Prevalence and Trends of Concurrent Opioid Analgesic and Benzodiazepine Use Among Veterans Affairs Patients with Post-traumatic Stress Disorder, 2003–2011

Association Between Hypnotic Use and All-Cause Mortality in Patients with Chronic Obstructive Pulmonary Disease and Insomnia

Purpose

Hypnotics are commonly prescribed in patients with COPD to manage insomnia. Given the considerable risks associated with these drugs, the aim of the study was to evaluate the risk of all-cause mortality associated with hypnotics in a cohort of veterans with COPD presenting with insomnia.

Methods

We conducted a retrospective cohort study that used Veterans Health Administration Corporate Data Warehouse with data supplemented by linkage to Medicare, Medicaid, and National Death Index data from 2010 through 2019. The primary outcome was all-cause mortality. Analyses were conducted using propensity score 1:1 matching to balance baseline characteristics.

Results

Of the 5759 veterans with COPD (mean [SD] age, 71.7 [11.2]; 92% men), 3585 newly initiated hypnotic agents during the study period. During a mean follow-up of 7.4 (SD, 2.7) years, a total of 2301 deaths occurred, with 65.2 and 48.7 total deaths per 1000 person-years among hypnotic users and nonusers, respectively. After propensity matching, hypnotic use was associated with a 22% increased risk of mortality compared with hypnotic nonusers (hazard ratio [HR] 1.22; 95% confidence interval [CI],1.11-1.35). The benzodiazepine receptor agonists (BZRAs) group experienced a higher incidence rate of all-cause mortality compared to hypnotic nonusers (Incidence rate ratio [IRR] 1.27; 95% CI, 1.14-1.43). Conversely, the mortality rate of non-BZRA hypnotics decreased after the first 2 years and was not significantly different for hypnotic nonusers (IRR 1.04; 95% CI, 0.82-1.11).

Conclusion

Among patients with COPD and insomnia, treatment with hypnotics was associated with a higher risk of all-cause mortality. The association was observed in patients prescribed BZRAs. The risk of mortality for non-BZRAs moderated after the first 2 years, indicating a class effect.

Post-traumatic stress disorder and risky opioid use among persons living with HIV and chronic pain

Persons with HIV (PWH) experience chronic pain and Post-Traumatic Stress Disorder (PTSD) at higher rates than the general population, and more often receive opioid medications to treat chronic pain. A known association exists between PTSD and substance use disorders, but less is known about the relationship between PTSD and risky opioid use among PWH taking prescribed opioid medications. In this observational study of PWH on long-term opioid medications for pain we examined associations between PTSD symptom severity based on the Post Traumatic Stress Disorder Checklist for DSM-5 (PCL-5, response range 0-80) and the following outcomes: 1) risk for opioid misuse (COMM score ≥13); 2) risky alcohol use (AUDIT score ≥8); 3) concurrent benzodiazepine prescription; and 4) morphine equivalent dose. Among 166 patients, 38 (23%) had a PCL-5 score over 38, indicating high PTSD symptom burden. Higher PCL-5 score (per 10 point difference) was associated with increased odds of opioid misuse (aOR 1.55; 95%CI: 1.31-1.83) and risky drinking (aOR: 1.28;1.07-1.52). No significant association was observed between PCL-5 score and benzodiazepine prescriptions or morphine equivalent dose. These findings suggest that when addressing alcohol and opioid use in PWH on long term opioid therapy, attention to PTSD symptoms is especially important given the higher risk for risky alcohol and opioid use among patients with this common comorbid condition.

Geospatial Analysis of Opioid Dispensing Patterns in California: A 2021 Real-World Study

The misuse and abuse of opioids has become a serious public health threat in the United States. The state of California has been hit particularly hard by the opioid epidemic, with a noticeable increase in opioid-related fatalities and hospitalizations. This brief report paper aims to contribute to the growing literature by conducting a geospatial analysis of opioid dispensing patterns in California in 2021. The primary objective was to identify areas characterized by high-risk opioid dispending patterns and explore possible contributing factors. This retrospective study analyzed data from over 7 million records of opioid and benzodiazepine prescriptions dispensed by outpatient pharmacies in California in 2021. A series of generalized linear regression models was employed to assess the impact of neighborhood characteristics on opioid recipients and high-risk opioid dispensing. The study defined high-risk opioid dispensing behavior as: (1) multiple provider episodes, (2) overlapping opioid prescriptions for seven or more days, (3) overlapping opioid and benzodiazepine prescriptions for seven or more days, and (4) a high standardized dosage of opioid prescriptions per month. The study identified variables associated with high-risk opioid dispensing behaviors, including age, population density, income, and housing-related variables, as well as marital status and family-related variables. The study uncovered that there are noticeable disparities in opioid dispensing among different racial and ethnic groups within California. The findings indicated a correlation of high-risk dispensing indicators with certain demographic and socioeconomic factors. There was a substantial regional variation in opioid dispensing practices, with certain rural areas having higher rates of opioid prescriptions than urban areas.

Prevention, Practice, and Policy: Older US Veterans' Perspectives on Cannabis Use

BACKGROUND AND OBJECTIVE

Veterans often struggle with disabling physical and mental health conditions that tend to worsen as they age. Current medications used to treat these conditions include opioids and benzodiazepines though they can have negative side effects. Looking for alternatives to these medications, many older Veterans use cannabis for medical purposes. We aimed to develop a deeper understanding of older Veterans' cannabis use.

METHODS

We used maximum variation sampling to select 32 Veterans who had completed baseline and follow-up surveys to participate in semi-structured interviews.

RESULTS

After applying a thematic analysis, results show older Veterans are using medical cannabis as a means of harm reduction as an adjunct or substitute for other medications and substances with limited guidance from their healthcare providers. Veterans also reported that there exists an inconsistency across the Veterans Health Administration system regarding the interpretation and application of cannabis policies.

CONCLUSIONS

Drawing from these findings, we explore medical cannabis as a harm reduction technique and discuss how a lack of physician engagement and current Veterans Health Administration policies discourage older Veterans from discussing and potentially benefiting from the use of medical cannabis.

Sex Differences in Oxycodone/Naloxone vs. Tapentadol in Chronic Non-Cancer Pain: An Observational Real-World Study

Despite the large body of research on sex differences in pain, there is a lack of translation to real-world pain management. Our aim was to analyse the sex differences in the analgesic response to oxycodone/naloxone (OXN) and tapentadol (TAP), in comparison with other opioids (OPO) commonly prescribed for chronic non-cancer pain (CNCP). An observational and cross-sectional study was conducted on ambulatory CNCP patients (n = 571). Sociodemographic, clinical (pain intensity, relief, and quality of life), safety (adverse events (AEs), adverse drug reactions), hospital frequentations and pharmacological (morphine equivalent daily dose (MEDD)) variables were collected. Multiple linear regressions were carried out to assess the association between sex and outcomes. Sex differences were observed, with lower female tolerability and higher hospital frequentation, especially in the OXN group (OR AEs report = 2.8 [1.8−4.4], p < 0.001). Here, females showed higher hospital use (23% hospital admission, 30% prescription change, p < 0.05), requiring a higher MEDD (127 ± 103 mg/day, p < 0.05), compared to OXN men. Regardless of the opioid group, CNCP women were significantly older than men (three years), with significantly higher benzodiazepine use (OR = 1.6 [1.1−2.3]), more constipation (OR = 1.34 [0.93−1.90]) and headache (OR = 1.45 [0.99−2.13]) AEs, than men who were more likely to refer sexual dysfunction (OR = 2.77 [1.53−5.01]), and loss of libido (OR = 1.93 [1.22−3.04]). Sex-differences were found related to poorer female drug tolerability and higher hospital resources, even worst in OXN female users. Other differences related to older female ages and benzodiazepine prescription, need to be further analysed from a gender perspective.

OUP accepted manuscript

Objective

To review evidence from longitudinal studies on the association between prescription opioid use and common mood and anxiety symptoms.

Design

We conducted a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Methods

We searched PubMed, Embase, and PsycINFO for search terms related to opioids AND (depression OR bipolar OR anxiety OR post-traumatic stress disorder [PTSD]). Findings were summarized narratively, and random-effects meta-analyses were used to pool effect sizes.

Results

We identified 10,290 records and found 10 articles that met our inclusion criteria. Incidence studies showed that people who used prescription opioids had an elevated risk of any mood outcome (adjusted effect size [aES] = 1.80 [95% confidence interval = 1.40–2.30]) and of an anxiety outcome (aES = 1.40 [1.20–1.80]) compared with those who did not use prescription opioids. Associations with depression were small and not significant after adjustment for potential confounders (aES = 1.18 [0.98–1.41]). However, some studies reported an increased risk of depressive symptoms after increased (aES = 1.58 [1.30–1.93]) or prolonged opioid use (aES = 1.49 [1.19–1.86]).

Conclusions

Mental health should be considered when opioids are prescribed because some patients could be vulnerable to adverse mental health outcomes.

Marijuana use and high-risk health behaviors among diverse college students post- legalization of recreational marijuana use

Objectives

This study examined high-risk health behaviors in marijuana-users among a diverse college population in Southern California, post legalization of marijuana for recreational use.

Study design

A cross-sectional research design was employed utilizing existing data via the 2018 National College Health Assessment (NCHA) from a large Minority-Serving Institution (MSI) population [n = 1345 (Hispanic/Latino/a, n = 456; White, n = 353; Asian Pacific Islander (API), n = 288; Multiracial/Biracial, n = 195; Other, n = 53)].

Methods

Chi square and t-tests assessed differences in descriptive characteristics (age, gender, race/ethnicity and GPA) and high-risk behaviors (alcohol, tobacco and sexual behaviors) among marijuana users and non-users. Logistic regression analyses examined the relationship between race/ethnicity and high-risk behaviors with marijuana use (dependent variable).

Results

Among marijuana-users, significant (p = 0.004) differences were observed between race/ethnicity with Whites reporting using most (32.7%), followed by Hispanics (27.6%) and then APIs (17.8%). Marijuana-users compared with non-users consistently reported high-risk alcohol behaviors (p < 0.0001), were more likely to smoke tobacco (p < 0.0001) and engaged in more high-risk sexual behaviors (p < 0.0001). Logistic regression showed after adjusting for demographic characteristics and high-risk behaviors, race/ethnicity was borderline significantly associated with marijuana use, specifically for Whites (OR = 1.53; 95% CI: (−0.01, 0.86), p = 0.06) and the Other race/ethnicity category (OR = 2.32; 95% CI: (0.12, 1.56), p = 0.02) compared with APIs.

Conclusion

Our findings clearly demonstrate deleterious high-risk behaviors such as alcohol use, tobacco use, and certain sexual behaviors occur more among marijuana-users compared to non-users, post legalization of marijuana for recreational use. Further, race-ethnic differences were observed. Therefore, continued examination of marijuana use trends and high-risk behaviors is critical in monitoring the implications of marijuana policy changes, specifically in diverse populations.

New Persistent Opioid and Benzodiazepine Use After Curative-Intent Treatment in Patients With Breast Cancer

BACKGROUND

Opioid and benzodiazepine use and abuse is a national healthcare crisis to which patients with cancer are particularly vulnerable. Long-term use and risk factors for opioid and benzodiazepine use in patients with breast cancer is poorly characterized.

METHODS

We conducted a retrospective population-based study of patients with breast cancer diagnosed between 2008 and 2015 undergoing curative-intent treatment identified through the SEER-Medicare linked database. Primary outcomes were new persistent opioid use and new persistent benzodiazepine use. Factors associated with new opioid and benzodiazepine use were investigated by univariate and multivariable logistic regression.

RESULTS

Among opioid-naïve patients, new opioid use was observed in 22,418 (67.4%). Of this group, 611 (2.7%) developed persistent opioid use at 3 months and 157 (0.7%) at 6 months after treatment. Risk factors for persistent use at 3 and 6 months included stage III disease (odds ratio [OR], 2.16; 95% CI, 1.49-3.12, and OR, 3.48; 95% CI, 1.58-7.67), surgery plus chemotherapy (OR, 1.44; 95% CI, 1.10-1.88, and OR, 2.28; 95% CI, 1.40-3.71), surgery plus chemoradiation therapy (OR, 1.47; 95% CI, 1.10-1.96, and OR, 2.34; 95% CI, 1.38-3.96), and initial tramadol use (OR, 2.66; 95% CI, 2.05-3.46, and OR, 3.12; 95% CI, 1.93-5.04). Among benzodiazepine-naïve patients, new benzodiazepine use was observed in 955 (10.3%), and 111 (11.6%) developed new persistent use at 3 months. Tamoxifen use was statistically significantly associated with new persistent benzodiazepine use at 3 months.

CONCLUSIONS

A large percentage of patients receiving curative-intent treatment of breast cancer were prescribed new opioids; however, only a small number developed new persistent opioid use. In contrast, a smaller proportion of patients received a new benzodiazepine prescription; however, new persistent use after completion of treatment was more likely and particularly related to concurrent treatment with tamoxifen.

Chronic Opioid Therapy: A Scoping Literature Review on Evolving Clinical and Scientific Definitions

The management of chronic noncancer pain (CNCP) with chronic opioid therapy (COT) is controversial. There is a lack of consensus on how COT is defined resulting in unclear clinical guidance. This scoping review identifies and evaluates evolving COT definitions throughout the published clinical and scientific literature. Databases searched included PubMed, Embase, and Web of Science. A total of 227 studies were identified from 8,866 studies published between January 2000 and July 2019. COT definitions were classified by pain population of application and specific dosage/duration definition parameters, with results reported according to PRISMA-ScR. Approximately half of studies defined COT as "days' supply duration >90 days" and 9.3% defined as ">120 days' supply," with other days' supply cut-off points (>30, >60, or >70) each appearing in <5% of total studies. COT was defined by number of prescriptions in 63 studies, with 16.3% and 11.0% using number of initiations or refills, respectively. Few studies explicitly distinguished acute treatment and COT. Episode duration/dosage criteria was used in 90 studies, with 7.5% by Morphine Milligram Equivalents + days' supply and 32.2% by other "episode" combination definitions. COT definitions were applied in musculoskeletal CNCP (60.8%) most often, and typically in adults aged 18 to 64 (69.6%). The usage of ">90 days' supply" COT definitions increased from 3.2 publications/year before 2016 to 20.7 publications/year after 2016. An increasing proportion of studies define COT as ">90 days' supply." The most recent literature trends toward shorter duration criteria, suggesting that contemporary COT definitions are increasingly conservative. PERSPECTIVE: This study summarized the most common, current definition criteria for chronic opioid therapy (COT) and recommends adoption of consistent definition criteria to be utilized in practice and research. The most recent literature trends toward shorter duration criteria overall, suggesting that COT definition criteria are increasingly stringent.

Gender Differences in Suicide and Self-Directed Violence Risk Among Veterans With Post-traumatic Stress and Substance Use Disorders

BACKGROUND

Veterans have a high prevalence of both post-traumatic stress disorder (PTSD) and substance use disorders (SUDs), which are related to suicide risk. Exploring gender-related differences in suicidal behavior risk among this subgroup of veterans is important to improve prevention and treatment strategies. To date, few studies have explored these differences.

METHODS

The sample included 352,476 men and women veterans from the Women Veterans Cohort Study with a diagnosis of PTSD. First, we conducted analyses to assess gender-related differences in sociodemographic and clinical variables at baseline, as well as by suicidal behavior. Then, we conducted a series of Cox proportional hazards regression models to estimate the hazard ratios of engaging in self-directed violence (SDV) and dying by suicide by SUD status and gender, controlling for potential confounders.

RESULTS

Adjusted analyses showed that, among veterans with PTSD, the presence of a SUD significantly increased the risk of SDV and death by suicide. Women with PTSD had a decreased risk of dying by suicide compared with men. No gender-related difference was observed for SDV. SUD increased the risk of SDV behavior in both women and men but increased the risk of dying by suicide only among men.

CONCLUSIONS

Our findings revealed gender-related differences in SDV and suicide among veterans with a PTSD diagnosis with or without a SUD. Our study, along with the increasing numbers of women serving in the military, stresses the need to conduct gender-based analyses to help improve prevention and treatment strategies.

Center Predictors of Long-Term Benzodiazepine Use in Chronic Obstructive Pulmonary Disease and Post-traumatic Stress Disorder

Rationale: Symptoms of insomnia and anxiety are common among patients with chronic obstructive pulmonary disease (COPD), especially among patients with comorbid mental health disorders such as post-traumatic stress disorder (PTSD). Benzodiazepines provide temporary relief of these symptoms, but guidelines discourage routine use of benzodiazepines because of the serious risks posed by these medications. A more thorough understanding of guideline-discordant benzodiazepine use will be critical to reduce potentially inappropriate prescribing and its associated risks.Objectives: Examine the national prevalence, variability, and center correlates of long-term benzodiazepine prescriptions for patients with COPD and comorbid PTSD.Methods: We identified patients with COPD and PTSD between 2010 and 2012 who received care within the Department of Veterans Affairs. We used a mixed-effects logistic regression model to assess center predictors of long-term benzodiazepine prescriptions (≥90 d), while accounting for patient characteristics.Results: Of 43,979 patients diagnosed with COPD and PTSD at 129 centers, 24.4% were prescribed benzodiazepines long term, with use varying from 9.5% to 49.4% by medical center. Patients with long-term prescriptions were more likely to be white (90.1% vs. 80.7%) and have other mental health comorbidities, including generalized anxiety disorder (31.3% vs. 16.5%). Accounting for patient mix and characteristics, long-term benzodiazepine use was associated with lower patient-reported access to mental health care (odds ratio, 0.54; 95% confidence interval, 0.37-0.80).Conclusions: Long-term benzodiazepine prescribing is common among patients at high risk for complications, although this practice varies substantially from center to center. Poor access to mental health care is a potential driver of this guideline inconsistent use.

Post-traumatic Stress Disorder: A Review of Therapeutic Role of Meditation Interventions

This review is an attempt to provide a comprehensive view of post-traumatic-stress disorder (PTSD) and its therapy, focusing on the use of meditation interventions. PTSD is a multimodal psycho-physiological-behavioral disorder, which calls for the potential usefulness of spiritual therapy. Recent times witness a substantial scientific interest in an alternative mind-to-body psychobehavioral therapy; the exemplary of which is meditation. Meditation is a form of mental exercise that has an extensive, albeit still mostly empiric, therapeutic value. Meditation steadily gains an increasing popularity as a psychobehavioral adjunct to therapy in many areas of medicine and psychology. While the review does not provide a final or conclusive answer on the use of meditation in PTSD treatment we believe the available empirical evidence demonstrates that meditation is associated with overall reduction in PTSD symptoms, and it improves mental and somatic quality of life of PTSD patients. Therefore, studies give a clear cue for a trial of meditation-associated techniques as an adjunct to pharmacotherapy or standalone treatment in otherwise resistant cases of the disease.

Prescription Opioid Misuse After a Recent Sexual Assault: A Randomized Clinical Trial of a Video Intervention

BACKGROUND AND OBJECTIVES

Prescription opioid (PO) misuse is increasing and is associated with overdose. Individuals who experienced a recent sexual assault are at risk for increased substance use, yet limited interventions target PO misuse after sexual assault. The current study examined the efficacy of video interventions on PO misuse after sexual assault.

METHODS

Adolescent girls and women (n = 154) were recruited in the context of a sexual assault medical forensic exam in the emergency department. Effects of a prevention of post-rape stress (PPRS) video and a pleasant imagery and relaxation instruction (PIRI) video were compared with treatment as usual (TAU) during a sexual assault medical forensic exam on PO misuse. Participants reported if they had used POs for non-medical purposes since the sexual assault at 1.5 month follow-up.

RESULTS

Results from a logistic regression analysis indicated that participants with a prior sexual assault were less likely to misuse prescription opioids 1.5 months after the assault in the PIRI condition compared with TAU. There were no main effects for video condition and no interactions for the PPRS condition on PO misuse.

DISCUSSION AND CONCLUSIONS

Providing the PIRI video, or teaching other types of mindfulness or relaxation exercises, may be warranted as a secondary prevention for individuals during the sexual assault medical forensic exam for those with a prior sexual assault history.

SCIENTIFIC SIGNIFICANCE

This research provides an initial examination of the impact of mindfulness skills recently after traumatic event exposure on PO misuse. (Am J Addict 2019;28:376-381).

Assessing The Impact Of State Policies For Prescription Drug Monitoring Programs On High-Risk Opioid Prescriptions

Policies and practices have proliferated to optimize prescribers' use of their states' prescription drug monitoring programs, which are statewide databases of controlled substances dispensed at retail pharmacies. Our study assessed the effectiveness of three such policies: comprehensive legislative mandates to use the program, laws that allow prescribers to delegate its use to office staff, and state participation in interstate data sharing. Our analysis of information from a large commercial insurance database indicated that comprehensive use mandates implemented during 2011-15 were associated with a 6-9 percent reduction in opioid prescriptions with high risk for misuse and overdose. We also found delegate laws to be associated with reductions of a similar magnitude for selected outcomes. In general, the effects of all three policies strengthened over time, especially beginning in the second year after implementation. Our findings support comprehensive use mandates and delegate laws to optimize prescribers' use of drug monitoring programs, but the results will need updates in the context of evolving state opioid policies-including the increasing integration of drug monitoring data with electronic health records.

Relationship between concomitant benzodiazepine-opioid use and adverse outcomes among US veterans

Benzodiazepines and opioids are commonly used among veterans suffering from mental health disorders and pain conditions. The objective of this study is to determine whether concomitant benzodiazepine-opioid use increases the incidence of adverse outcomes above the baseline risk of nonacute opioid-only use. The dataset contained all veterans who filled at least 1 opioid prescription during the years 2008 to 2012. Nonacute opioid use was defined as having opioid prescriptions greater than or equal to 20 days within a 60-day period. Concomitant use was defined as having opioid and benzodiazepine prescriptions that overlapped for at least 7 days. Nonacute opioid-only users were matched to concomitant opioid-benzodiazepine users based on propensity scores. A 365-day observation period was used to identify adverse outcomes. The primary outcome examines the existence of one or more of the following outcomes: opioid-related accidents and overdoses, alcohol- and nonopioid drug-related accidents and overdoses, self-inflicted injuries, violence-related injuries, wounds/injuries overall, and death. A logistic propensity score adjusted regression controlling for propensity toward concomitant use was used to determine the association of concomitant use with adverse outcomes. The final matched sample consisted of 396,141 nonacute opioid-only using veterans and 48,971 concomitant benzodiazepine-opioid users. Receiving opioids and benzodiazepines concomitantly increased the risk of experiencing an adverse outcome with an odds ratio of 1.359 (95% confidence interval: 1.320-1.400; P < 0.0001). Among veterans receiving opioids, concomitant benzodiazepine use is associated with an increased risk of adverse outcomes when compared to the baseline risk of opioid-only using veterans.

Theranostic pharmacology in PTSD: Neurobiology and timing

Recent reviews and treatment guidelines regard trauma-focused cognitive-behavior therapies as the treatments of choice for chronic post-traumatic stress disorder (PTSD). However, many patients do not engage in this treatment when it is available, drop out before completion, or do not respond. Medications remain widely used, alone and in conjunction with psychotherapy, although the limitations of traditional monoamine-based pharmacotherapy are increasingly recognized. This article will review recent developments in psychopharmacology for PTSD, with a focus on current clinical data that apply putative neurobiologic mechanisms to medication use-i.e., a theranostic approach. A theranostic approach however, also requires consideration of timing, pre, peri or post trauma in conjunction with underlying dynamic processes affecting synaptic plasticity, the HPA axis, hippocampal activation, PFC-amygdala circuitry and fear memory.

Concomitant use of benzodiazepines and opioids in community-dwelling older people with or without Alzheimer's disease-A nationwide register-based study in Finland

OBJECTIVE

The study aims to determine the prevalence of concomitant use of benzodiazepines and opioids among community-dwelling older people with or without Alzheimer's disease (AD). An additional aim was to describe the factors associated with prolonged concomitant use, and the most commonly used combinations of these drugs.

METHODS

This study utilized data from the register-based Medication Use and Alzheimer's disease (MEDALZ) study, including all community-dwelling residents of Finland who received a clinically verified AD diagnosis between 2005 and 2011 (n = 70 718) and their matched comparison persons without AD. After exclusion of individuals who were hospitalized throughout the follow-up, 69 353 persons with and 69 353 without AD were included in this study.

RESULTS

Benzodiazepines and related drugs (BZDRs) were used by 28 475 (41.1%) of those with and 24 506 (35.3%) of those without AD. Prolonged (greater than or equal to 90 days) concomitant use of BZDRs and opioids was more common among BZDR users without AD (N = 3936; 16.1%) than among those with AD (N = 2963; 10.4%). A shorter duration of concomitant use (1-89 days) revealed similar results, N = 3821; 15.6% and N = 3008; 10.6%, respectively. Prolonged concomitant use of BZDRs and opioids was associated with female sex, low socioeconomic position, most of the common comorbidities and history of substance abuse or long-term benzodiazepine use. The most commonly used combinations were Z-drug (31.7%) or benzodiazepine (29.9%) with a weak opioid.

CONCLUSIONS

Despite the recommendations and risks, the prevalence of concomitant BZDR and opioid use was common in older persons with or without AD. It is important to develop strategies to reduce unnecessary concomitant use of these drugs.

First Opioid Prescription and Subsequent High-Risk Opioid Use: a National Study of Privately Insured and Medicare Advantage Adults

BACKGROUND

National guidelines make recommendations regarding the initial opioid prescriptions, but most of the supporting evidence is from the initial episode of care, not the first prescription.

OBJECTIVE

To examine associations between features of the first opioid prescription and high-risk opioid use in the 18 months following the first prescription.

DESIGN

Retrospective cohort study using data from a large commercial insurance claims database for 2011-2014 to identify individuals with no recent use of opioids and follow them for 18 months after the first opioid prescription.

PARTICIPANTS

Privately insured patients aged 18-64 and Medicare Advantage patients aged 65 or older who filled a first opioid prescription between 07/01/2011 and 06/30/2013.

MAIN OUTCOMES AND MEASURES

High-risk opioid use was measured by having (1) opioid prescriptions overlapping for 7 days or more, (2) opioid and benzodiazepine prescriptions overlapping for 7 days or more, (3) three or more prescribers of opioids, and (4) a daily dosage exceeding 120 morphine milligram equivalents, in each of the six quarters following the first prescription.

KEY RESULTS

All three features of the first prescription were strongly associated with high-risk use. For example, among privately insured patients, receiving a long- (vs. short-) acting first opioid was associated with a 16.9-percentage-point increase (95% CI, 14.3-19.5), a daily MME of 50 or more (vs. less than 30) was associated with a 12.5-percentage-point increase (95% CI, 12.1-12.9), and a supply exceeding 7 days (vs. 3 or fewer days) was associated with a 4.8-percentage-point increase (95% CI, 4.5-5.2), in the probability of having a daily dosage of 120 MMEs or more in the long term, compared to a sample mean of 4.2%. Results for the Medicare Advantage patients were similar.

CONCLUSIONS

Long-acting formulation, high daily dosage, and longer duration of the first opioid prescription were each associated with increased high-risk use of opioids in the long term.

Traumatic Brain Injury and Receipt of Prescription Opioid Therapy for Chronic Pain in Iraq and Afghanistan Veterans: Do Clinical Practice Guidelines Matter?

Clinical practice guidelines admonish against prescribing opioids for individuals with chronic pain and traumatic brain injury (TBI) because of increased risk for adverse outcomes, yet no studies have described opioid prescribing patterns in these higher-risk patients. Between October 2007 and March 2015, 53,124 Iraq and Afghanistan veterans with chronic pain not prescribed opioids in the previous year were followed for 1 year after completing a Comprehensive TBI Evaluation within the Department of Veterans Affairs health care facilities. Veterans reporting the most severe TBI sequelae (eg, loss of consciousness >30 minutes) were significantly more likely to receive short-term and long-term opioid therapy than those with less severe or no TBI sequelae (P values < .001). In analyses adjusted for sociodemographic characteristics, military service, pain disability, and previous nonopioid treatment modalities, veterans with moderate to severe TBI had a significantly increased risk of receiving opioid therapy. Veterans with moderate to severe TBI and comorbid post-traumatic stress disorder and depression had an even greater risk of initiating long-term opioid therapy in the year after the Comprehensive TBI Evaluation (adjusted relative risk = 3.57 [95% confidence interval = 2.85-4.47]). Higher-risk patients with chronic pain and TBI with mental health comorbidities may benefit from improved access to behavioral health and nonpharmacological therapies for chronic pain.

PERSPECTIVE

Paradoxically, veterans with greater TBI severity and comorbid mental health burden are more likely to be prescribed opioids for chronic pain. More vulnerable veterans may benefit from improved access to behavioral health and nonpharmacological modalities for chronic pain, because of the health and safety risks of opioids.

Cultivating change door to door: Educational outreach to improve prescribing practices in rural veterans with posttraumatic stress disorder

BACKGROUND

Clinical guidelines for the management of posttraumatic stress disorder (PTSD) recommend against the use of benzodiazepines. Benzodiazepines and PTSD are both associated with addiction-related risks. The Department of Veterans Affairs (VA) prescribing trends show continued use of benzodiazepines and polysedative use in veterans with PTSD, particularly in rural areas. The authors examine the use of an educational intervention to improve pharmacologic management of veterans with PTSD in rural clinics.

METHODS

The VA Academic Detailing Service Informatics Toolset provides prescribing, demographic and risk factor data for veterans with PTSD treated at the White River Junction VA Medical Center (WRJ VA) and affiliated rural clinics in Vermont and New Hampshire. Individualized academic detailing visits were provided to clinicians identified by the informatics tool with the aim of increasing guideline-concordant care. Other educational efforts included traditional, didactic group education on evidence-based PTSD care and the development and dissemination of educational materials for clinicians and patients. Prescribing trends of benzodiazepines, off-label atypical antipsychotics, and prazosin were collected quarterly for 3 years (October 1, 2013, to September 30, 2016).

RESULTS

Prescribing rates of benzodiazepines during the educational intervention decreased from 13% to 9.3%. Use of off-label atypical antipsychotics, a class of medications not recommended for PTSD, stayed relatively flat at about 10%. Prescribing of prazosin, a medication recommended for treatment of trauma nightmares, increased from 9.8% to 14.3%.

CONCLUSIONS

Academic detailing and other educational programming appear to be effective for addressing gaps and lag in quality PTSD care and are associated with a positive trend of decreased benzodiazepine use. Efforts will continue, now with added focus on concurrent use of benzodiazepines and opioids and the use of off-label atypical antipsychotics in rural veterans with PTSD.

Endogenous Opiates and Behavior: 2016

This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.

US Epidemiology of Cannabis Use and Associated Problems

This review provides an overview of the changing US epidemiology of cannabis use and associated problems. Adults and adolescents increasingly view cannabis as harmless, and some can use cannabis without harm. However, potential problems include harms from prenatal exposure and unintentional childhood exposure; decline in educational or occupational functioning after early adolescent use, and in adulthood, impaired driving and vehicle crashes; cannabis use disorders (CUD), cannabis withdrawal, and psychiatric comorbidity. Evidence suggests national increases in cannabis potency, prenatal and unintentional childhood exposure; and in adults, increased use, CUD, cannabis-related emergency room visits, and fatal vehicle crashes. Twenty-nine states have medical marijuana laws (MMLs) and of these, 8 have recreational marijuana laws (RMLs). Many studies indicate that MMLs or their specific provisions did not increase adolescent cannabis use. However, the more limited literature suggests that MMLs have led to increased cannabis potency, unintentional childhood exposures, adult cannabis use, and adult CUD. Ecological-level studies suggest that MMLs have led to substitution of cannabis for opioids, and also possibly for psychiatric medications. Much remains to be determined about cannabis trends and the role of MMLs and RMLs in these trends. The public, health professionals, and policy makers would benefit from education about the risks of cannabis use, the increases in such risks, and the role of marijuana laws in these increases.

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015)

BACKGROUND

Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning.

METHODS

The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps.

RESULTS

We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials.

CONCLUSIONS

Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

The effect of post-traumatic stress disorder on the risk of developing prescription opioid use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III

OBJECTIVE

To evaluate the effect of baseline post-traumatic stress disorder (PTSD) and each symptoms cluster on the risk of developing opioid use disorder (OUD) in those exposed to opioid painkillers and to assess the effect of comorbid PTSD and OUD on functioning, OUD severity, and treatment seeking compared with individuals with OUD only.

METHODS

We obtained data from 4025 individuals exposed to opioid painkillers from the National Epidemiologic Survey on Alcohol and Related Conditions III. We matched individuals with baseline PTSD with individuals without PTSD on demographics, developmental background, family history, personalities, and exposure to stressful life events with propensity score methodology. We controlled for clinical diagnoses and other risk factors that may have occurred after PTSD onset. Quality of life was assessed with the SF-12; the number of diagnostic criteria met indicated OUD severity.

RESULTS

Baseline PTSD predicted OUD after controlling for matching variables and other risk factors, including baseline mood/anxiety disorders and other substance use disorders (odds ratio[OR]: 1.58; 95% confidence interval[CI]: 1.14-2.17; p=0.02). Among individuals with PTSD, arousal/reactivity cluster predicted OUD. Individuals with comorbid PTSD and OUD had lower mean scores on the SF-12 scale and greater severity of OUD than individuals with OUD. There were no differences in help-seeking.

CONCLUSION

Baseline PTSD increases the risk of developing OUD after exposure to opioid painkillers. Clinicians should screen for PTSD diagnosis and arousal/reactivity symptoms prior to prescribing painkillers. Integrated treatments are strongly recommended for patients with this dual diagnosis.

Medication Overuse in Chronic Pain

PURPOSE OF REVIEW

Chronic pain is usually managed by various pharmacotherapies after exhausting the conservative modalities such as over-the-counter choices. The goal of this review is to investigate current state of opioids and non-opioid medication overuse that includes NSAIDs, skeletal muscle relaxants, antidepressants, membrane stabilization agents, and benzodiazepine. How to minimize medication overuse and achieve better outcome in chronic pain management?

RECENT FINDINGS

Although antidepressants and membrane stabilization agents contribute to the crucial components for neuromodulation, opioids were frequently designated as a rescue remedy in chronic pain since adjunct analgesics usually do not provide instantaneous relief. The updated CDC guideline for prescribing opioids has gained widespread attention via media exposure. Both patients and prescribers are alerted to respond to the opioid epidemic and numerous complications. However, there has been overuse of non-opioid adjunct analgesics that caused significant adverse effects in addition to concurrent opioid consumption. It is a common practice to extrapolate the WHO three-step analgesic ladder for cancer pain to apply in non-cancer pain that emphasizes solely on pharmacologic therapy which may result in overuse and escalation of opioids in non-cancer pain. There has been promising progress in non-pharmacologic therapies such as biofeedback, complementary, and alternative medicine to facilitate pain control instead of dependency on pharmacologic therapies. This review article presents the current state of medication overuse in chronic pain and proposes precaution to balance the risk and benefit ratio. It may serve as a premier for future study on clinical pathway for comprehensive chronic pain management and reduce medication overuse.

Co-prescription of opioids with benzodiazepine and other co-medications among opioid users: differential in opioid doses

Purpose

This study investigated the patterns of opioid co-prescription with benzodiazepine and other concomitant medications among opioid users. Opioid dose in each type of co-prescription was also examined.

Patients and methods

This cross-sectional study was conducted among opioid users receiving concomitant medications at an outpatient tertiary hospital setting in Malaysia. Opioid prescriptions (morphine, fentanyl, oxycodone, dihydrocodeine and tramadol) that were co-prescribed with other medications (opioid + benzodiazepines, opioid + antidepressants, opioid + anticonvulsants, opioid + antipsychotics and opioid + hypnotics) dispensed from January 2013 to December 2014 were identified. The number of patients, number of co-prescriptions and the individual mean opioid daily dose in each type of co-prescription were calculated.

Results

A total of 276 patients receiving 1059 co-prescription opioids with benzodiazepine and other co-medications were identified during the study period. Of these, 12.3% of patients received co-prescriptions of opioid + benzodiazepine, 19.3% received opioid + anticonvulsant, 6.3% received opioid + antidepressant and 10.9% received other co-prescriptions, including antipsychotics and hypnotics. The individual mean opioid dose was <100 mg/d of morphine equivalents in all types of co-prescriptions, and the dose ranged from 31 to 66 mg/d in the co-prescriptions of opioid + benzodiazepine.

Conclusion

Among the opioid users receiving concomitant medications, the co-prescriptions of opioid with benzodiazepine were prescribed to 12.3% of patients, and the individual opioid dose in this co-prescription was moderate. Other co-medications were also commonly used, and their opioid doses were within the recommended dose. Future studies are warranted to evaluate the adverse effect and clinical outcomes of the co-medications particularly in long-term opioid users with chronic non-cancer pain.

Comorbidities and concurrent medications increasing the risk of adverse drug reactions: prevalence in French benzodiazepine users

PURPOSE

To estimate benzodiazepine prevalence of use and to quantify, in benzodiazepine users, the prevalence of comorbidities and concurrent medications increasing the risk of adverse drug reactions (ADRs).

METHODS

Cross-sectional study performed using data from the French national healthcare insurance system. The prevalence of use was estimated by considering as users, patients who had at least one benzodiazepine reimbursement during the year 2013. Patients at increased risk for benzodiazepine ADRs were those who had (i) drug-drug interactions at risk for central nervous system and respiratory depression and (ii) comorbidities at risk for adverse respiratory effects, or for falls or fractures.

RESULTS

Overall, the prevalence of benzodiazepine use in 2013 was estimated to be 13.8 %; it was higher among women and increased with age. This prevalence was 10.6 % for anxiolytic benzodiazepines, and 6.1 % for hypnotic benzodiazepines. Approximately half of the benzodiazepine users (48.1 %) were at increased risk for benzodiazepine ADRs; this proportion increased with age. Drug-drug interactions represented the most prevalent condition (39.3 % of benzodiazepine users). The drugs most frequently involved were opioids: analgesics (15.9 %) and antitussives (6.8 %). Overall, 11.3 % of benzodiazepine users had comorbidities at increased risk for adverse respiratory effects (13.9 % in those aged 65-79), and 7.0 % comorbidities at increased risk for falls or fractures (13.4 % in those aged ≥80).

CONCLUSIONS

This study found that benzodiazepine use remained high in France, and that roughly half of the users presented with comorbidities and concurrent medications increasing the risk of ADRs. These findings are of concern, given that benzodiazepines are frequently used, and especially among the elderly.