Prescription drug abuse as a public health problem in Ohio: a case report

Decreasing Opioid Use in Pediatric Lower Extremity Trauma: A Quality Improvement Project

INTRODUCTION

Perioperative anxiety increases postoperative pain and the risk of complications in hospitalized children. Nonpharmacologic pain resources provided by Certified Child Life Specialists (CCLS) are a viable adjunct for pain management.

METHOD

A routine CCLS consult was implemented for patients admitted to the orthopedic service with traumatic lower extremity injuries requiring surgery. A retrospective chart review compared patients who did not receive a CCLS consult. Daily pain rating scores, total doses of opioid and nonopioid pain medication, number of physical therapy attempts, length of stay, and demographics were compared for both groups.

RESULTS

A clinically significant improvement was seen for decreased pain rating scores and opioid use after a routine CCLS consult was implemented.

DISCUSSION

Adopting a routine CCLS consult for children with unplanned admissions because of trauma reduces the number of opioids used, provides children with pain management resources, and promotes coping skills that may be used in the future.

The payer's role in addressing the opioid epidemic: It's more than money

BACKGROUND AND OBJECTIVE

County, State, and Federal agencies are addressing the public health opioid crisis. Ohio's 51 county-based Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Boards finance and regulate opioid treatment services within their jurisdictions. This three-year comparative trial collaborated with ADAMHS Boards (n = 14) to test the Advancing Recovery Framework, a suite of organizational and system change strategies designed to promote use of buprenorphine for opioid agonist therapy.

METHODS

A multi-level intervention directed payers and treatment agencies to leverage their roles in increasing the use of buprenorphine. Half of the boards partnered with local substance use disorder treatment providers using the partnership strategies recommended by the Advancing Recovery (AR) framework. The comparison boards did not use the partnership strategies.

RESULTS AND CONCLUSION

A logistic regression analysis detected increases in the number of patients receiving buprenorphine in both conditions. Buprenorphine use, as a percentage of patients with an opioid use disorder diagnosis, was significantly greater among the boards using the Advancing Recovery strategies during the three-year experimental period (odds ratio (OR) 1.63, 95% CI, 1.50 to 1.76, p < .001) and a one-year maintenance period (OR 2.13, 95% CI, 1.85 to 2.46, p < .001). Boards in both groups provided similar levels of financial support to implement and maintain buprenorphine prescribing. Strategy differences between the study conditions existed in use of a committee that facilitated payer-provider partnering and the ADAMHS boards setting expectations for using buprenorphine. Payer-provider partnerships achieved greater improvements and maximized the effectiveness of funding in increasing access to buprenorphine.

Using a mock board of pharmacy disciplinary hearing to teach concepts related to administrative law, addiction, empathy, and professionalism

BACKGROUND AND PURPOSE

The purpose of this project was to impact pharmacy students' personal and professional development through simulation of a board of pharmacy disciplinary hearing regarding addiction.

EDUCATIONAL ACTIVITY AND SETTING

The mock board hearing was conducted as part of the required curriculum. Faculty obtained materials from a prior board hearing. The actual respondent, lawyer, former executive director, and a board agent participated. Students served as board members and president, asked questions of the witnesses, and deliberated per board procedure. After the event, student learning and perceptions were assessed through knowledge-based, opinion-based questions, and open-ended questions.

FINDINGS

Of the 141 students who attended the event, 97% completed the assessment. The average score on the knowledge-based questions was 95%. Ratings of perceptions and reflections of the experience were used in tandem to understand the experience. In general, students indicated the experience was positive and impactful towards their education. Students indicated they felt that the experience allowed them to better understand addiction and empathize with someone called before the board. In fact, there were fundamental differences in perceptions regarding the "addicted person," going from a penalizing and stigmatized perspective to one of caring and compassion.

SUMMARY

Students were knowledgeable about the board and its regulatory process after the event. More than knowledge, students indicated fundamental changes in their views of addiction. Other institutions may consider implementing similar exercises to engender empathy and professionalism regarding drug addiction and regulatory compliance.

Mandatory review of a prescription drug monitoring program and impact on opioid and benzodiazepine dispensing

BACKGROUND

The purpose of this study is to determine whether Ohio House Bill 341, which mandated the use of Ohio's Prescription Drug Monitoring Program (PDMP), was an effective regulatory strategy to reduce opioid and benzodiazepine dispensing.

METHOD

Secondary analysis of Ohio's PDMP data on prescription opioids and benzodiazepines dispensed from November 2014 to March 2017. An interrupted time series analysis was conducted to determine if there was a significant change in the quantity of opioids and benzodiazepines dispensed.

RESULTS

After HB341 became effective in April 2015, there was a statistically significant decrease in the monthly quantity (number of pills) opioids and benzodiazepines dispensed in Ohio. There was a modest increase in the mean days' supply of opioids and no change in the mean morphine equivalent dose.

CONCLUSIONS

Legislation in Ohio requiring prescribers to check the PDMP was effective in reducing the quantity of opioids and benzodiazepines dispensed.

Statewide cross-sectional survey of emergency departments' adoption and implementation of the Ohio opioid prescribing guidelines and opioid prescribing practices

STUDY OBJECTIVE

To evaluate the implementation of the Ohio Emergency and Acute Care Facility Opioids and Other Controlled Substances Prescribing Guidelines and their perceived impact on local policies and practice.

METHODS

The study design was a cross-sectional survey of emergency department (ED) medical directors, or appropriate person identified by the hospital, perception of the impact of the Ohio ED Opioid Prescribing Guidelines on their departments practice. All hospitals with an ED in Ohio were contacted throughout October and November 2016. Distribution followed Dillman's Tailored Design Method, augmented with telephone recruitment. Hospital chief executive officers were contacted when necessary to encourage ED participation. Descriptive statistics were used to assess the impact of opioid prescribing policies on prescribing practices.

RESULTS

A 92% response rate was obtained (150/163 EDs). In total, 112 (75%) of the respondents stated that their ED has an opioid prescribing policy, is adopting one or is implementing prescribing guidelines without a specific policy. Of these 112 EDs, 81 (72%) based their policy on the Ohio ED Opioid Prescribing Guidelines. The majority of respondents strongly agreed/agreed that the prescribing guidelines have increased the use of the prescription drug monitoring programme (86%) and have reduced inappropriate opioid prescribing (71%).

CONCLUSION

This study showed that the Ohio ED Opioid Prescribing Guidelines have been widely disseminated and that the majority of EDs in Ohio are using them to develop local policies. The majority of respondents believed that the Ohio opioid prescribing guidelines reduced inappropriate opioid prescribing. However, prescribing practices still varied greatly between EDs.

Correlates of Risky Alcohol Use Among Women from Appalachian Ohio

Women from Appalachian regions of the United States (US) face a number of health related disparities, including mental health and substance misuse. Alcohol misuse is a significant public health concern among women in the US, associated with numerous adverse consequences for the woman, her unborn children, and any children in her care, yet data on correlates of risky alcohol use is limited among women from Appalachian Ohio. The current study examines the prevalence and predictors of risky alcohol use (e.g., heavy episodic drinking) in 2,349 women from 18 clinics in the Community Awareness Resources and Education I (CARE I) study in Appalachian Ohio. Alcohol use history was collected over the past 30 days. Regression models were employed to identify predictors of heavy episodic drinking. Results indicate that 20% of the current sample reported heavy episodic drinking. Being an emerging adult (18-26), single, a current smoker, and reporting a history of four or more partners were independently associated with heavy episodic drinking. Self-identifying as Appalachian was not protective or predictive of heavy episodic drinking. Further research identifying risk factors and enhancing protective factors will inform culturally competent preventive efforts, particularly for emerging adult women from Appalachian Ohio at risk for alcohol misuse and associated morbidities.

Strategies and policies to address the opioid epidemic: A case study of Ohio

OBJECTIVE

To describe the strategies and policies implemented in Ohio to improve opioid safety and to discuss the role that pharmacists can play in implementing, promoting, and enhancing the effectiveness of these policies.

SETTING

Ohio has the fifth highest rate of drug overdose deaths (24.6 deaths per 100,000) in the United States. Unintentional drug overdose has become the leading cause of injury-related death in Ohio. In 2015, there were 3050 overdose deaths in Ohio, and in 2014 there were an estimated 12,847 overdose events reversed by emergency medical services with naloxone.

PRACTICE DESCRIPTION

Not applicable.

PRACTICE POLICY INNOVATION

In 2011, the Governor's Cabinet Opiate Action Team was created to implement a multifaceted strategy, in part (1) to promote the responsible use of opioids, (2) to reduce the supply of opioids, and (3) to support overdose prevention and expand access to naloxone. Innovations to assist these goals include the development of Ohio guidelines on the responsible use of opioids, mandatory use of Ohio's prescription drug monitoring program, closing pill mills, promotion of drug take-back programs and increased access to naloxone and public health campaigns.

EVALUATION

Not applicable.

RESULTS

Since the development of the Governor's Cabinet Opiate Action Team, there were 81 million fewer doses of opioids dispensed to Ohio patients in 2015 compared with 782 million doses dispensed in 2011. As such, the proportion of unintentional drug overdose deaths involving prescription opioids has reduced from 45% in 2011 to 22% in 2015.

CONCLUSION

Strong political support was crucial in Ohio to facilitate the rapid implementation opioid overdose prevention programs and the promotion of public awareness campaigns. However, the misuse and abuse of prescription opioids are complex problems requiring a comprehensive and multifaceted approach. Pharmacists are identified as a crucial component of the state strategy to addressing opioid abuse by promoting responsible prescribing and adopting prevention practices.

Barriers to implementation of opioid overdose prevention programs in Ohio

BACKGROUND

Nationally, overdose fatalities have reached epidemic proportions. Ohio has one of the highest overdose death rates in the country, as well as high rates of prescription opioid trafficking.

METHODS

A cross-sectional self-report survey of opioid overdose prevention programs (OOPPs) in Ohio was conducted between August and October 2014 to characterize programs and ascertain barriers to successful implementation. A 91% response rate was achieved with 18 programs participating in the study.

RESULTS

The first Ohio OOPP opened in August 2012, a second program opened in 2013, and the remaining programs began in 2014. All of the programs distribute nasal naloxone and provide overdose prevention education, and 89% (n = 16) provide overdose kits for free. Six OOPPs are funded by the Ohio Department of Health, 3 programs are funded by a local health foundation, and several other public and private funding sources were reported. The OOPPs have funding to distribute a combined total of 8,670 overdose kits and had distributed 1998 kits by October 2014. The OOPPs reported 149 overdose reversals. Fifteen programs (83%) reported implementation barriers that were categorized as stigma-, cost-, staffing-, legal, regulatory, and client-related problems. Legislative changes aimed at removing some of the obstacles to distribution and lay administration of naloxone have recently been enacted in Ohio.

CONCLUSIONS

OOPPs have rapidly expanded in Ohio during the past 3 years. Although recent legislative changes have addressed some of the reported implementation barriers, stigma and the cost of naloxone remain significant problems.

Drug use, hepatitis C, and service availability: perspectives of incarcerated rural women

This study examined drug use, hepatitis C, and service availability and use among a high-risk sample of rural women serving time in jails. Data was collected from female offenders (N = 22) who participated in four focus groups in three rural jail facilities located in Appalachia. Findings indicated that drug misuse is prevalent in this impoverished area of the country, and that the primary route of administration of drug use is injection. Findings also indicate that injection drug use is also commonly associated with contracting hepatitis C (HCV), which is also perceived to be prevalent in the area. Despite knowledge associated with HCV risks, women in this sample were seemingly apathetic about the increasing spread of HCV in the area and unconcerned about the long-term consequences of the course of the infection. Implications for future research and practice are discussed.

Design considerations for point-of-care clinical trials comparing methadone and buprenorphine treatment for opioid dependence in pregnancy and for neonatal abstinence syndrome

RATIONALE

In recent years, the U.S. has experienced a significant increase in the prevalence of pregnant opioid-dependent women and of neonatal abstinence syndrome (NAS), which is caused by withdrawal from in-utero drug exposure. While methadone-maintenance currently is the standard of care for opioid dependence during pregnancy, research suggests that buprenorphine-maintenance may be associated with shorter infant hospital lengths of stay (LOS) relative to methadone-maintenance. There is no "gold standard" treatment for NAS but there is evidence that buprenorphine, relative to morphine or methadone, treatment may reduce LOS and length of treatment.

DESIGN

Point-of-care clinical trial (POCCT) designs, maximizing external validity while reducing cost and complexity associated with classic randomized clinical trials, were selected for two planned trials to compare methadone to buprenorphine treatment for opioid dependence during pregnancy and for NAS. This paper describes design considerations for the Medication-assisted treatment for Opioid-dependent expecting Mothers (MOMs; estimated N = 370) and Investigation of Narcotics for Ameliorating Neonatal abstinence syndrome on Time in hospital (INFANTs; estimated N = 284) POCCTs, both of which are randomized, intent-to-treat, two-group trials. Outcomes would be obtained from participants' electronic health record at three participating hospitals. Additionally, a subset of infants in the INFANTs POCCT would be from mothers in the MOMs POCCT and, thus, potential interaction between medication treatment of mother and infant could be evaluated.

CONCLUSION

This pair of planned POCCTs would evaluate the comparative effectiveness of treatments for opioid dependence during pregnancy and for NAS. The results could have a significant impact on practice.