721. [PMID: 30688044 DOI: 10.1002/art.40834] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/03/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate the variation in long-term opioid use in osteoarthritis (OA) patients according to geography and health care access. METHODS We designed an observational cohort study among OA patients undergoing total joint replacement (TJR) in the Medicare program (2010 through 2014). The independent variables of interest were the state of residence and health care access, which was quantified at the primary care service area (PCSA) level as categories of number of practicing primary care providers (PCPs) and categories of rheumatologists per 1,000 Medicare beneficiaries. The percentage of OA patients taking long-term opioids (≥90 days in the 360-day period immediately preceding TJR) within each PCSA was the outcome variable in a multilevel, generalized linear regression model, adjusting for case-mix at the PCSA level and for policies, including rigor of prescription drug monitoring programs and legalized medical marijuana, at the state level. RESULTS A total of 358,121 patients with advanced OA, with a mean age of 74 years, were included from 4,080 PCSAs. The unadjusted mean percentage of long-term opioid users varied widely across states, ranging from 8.9% (Minnesota) to 26.4% (Alabama), and this variation persisted in the adjusted models. Access to PCPs was only modestly associated with rates of long-term opioid use between PCSAs with highest (>8.6) versus lowest (<3.6) concentration of PCPs (adjusted mean difference 1.4% [95% confidence interval 0.8%, 2.0%]), while access to rheumatologists was not associated with long-term opioid use. CONCLUSION We note a substantial statewide variation in rates of long-term treatment with opioids in OA, which is not fully explained by the differences in access to health care providers, varying case-mix, or state-level policies.
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Affiliation(s)
- Rishi J Desai
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yinzhu Jin
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Yvonne C Lee
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Brian T Bateman
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joyce Lii
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel H Solomon
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey N Katz
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seoyoung C Kim
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Jayawardhana J, Abraham AJ, Perri M. Deaths among opioid users: impact of potential inappropriate prescribing practices. THE AMERICAN JOURNAL OF MANAGED CARE 2019; 25:e98-e103. [PMID: 30986018 PMCID: PMC7083064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To examine the association between potential inappropriate prescribing practices of opioids and deaths among opioid users in the Georgia Medicaid population. STUDY DESIGN A retrospective analysis of individual pharmacy claims data from Georgia Medicaid from 2009 through 2014. METHODS The sample was restricted to patients without cancer aged 18 to 64 years with an opioid prescription and included 3,562,227 observations representing 401,488 individuals. A descriptive analysis and a multivariate logistic regression analysis were conducted. RESULTS Results indicate a total of 14,516 deaths among opioid users in the study sample, of whom approximately 42% experienced at least 1 incidence of potential inappropriate prescribing practices. Regression results indicate that the odds of opioid users experiencing death were 1.76 times higher for those who experienced at least 1 incidence of potential inappropriate prescribing practices of opioids compared with those who did not experience any incidence, even after controlling for other covariates (P <.001). Moreover, opioid users in managed care Medicaid were less likely to experience death compared with fee-for-service (FFS) enrollees. CONCLUSIONS The results indicate a positive and statistically significant association between potential inappropriate opioid prescribing practices and deaths among opioid users in Georgia Medicaid, with FFS enrollees experiencing higher rates of death compared with managed care enrollees. Appropriate policies and interventions targeted at reducing potential inappropriate prescribing practices may help reduce the risk factors associated with mortality among opioid users in this population.
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Torchia MT, Munson J, Tosteson TD, Tosteson ANA, Wang Q, McDonough CM, Morgan TS, Bynum JPW, Bell JE. Patterns of Opioid Use in the 12 Months Following Geriatric Fragility Fractures: A Population-Based Cohort Study. J Am Med Dir Assoc 2019; 20:298-304. [PMID: 30824217 PMCID: PMC6400293 DOI: 10.1016/j.jamda.2018.09.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 09/19/2018] [Accepted: 09/20/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Fractures of the hip, distal radius, and proximal humerus are common in the Medicare population. This study's objective was to characterize patterns and duration of opioid use, including regional variations in use, after both surgical and nonoperative management. DESIGN Population-based cohort study. SETTING AND PARTICIPANTS A cohort of opioid-naïve community-dwelling US Medicare beneficiaries who survived a hip, distal radius, or proximal humerus fracture between January 1, 2007 and December 31, 2010. Cohort members were required to be opioid-naïve for 4 months prior to fracture. MEASURES We analyzed the proportion of patients with an active opioid prescription in each month following the index fracture, and report continued fills at 12 months postfracture. We also compared opioid prescription use in fractures treated surgically and nonsurgically and characterized state-level variation in opioid prescription use at 3 months postfracture. RESULTS There were 91,749 patients included in the cohort. Hip fracture patients had the highest rate of opioid use at 12 months (6.4%), followed by proximal humerus (5.7%), and distal radius (3.7%). Patients who underwent surgical fixation of proximal humerus and wrist fractures had higher rates of opioid use in each of the first 12 postoperative months compared with those managed nonoperatively. There was significant variation of opioid use at the state level, ranging from 7.6% to 18.2% of fracture patients filling opioid prescriptions 3 months after the index fracture. CONCLUSIONS/IMPLICATIONS Opioid-naïve patients sustaining fragility fractures of the hip, proximal humerus, or distal radius are at risk to remain on opioid medications 12 months after their index injury, and surgical management of proximal humerus and distal radius fractures increases opioid use in the 12 months after the index fracture. There is significant state-level variation in opiate consumption after index fracture in nonvertebral geriatric fragility fractures. Opportunity exists for targeted quality improvement efforts to reduce the variation in opioid use following common geriatric fragility fractures.
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Affiliation(s)
- Michael T Torchia
- Department of Orthopedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jeffrey Munson
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Tor D Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Anna N A Tosteson
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH; Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Christine M McDonough
- Department of Physical Therapy, School of Rehabilitation Sciences, and Department of Orthopedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Tamara S Morgan
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Julie P W Bynum
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - John-Erik Bell
- Department of Orthopedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.
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Chen TC, Chen LC, Kerry M, Knaggs RD. Prescription opioids: Regional variation and socioeconomic status - evidence from primary care in England. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 64:87-94. [PMID: 30641450 DOI: 10.1016/j.drugpo.2018.10.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 09/14/2018] [Accepted: 10/22/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND This study aimed to quantify opioid prescriptions dispensed from primary care practices throughout England and investigate its association with socioeconomic status (SES). METHODS This cross-sectional study used publicly available data in 2015, including practice-level dispensing data and characteristics of registrants from the United Kingdom (UK) National Health Service Digital, and Index of Multiple Deprivation (IMD) data from Department of Communities and Local Government. Practices in England which issued opioid prescriptions that could be assigned a defined daily dose (DDD) in the claim-based dispensing database were included. The total amount of opioid prescriptions dispensed (DDD/1000 registrants/day) was calculated for each practice. The association between dispensed opioid prescriptions and IMD was analyzed by multi-level regression and adjusted for registrants' characteristics and the clustered effect of Clinical Commissioning Groups. Subgroup analysis was conducted for practices in London, Birmingham, Manchester and Newcastle. RESULTS Of the 7856 included practices in England, the median and interquartile range (IQR) of prescription opioids dispensed was 36.9 (IQR: 23.1, 52.5) DDD/1000 registrants/day. The median opioid utilization (DDD/1000 registrants/day) amongst practices varied between Manchester (53.1; IQR: 36.8, 71.4), Newcastle (48.9; IQR: 38.8, 60.1), Birmingham (35.3; IQR: 23.1, 49.4) and London (13.9; IQR: 8.1, 18.8). Lower SES, increased prevalence of patients aged more than 65 years, female gender, smoking, obesity and depression were significantly associated with increased opioid prescriptions. For every decrease in IMD decile (lower SES), there was a significant increase of opioid utilization by 1.0 (95% confidence interval: 0.89, 1.2, P < 0.001) DDD/1000 registrants/day. CONCLUSION There was substantial variation in opioid prescriptions among practices from Northern and Eastern England to Southern England. A significant association between increased opioid prescriptions and greater deprivation at a population level was observed. Further longitudinal studies using individual patient data are needed to validate this association and identify the potential mechanisms.
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Affiliation(s)
- Teng-Chou Chen
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, East Drive, University Park, Nottingham NG7 2RD, United Kingdom.
| | - Li-Chia Chen
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre Stopford Building, Oxford Road, Manchester M13 9PT, United Kingdom.
| | - Miriam Kerry
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, East Drive, University Park, Nottingham NG7 2RD, United Kingdom.
| | - Roger David Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, East Drive, University Park, Nottingham NG7 2RD, United Kingdom; Primary Integrated Community Solutions, Unit 4 Ash Tree Court, Nottingham Business Park, Nottingham NG6 8PY, United Kingdom.
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Adogwa O, Davison MA, Vuong VD, Desai SA, Lilly DT, Moreno J, Cheng J, Bagley C. Regional Variation in Opioid Use After Lumbar Spine Surgery. World Neurosurg 2019; 121:e691-e699. [DOI: 10.1016/j.wneu.2018.09.192] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 11/28/2022]
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Philpot LM, Ramar P, Elrashidi MY, Sinclair TA, Ebbert JO. A Before and After Analysis of Health Care Utilization by Patients Enrolled in Opioid Controlled Substance Agreements for Chronic Noncancer Pain. Mayo Clin Proc 2018; 93:1431-1439. [PMID: 30244811 DOI: 10.1016/j.mayocp.2018.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 05/10/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To evaluate the impact of opioid controlled substance agreements (CSAs) enrollment on health care utilization. PATIENTS AND METHODS We retrospectively evaluated health care utilization changes among 772 patients receiving long-term opioid therapy for chronic noncancer pain enrolled in a CSA between July 1, 2015, and December 31, 2015. We ascertained patient characteristics and utilization 12 months before and after CSA enrollment. Decreased utilization was defined as a decrease of 1 or more hospitalizations or emergency department visits and 3 or more outpatient primary and specialty care visits. Multivariate modeling assessed demographic characteristics associated with utilization changes. RESULTS The 772 patients enrolled in an opioid CSA during the study period had a mean ± SD age of 63.5±14.9 years and were predominantly female, white, and married. The CSA enrollment was associated with decreased outpatient primary care visits (odds ratio [OR], 0.16; 95% CI, 0.14-0.19) and increased diagnostic radiology services (OR, 1.22; 95% CI, 1.02-1.47). After CSA enrollment, patients with greater comorbidity (Charlson Comorbidity Index score >3) were more likely to have reduced hospitalizations (adjusted OR, 2.8; 95% CI, 1.3-6.0; P=.008), reduced outpatient primary care visits (adjusted OR, 2.0; 95% CI, 1.2-3.2; P=.005), and reduced specialty care visits (adjusted OR, 2.0; 95% CI, 1.2-3.3; P=.006). CONCLUSION For patients receiving long-term opioid therapy for chronic noncancer pain, CSA enrollment is associated with reductions in primary care visits and increased radiologic service utilization. Patients with greater comorbidity were more likely to have reductions in hospitalizations, outpatient primary care visits, and outpatient specialty clinic visits after CSA enrollment. The observational nature of the study does not allow the conclusion that CSA implementation is the primary reason for these observed changes.
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Affiliation(s)
- Lindsey M Philpot
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Priya Ramar
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Muhamad Y Elrashidi
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine and Science, Rochester, MN; Division of Primary Care Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Tiffany A Sinclair
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Jon O Ebbert
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine and Science, Rochester, MN; Division of Primary Care Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
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Wiznia DH, Zaki T, Leslie MP, Halaszynski TM. Complexities of Perioperative Pain Management in Orthopedic Trauma. Curr Pain Headache Rep 2018; 22:58. [PMID: 29987515 DOI: 10.1007/s11916-018-0713-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW This review discusses both obvious and hidden barriers in trauma patient access to pain management specialists and provides some suggestions focusing on outcome optimization in the perioperative period. RECENT FINDINGS Orthopedic trauma surgeons strive to provide patients the best possible perioperative pain management, while balancing against potential risks of opioid abuse and addiction. Surgeons often find they are ill-prepared to effectively manage postoperative pain in patients returning several months following trauma surgery, many times still dependent on opioids for pain control. Some individuals from this trauma patient population may also require the care of pain management specialists and/or consultation with drug addiction specialists. As the US opioid epidemic continues to worsen, orthopedic trauma surgeons can find it difficult to obtain access to pain management specialists for those patients requiring complex pain medication management and substance abuse counseling. The current state of perioperative pain management for orthopedic trauma patients remains troubling due to reliance on only opioid analgesics, society-associated risks of opioid medication addiction, an "underground" prescription drug marketplace, and an uncertain legal atmosphere related to opioid pain medication management that can deter pain management physicians from accepting narcotic-addicted patients and discourage future physicians from pursuing advanced training in the specialty of pain management. Additionally, barriers continue to exist among Medicaid patients that deter this patient population from access to pain medicine subspecialty care, diminishing medication management reimbursement rates make it increasingly difficult for trauma patients to receive proper opioid analgesic pain medication management, and a lack of proper opioid analgesic medication management training among PCPs and orthopedic trauma surgeons further contributes to an environment ill-prepared to provide effective perioperative pain management for orthopedic trauma patients.
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Affiliation(s)
- Daniel H Wiznia
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Theodore Zaki
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Michael P Leslie
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Thomas M Halaszynski
- Yale Anesthesiology, Yale-New Haven Hospital, 20 York Street, New Haven, CT, 06510, USA. .,Department of Adult and Perioperative Anesthesiology, Yale University School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA.
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Preoperative Opioid Use: A Risk Factor for Poor Return to Work Status After Single-level Cervical Fusion for Radiculopathy in a Workers' Compensation Setting. Clin Spine Surg 2018; 31:E19-E24. [PMID: 28538083 DOI: 10.1097/bsd.0000000000000545] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective comparative case-control study. OBJECTIVES The objectives of this study are: (1) How preoperative opioid use impacts RTW status after single-level cervical fusion for radiculopathy? and (2) What are other postsurgical outcomes affected by preoperative opioid use? SUMMARY OF BACKGROUND DATA Opioid use has increased significantly in the past decade. The use of opioids has a drastic impact on workers' compensation population, an at-risk cohort for poorer surgical and functional outcomes than the general population. METHODS AND MATERIALS Data was retrospectively collected from Ohio Bureau of Workers' Compensation between 1993 and 2011. The study population included patients who underwent single-level cervical fusion for radiculopathy as identified by current procedural terminology codes and International Classification of Diseases-9 codes. On the basis of opioid use before surgery, two groups were constructed (opioids vs. non-opioids). Using a multivariate logistic regression model, the effect of preoperative opioid use on return to work (RTW) status after fusion was analyzed and compared between the groups. RESULTS In the regression model, preoperative opioid use was a negative predictor of RTW status within 3-year follow-up after surgery. Opioid patients were less likely to have stable RTW status [odds ratio (OR), 0.50; 95% confidence interval (CI), 0.38-0.65; P=0.05] and were less likely to RTW within the first year after surgery (OR, 0.50; 95% CI, 0.37-0.66; P=0.05) compared with controls. Stable RTW was achieved in 43.3% of the opioids group and 66.6% of control group (P=0.05). RTW rate within the first year after fusion was 32.5% of opioids group and 57% of control group (P<0.05).Reoperation and permanent disability rates after surgery were higher in the opioid group compared with the control group (P<0.05). CONCLUSIONS In a workers' compensation, patients with work-related injury who underwent single-level cervical fusion for radiculopathy and received opioids before surgery had worse RTW status, a higher reoperation rate, and higher rate of awarded permanent disability after surgery.
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Abstract
While the evidence for urine drug testing for patients on chronic opioid therapy is weak, the guidelines created by numerous medical societies and state and federal regulatory agencies recommend that it be included as one of the tools used to monitor patients for compliance with chronic opioid therapy. To get the most comprehensive results, clinicians should order both an immunoassay screen and confirmatory urine drug test. The immunoassay screen, which can be performed as an in-office point-of-care test or as a laboratory-based test, is a cheap and convenient study to order. Limitations of an immunoassay screen, however, include having a high threshold of detectability and only providing qualitative information about a select number of drug classes. Because of these restrictions, clinicians should understand that immunoassay screens have high false-positive and false-negative rates. Despite these limitations, though, the results can assist the clinician with making preliminary treatment decisions. In comparison, a confirmatory urine drug test, which can only be performed as a laboratory-based test, has a lower threshold of detectability and provides both qualitative and quantitative information. A urine drug test's greater degree of specificity allows for a relatively low false-negative and false-positive rate in contrast to an immunoassay screen. Like any other diagnostic test, an immunoassay screen and a confirmatory urine drug test both possess limitations. Clinicians must keep this in mind when interpreting an unexpected test result and consult with their laboratory when in doubt about the meaning of the test result to avoid making erroneous decisions that negatively impact both the patient and clinician.
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Influence of Medical Insurance Under the Affordable Care Act on Access to Pain Management of the Trauma Patient. Reg Anesth Pain Med 2017; 42:39-44. [PMID: 27776094 DOI: 10.1097/aap.0000000000000502] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The Affordable Care Act intended to "extend affordable coverage" and "ensure access" for vulnerable patient populations. This investigation examined whether the type of insurance (Medicaid, Medicare, Blue Cross, cash pay) carried by trauma patients influences access to pain management specialty care. METHODS Investigators phoned 443 board-certified pain specialists, securing office visits with 235 pain physicians from 8 different states. Appointments for pain management were for a patient who sustained an ankle fracture requiring surgery and experiencing difficulty weaning off opioids. Offices were phoned 4 times assessing responses to the 4 different payment methodologies. RESULTS Fifty-three percent of pain specialists contacted (235 of 443) were willing to see new patients to manage pain medication. Within the 53% of positive responses, 7.2% of physicians scheduled appointments for Medicaid patients, compared with 26.8% for cash-paying patients, 39.6% for those with Medicare, and 41.3% with Blue Cross (P < 0.0001). There were no differences in appointment access between states that had expanded Medicaid eligibility for low-income adults versus states that had not expanded Medicaid eligibility. Neither Medicaid nor Medicare reimbursement levels for new patient visits correlated with ability to schedule an appointment or influenced wait times. CONCLUSIONS Access to pain specialists for management of pain medication in the postoperative trauma patient proved challenging. Despite the Affordable Care Act, Medicaid patients still experienced curtailed access to pain specialists and confronted the highest incidence of barriers to receiving appointments.
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Philpot LM, Ramar P, Elrashidi MY, Mwangi R, North F, Ebbert JO. Controlled Substance Agreements for Opioids in a Primary Care Practice. J Pharm Policy Pract 2017; 10:29. [PMID: 28919978 PMCID: PMC5596855 DOI: 10.1186/s40545-017-0119-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/06/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Opioids are widely prescribed for chronic non cancer pain (CNCP). Controlled substance agreements (CSAs) are intended to increase adherence and mitigate risk with opioid prescribing. We evaluated the demographic characteristics of and opioid dosing for patients with CNCP enrolled in CSAs in a primary care practice. METHODS We conducted a retrospective cohort study of 1066 patients enrolled in CSAs between May 9, 2013 and August 15, 2016 for CNCP in a Midwest primary care practice. RESULTS Patients were prescribed an average of 40.8 (SD ± 57.0) morphine milligram equivalents per day (MME/day), and 21.5% of patients were receiving ≥50 MME/day and 9.7% were receiving ≥90 MME/day. Patients who were younger in age (≥ 65 vs. < 65 years, P < 0.0001), male gender (P = 0.0001), and used tobacco (P = 0.0002) received significantly higher MME/day. Patients with more co-morbidities (Charlson Comorbidity Index, CCI) received higher MME/day (CCI > 3 vs. CCI ≤ 3, P = 0.03), and reported higher average pain (CCI > 3 mean 5.8 [SD ± 2.1] vs. CCI ≤ 3 mean 5.3 [SD ± 2.0], P = 0.0011). Patients on an identified tapering plan (6.9%) had higher MME/day than patients not on a tapering plan (P = 0.0002). CONCLUSIONS CSAs present an opportunity to engage patients taking higher doses of opioids in discussions about opioid safety, appropriate dosing and tapering. CSAs could be leveraged to develop a population health management approach to the care of patients with CNCP.
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Affiliation(s)
- Lindsey M Philpot
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA
| | - Priya Ramar
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA
| | - Muhamad Y Elrashidi
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA.,Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN USA
| | - Raphael Mwangi
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA
| | - Frederick North
- Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN USA
| | - Jon O Ebbert
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA.,Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN USA
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Ebbert JO, Philpot LM, Clements CM, Lovely JK, Nicholson WT, Jenkins SM, Lamer TJ, Gazelka HM. Attitudes, Beliefs, Practices, and Concerns Among Clinicians Prescribing Opioids in a Large Academic Institution. PAIN MEDICINE 2017; 19:1790-1798. [DOI: 10.1093/pm/pnx140] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Jon O Ebbert
- College of Medicine
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsey M Philpot
- College of Medicine
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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Psychiatric disorders as predictors of long-term opioid therapy and the need for treating chronic pain correctly in patients with prior opioid substance use disorder: a commentary. Pain 2017; 158:6-7. [PMID: 27764036 DOI: 10.1097/j.pain.0000000000000748] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Placebos are often used by clinicians, usually deceptively and with little rationale or evidence of benefit, making their use ethically problematic. In contrast with their typical current use, a provocative line of research suggests that placebos can be intentionally exploited to extend analgesic therapeutic effects. Is it possible to extend the effects of drug treatments by interspersing placebos? We reviewed a database of placebo studies, searching for studies that indicate that placebos given after repeated administration of active treatments acquire medication-like effects. We found a total of 22 studies in both animals and humans hinting of evidence that placebos may work as a sort of dose extender of active painkillers. Wherever effective in relieving clinical pain, such placebo use would offer several advantages. First, extending the effects of a painkiller through the use of placebos may reduce total drug intake and side effects. Second, dose-extending placebos may decrease patient dependence. Third, using placebos along with active medication, for part of the course of treatment, should limit dose escalation and lower costs. Provided that nondisclosure is preauthorized in the informed consent process and that robust evidence indicates therapeutic benefit comparable to that of standard full-dose therapeutic regimens, introducing dose-extending placebos into the clinical arsenal should be considered. This novel prospect of placebo use has the potential to change our general thinking about painkiller treatments, the typical regimens of painkiller applications, and the ways in which treatments are evaluated.
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Reply. Pain 2017; 158:361-362. [PMID: 28092327 DOI: 10.1097/j.pain.0000000000000757] [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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Kandil E, Melikman E, Adinoff B. Lidocaine Infusion: A Promising Therapeutic Approach for Chronic Pain. ACTA ACUST UNITED AC 2017; 8. [PMID: 28239510 PMCID: PMC5323245 DOI: 10.4172/2155-6148.1000697] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Opioid abuse is a national epidemic in the United States, where it is estimated that a prescription drug overdose death occurs every 19 minutes. While opioids are highly effective in acute and subacute pain control, their use for treatment of chronic pain is controversial. Chronic opioids use is associated with tolerance, dependency, hyperalgesia. Although there are new strategies and practice guidelines to reduce opioid dependence and opioid prescription drug overdose, there has been little focus on development of opioid-sparing therapeutic approaches. Lidocaine infusion has been shown to be successful in controlling pain where other agents have failed. The opioid sparing properties of lidocaine infusion added to its analgesic and antihyperalgesic properties make lidocaine infusion a viable option for pain control in opioid dependent patients. In this review, we provide an overview of the opioid abuse epidemic, and we outline current evidence supporting the potential use of lidocaine infusion as an adjuvant therapeutic approach for management of chronic pain.
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Affiliation(s)
- Enas Kandil
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emily Melikman
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Bryon Adinoff
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Livingstone MJ, Groenewald CB, Rabbitts JA, Palermo TM. Codeine use among children in the United States: a nationally representative study from 1996 to 2013. Paediatr Anaesth 2017; 27:19-27. [PMID: 27779367 PMCID: PMC5179302 DOI: 10.1111/pan.13033] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Concerns regarding the safety of codeine have been raised. Cases of life-threatening respiratory depression and death in children have been attributed to codeine's polymorphic metabolic pathway. International health agencies recommend restricted use of codeine in children. Despite these recommendations, the epidemiology of codeine use among children remains unknown. AIMS Our objective was to examine patterns of codeine use in the US among children. METHODS A cross-sectional analysis of children of age 0-17 years from 1996 to 2013 in the US was performed. Data were extracted from MEPS, a nationally representative set of health care surveys. Prevalence rates of codeine use between 1996 and 2013 were examined. Multivariable logistic regression examined relationships between codeine use and patient demographics. RESULTS Codeine use remained largely unchanged from 1996 to 2013 (1.08 vs 1.03 million children, respectively). Odds of codeine use was higher in ages 12-17 (OR, 1.40; [1.21-1.61]), outside of the Northeastern US, and among those with poor physical health status (OR, 3.29 [1.79-6.03]). Codeine use was lower in children whose ethnicity was not white and those uninsured (OR, 0.47 [0.34-0.63]). Codeine was most frequently prescribed by emergency physicians (18%) and dentists (14%). The most common condition associated with codeine use was trauma-related pain. CONCLUSIONS Pediatric codeine use has declined since 1996; however, more than 1 million children still used codeine in 2013. Health care providers must be made aware of guidelines advising against the use of codeine in children. Codeine is potentially hazardous and safer alternatives to treat children's pain are available.
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Affiliation(s)
- Margaret J Livingstone
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Cornelius B Groenewald
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Jennifer A Rabbitts
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Department of Psychiatry, University of Washington School of Medicine, Seattle, WA, USA
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Shafrin J, Griffith J, Shim JJ, Huber C, Ganguli A, Aubry W. Geographic Variation in Diagnostic Ability and Quality of Care Metrics: A Case Study of Ankylosing Spondylitis and Low Back Pain. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2017; 54:46958017707873. [PMID: 28548005 PMCID: PMC5798677 DOI: 10.1177/0046958017707873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Studies examining geographic variation in care for low back pain often focus on process and outcome measures conditional on patient diagnosis but generally do not take into account a physician's ability to diagnose the root cause of low back pain. In our case study, we used increased detection of ankylosing spondylitis-a relatively rare inflammatory back disease-as a proxy for diagnostic ability and measured the relationship between ankylosing spondylitis detection, potentially inappropriate low back pain care, and cost. Using 5 years of health insurance claims data, we found significant variation in ankylosing spondylitis detection across metropolitan statistical areas (MSAs), with 8.1% of the variation in detection explained by a region's racial composition. Furthermore, low back pain patients in MSAs with higher ankylosing spondylitis detection had 7.9% lower use of corticosteroids, 9.0% lower use of opioids, and 8.2% lower pharmacy cost, compared with patients living in low-detection MSAs.
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Affiliation(s)
| | | | - Jin Joo Shim
- 1 Precision Health Economics, Los Angeles, CA, USA
| | | | | | - Wade Aubry
- 3 University of California, San Francisco, USA
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Opioid prescribing for patients with cancer in the last year of life: a longitudinal population cohort study. Pain 2016; 157:2445-2451. [DOI: 10.1097/j.pain.0000000000000656] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nagarajan R, Miller CS, Dawson D, Al-Sabbagh M, Ebersole JL. Cross-talk between clinical and host-response parameters of periodontitis in smokers. J Periodontal Res 2016; 52:342-352. [PMID: 27431617 DOI: 10.1111/jre.12397] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVE Periodontal diseases are a major public health concern leading to tooth loss and have also been shown to be associated with several chronic systemic diseases. Smoking is a major risk factor for the development of numerous systemic diseases, as well as periodontitis. While it is clear that smokers have a significantly enhanced risk for developing periodontitis leading to tooth loss, the population varies regarding susceptibility to disease associated with smoking. This investigation focused on identifying differences in four broad sets of variables, consisting of: (i) host-response molecules; (ii) periodontal clinical parameters; (iii) antibody responses to periodontal pathogens and oral commensal bacteria; and (iv) other variables of interest, in a population of smokers with (n = 171) and without (n = 117) periodontitis. MATERIAL AND METHODS Bayesian network structured learning (BNSL) techniques were used to investigate potential associations and cross-talk between the four broad sets of variables. RESULTS BNSL revealed two broad communities with markedly different topology between the populations of smokers, with and without periodontitis. Confidence of the edges in the resulting network also showed marked variations within and between the periodontitis and nonperiodontitis groups. CONCLUSION The results presented validated known associations and discovered new ones with minimal precedence that may warrant further investigation and novel hypothesis generation. Cross-talk between the clinical variables and antibody profiles of bacteria were especially pronounced in the case of periodontitis and were mediated by the antibody response profile to Porphyromonas gingivalis.
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Affiliation(s)
- R Nagarajan
- Division of Biomedical Informatics, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - C S Miller
- Center for Oral Health Research, College of Dentistry, University of Kentucky, Lexington, KY, USA.,Department of Oral Health Practice, Division of Oral Medicine, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - D Dawson
- Center for Oral Health Research, College of Dentistry, University of Kentucky, Lexington, KY, USA.,Department of Oral Health Practice, Division of Periodontics, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - M Al-Sabbagh
- Department of Oral Health Practice, Division of Periodontics, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - J L Ebersole
- Center for Oral Health Research, College of Dentistry, University of Kentucky, Lexington, KY, USA.,Department of Oral Health Practice, Division of Periodontics, College of Dentistry, University of Kentucky, Lexington, KY, USA
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Abstract
BACKGROUND Chronic opioid therapy for chronic pain treatment has increased. Hospital physicians, including hospitalists and medical/surgical resident physicians, care for many hospitalized patients, yet little is known about opioid prescribing at hospital discharge and future chronic opioid use. OBJECTIVE We aimed to characterize opioid prescribing at hospital discharge among 'opioid naïve' patients. Opioid naïve patients had not filled an opioid prescription at an affiliated pharmacy 1 year preceding their hospital discharge. We also set out to quantify the risk of chronic opioid use and opioid refills 1 year post discharge among opioid naïve patients with and without opioid receipt at discharge. DESIGN This was a retrospective cohort study. PARTICIPANTS From 1 January 2011 to 31 December 2011, 6,689 opioid naïve patients were discharged from a safety-net hospital. MAIN MEASURE Chronic opioid use 1 year post discharge. KEY RESULTS Twenty-five percent of opioid naïve patients (n = 1,688) had opioid receipt within 72 hours of discharge. Patients with opioid receipt were more likely to have diagnoses including neoplasm (6.3% versus 3.5%, p < 0.001), acute pain (2.7% versus 1.0 %, p < 0.001), chronic pain at admission (12.1% versus 3.3%, p < 0.001) or surgery during their hospitalization (65.1% versus 18.4%, p < 0.001) compared to patients without opioid receipt. Patients with opioid receipt were less likely to have alcohol use disorders (15.7% versus 20.7%, p < 0.001) and mental health disorders (23.9% versus 31.4%, p < 0.001) compared to patients without opioid receipt. Chronic opioid use 1 year post discharge was more common among patients with opioid receipt (4.1% versus 1.3%, p < 0.0001) compared to patients without opioid receipt. Opioid receipt was associated with increased odds of chronic opioid use (AOR = 4.90, 95% CI 3.22-7.45) and greater subsequent opioid refills (AOR = 2.67, 95% CI 2.29-3.13) 1 year post discharge compared to no opioid receipt. CONCLUSION Opioid receipt at hospital discharge among opioid naïve patients increased future chronic opioid use. Physicians should inform patients of this risk prior to prescribing opioids at discharge.
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Gallagher BK, Shin Y, Roohan P. Opioid Prescriptions Among Women of Reproductive Age Enrolled in Medicaid - New York, 2008-2013. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2016; 65:415-7. [PMID: 27124815 DOI: 10.15585/mmwr.mm6516a2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Exposure to opioids during pregnancy can lead to adverse infant outcomes, including neonatal abstinence syndrome (1) and birth defects (2). Ascertaining opioid prescriptions for women who become pregnant or have no indication of contraceptive use is important to determine the number of women who are at potential risk for adverse fetal outcomes. The New York State (NYS) Department of Health (DOH) analyzed data for women aged 15-44 years (i.e., reproductive-aged women) enrolled in Medicaid to examine opioid drug prescriptions during 2008-2013. On the basis of Medicaid drug claims for any drug with an opioid ingredient, prescriptions were identified for the enrolled population of reproductive-aged women and for three subgroups: women whose diagnosis, procedure, and drug codes indicated contraceptive use or infertility; women who were not using contraceptives and not infertile; and women who had had a live birth during the reporting year. During 2008-2013, among all women of reproductive age, 20.0% received a prescription for a drug with an opioid component; the proportion was highest (27.3%) among women with an indication of contraceptive use or infertility, intermediate (17.3%) among women who had no indication of contraceptive use, and lowest (9.5%) among women who had had a live birth. Although New York's proportion of opioid prescriptions among female Medicaid recipients who had a live birth is lower than a recent U.S. estimate (3), these results suggest nearly one in 10 women in this group may have been exposed to opioids in the prenatal period.
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Ben-Joseph R, Bell JA, Brixner D, Kansal A, Paramore C, Chitnis A, Holly P, S Burgoyne D. Opioid Treatment Patterns Following Prescription of Immediate-Release Hydrocodone. J Manag Care Spec Pharm 2016; 22:358-66. [PMID: 27023689 PMCID: PMC10397816 DOI: 10.18553/jmcp.2016.22.4.358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Immediate-release (IR) hydrocodone is the most widely prescribed opioid in the United States; however, little is known about the utilization patterns and duration of opioid use among patients prescribed IR hydrocodone. A better understanding of the use of IR hydrocodone would result in more appropriate prescribing patterns of extended-release opioids. OBJECTIVE To assess downstream length of opioid therapy and utilization patterns of extended-release/long-acting (ER/LA) opioids among patients on IR hydrocodone to provide a better understanding of how IR and ER/LA opioids are used to manage pain. METHODS Retrospective analysis using health care claims from the Truven MarketScan Commercial, Medicare Supplemental, and Medicaid databases was performed. Patients prescribed IR hydrocodone during the 6-month baseline period (July 2011-December 2011) and with continuous enrollment for a 12-month follow-up period (2012) post-index date (January 1, 2012) were selected. Downstream length of therapy, defined as number of days supplied with opioids, and downstream use of ER/LA opioids during follow-up were examined by average pills per month (≤ 60 vs. > 60 pills per month) and days supply (< 60 vs. ≥ 60 days supply) of IR hydrocodone during baseline to mimic intermittent and consistent IR users. RESULTS At baseline, 1,743,933 commercial, 277,096 Medicare, and 157,922 Medicaid IR hydrocodone patients were identified. During follow-up, 1.7%, 2.9%, and 2.8% of patients initiated (i.e., converted to or newly started) ER/LA opioids for commercial, Medicare, and Medicaid groups, respectively. Approximately 90% of patients were prescribed IR hydrocodone for less than 2 months in the following year, while 10% were high utilizers, averaging nearly 8 months of prescribed opioid use during follow-up. Downstream initiation of ER/LA opioids was significantly higher among commercial patients prescribed IR hydrocodone for > 60 pills per month than with ≤ 60 pills per month (7.8% vs. 1.2%, respectively, P < 0.05) at baseline. For commercial patients initiating ER/LA opioids, length of ER/LA therapy during follow-up was significantly longer among patients with baseline IR hydrocodone > 60 pills per month than with ≤ 60 pills per month. All results were consistent when examined by levels of days supply. CONCLUSIONS A majority of the population prescribed IR hydrocodone was not prescribed opioid therapy beyond 2 months on average in the 1-year follow-up period. Only a small subset of patients with increased pills per month or days supply of IR hydrocodone in the baseline period continued to be high utilizers in the following year, averaging nearly 8 months of prescribed opioid use. A limited proportion of patients prescribed IR hydrocodone converted to ER/LA opioids. This knowledge can assist policymakers and physicians, providing an opportunity to identify small subsets of patients to improve ER/LA opioid prescribing. DISCLOSURES Funding and support for this study was provided by Purdue Pharma L.P. Consulting fees were paid to Evidera by Purdue Pharma L.P. for this study. Kansal, Chitnis, and Paramore are employees of Evidera and were paid consultants to Purdue Pharma for this research. Holly is an employee for Purdue Pharma, and Bell and Ben-Joseph were full-time employees of Purdue Pharma during the design, planning, and execution of the studies and during the preparation of this manuscript. Burgoyne and Brixner were consultants on this project. Study design was created by Ben-Joseph, Brixner, Paramore, and Burgoyne. Data were collected by Kansal, Chitnis, Bell, Ben-Joseph, and Holly and interpreted by Ben-Joseph, Bell, Kansal, and Holly, with assistance from Brixner, Paramore, Burgoyne, and Chitnis. The manuscript was written by Ben-Joseph, Bell, Paramore, Chitnis, and Holly, with assistance from Kansal, and revised by Bell and Holly, along with Ben-Joseph, Brixner, Kansal, Paramore, Burgoyne, and Chitnis.
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Affiliation(s)
| | | | - Diana Brixner
- 2 Pharmacotherapy Outcomes Research Center, Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City
| | | | | | | | - Pamela Holly
- 4 Medical Affairs Strategic Research, Purdue Pharma L.P., Stamford, Connecticut
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Overdyk FJ, Dowling O, Marino J, Qiu J, Chien HL, Erslon M, Morrison N, Harrison B, Dahan A, Gan TJ. Association of Opioids and Sedatives with Increased Risk of In-Hospital Cardiopulmonary Arrest from an Administrative Database. PLoS One 2016; 11:e0150214. [PMID: 26913753 PMCID: PMC4767404 DOI: 10.1371/journal.pone.0150214] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 02/10/2016] [Indexed: 11/18/2022] Open
Abstract
Background While opioid use confers a known risk for respiratory depression, the incremental risk of in-hospital cardiopulmonary arrest, respiratory arrest, or cardiopulmonary resuscitation (CPRA) has not been studied. Our aim was to investigate the prevalence, outcomes, and risk profile of in-hospital CPRA for patients receiving opioids and medications with central nervous system sedating side effects (sedatives). Methods A retrospective analysis of adult inpatient discharges from 2008–2012 reported in the Premier Database. Patients were grouped into four mutually exclusive categories: (1) opioids and sedatives, (2) opioids only, (3) sedatives only, and (4) neither opioids nor sedatives. Results Among 21,276,691 inpatient discharges, 53% received opioids with or without sedatives. A total of 96,554 patients suffered CPRA (0.92 per 1000 hospital bed-days). Patients who received opioids and sedatives had an adjusted odds ratio for CPRA of 3.47 (95% CI: 3.40–3.54; p<0.0001) compared with patients not receiving opioids or sedatives. Opioids alone and sedatives alone were associated with a 1.81-fold and a 1.82-fold (p<0.0001 for both) increase in the odds of CPRA, respectively. In opioid patients, locations of CPRA were intensive care (54%), general care floor (25%), and stepdown units (15%). Only 42% of patients survived CPRA and only 22% were discharged home. Opioid patients with CPRA had mean increased hospital lengths of stay of 7.57 days and mean increased total hospital costs of $27,569. Conclusions Opioids and sedatives are independent and additive risk factors for in-hospital CPRA. The impact of opioid sparing analgesia, reduced sedative use, and better monitoring on CPRA incidence deserves further study.
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Affiliation(s)
- Frank J. Overdyk
- Department of Anesthesiology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, United States of America
- North American Partners in Anesthesia, Melville, NY, United States of America
- * E-mail:
| | - Oonagh Dowling
- Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, United States of America
| | - Joseph Marino
- Department of Anesthesiology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, United States of America
- North American Partners in Anesthesia, Melville, NY, United States of America
| | - Jiejing Qiu
- Covidien Healthcare Economics and Outcomes Research, Mansfield, MA, United States of America
| | - Hung-Lun Chien
- Covidien Healthcare Economics and Outcomes Research, Mansfield, MA, United States of America
| | - Mary Erslon
- Covidien Respiratory and Monitoring Solutions, Boulder, CO, United States of America
| | | | - Brooke Harrison
- Boulder Medical Writing, Boulder, CO, United States of America
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Tong J. Gan
- Department of Anesthesiology, Stony Brook University (SUNY), Stony Brook, NY, United States of America
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American College Of Medical Toxicology. ACMT Position Statement: The Use of Methadone as an Analgesic. J Med Toxicol 2016; 12:213-5. [PMID: 26746475 DOI: 10.1007/s13181-015-0532-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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