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Lee IH, Kim SY, Park S, Ryu JG, Je NK. Impact of the Narcotics Information Management System on Opioid Use Among Outpatients With Musculoskeletal and Connective Tissue Disorders: Quasi-Experimental Study Using Interrupted Time Series. JMIR Public Health Surveill 2024; 10:e47130. [PMID: 38381481 PMCID: PMC10918548 DOI: 10.2196/47130] [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: 03/09/2023] [Revised: 09/09/2023] [Accepted: 01/07/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Opioids have traditionally been used to manage acute or terminal pain. However, their prolonged use has the potential for abuse, misuse, and addiction. South Korea introduced a new health care IT system named the Narcotics Information Management System (NIMS) with the objective of managing all aspects of opioid use, including manufacturing, distribution, sales, disposal, etc. OBJECTIVE This study aimed to assess the impact of NIMS on opioid use. METHODS We conducted an analysis using national claims data from 45,582 patients diagnosed with musculoskeletal and connective tissue disorders between 2016 and 2020. Our approach included using an interrupted time-series analysis and constructing segmented regression models. Within these models, we considered the primary intervention to be the implementation of NIMS, while we treated the COVID-19 outbreak as the secondary event. To comprehensively assess inappropriate opioid use, we examined 4 key indicators, as established in previous studies: (1) the proportion of patients on high-dose opioid treatment, (2) the proportion of patients receiving opioid prescriptions from multiple providers, (3) the overlap rate of opioid prescriptions per patient, and (4) the naloxone use rate among opioid users. RESULTS During the study period, there was a general trend of increasing opioid use. After the implementation of NIMS, significant increases were observed in the trend of the proportion of patients on high-dose opioid treatment (coefficient=0.0271; P=.01) and in the level of the proportion of patients receiving opioid prescriptions from multiple providers (coefficient=0.6252; P=.004). An abrupt decline was seen in the level of the naloxone use rate among opioid users (coefficient=-0.2968; P=.04). While these changes were statistically significant, their clinical significance appears to be minor. No significant changes were observed after both the implementation of NIMS and the COVID-19 outbreak. CONCLUSIONS This study suggests that, in its current form, the NIMS may not have brought significant improvements to the identified indicators of opioid overuse and misuse. Additionally, the COVID-19 outbreak exhibited no significant influence on opioid use patterns. The absence of real-time monitoring feature within the NIMS could be a key contributing factor. Further exploration and enhancements are needed to maximize the NIMS' impact on curbing inappropriate opioid use.
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Affiliation(s)
- Iyn-Hyang Lee
- College of Pharmacy, Yeungnam University, Gyeongsan, Republic of Korea
| | - So Young Kim
- Department of Pharmacy, Kosin University Gospel Hospital, Busan, Republic of Korea
| | - Susin Park
- College of Pharmacy, Woosuk University, Wanju, Republic of Korea
| | - Jae Gon Ryu
- Department of Pharmacy, Sungkyunkwan University Samsung Changwon Hospital, Changwon, Republic of Korea
| | - Nam Kyung Je
- College of Pharmacy, Pusan National University, Busan, Republic of Korea
- Research Institute for Drug Development, Pusan National University, Busan, Republic of Korea
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Ndai AM, Morris EJ, Winterstein AG, Vouri SM. Evaluating Provider and Pharmacy Discordance in Potential Calcium Channel Blocker-Loop Diuretic Prescribing Cascade. Drugs Aging 2024; 41:177-186. [PMID: 38252391 DOI: 10.1007/s40266-023-01091-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Prescribing cascades occur when a drug-induced adverse event is treated with a new medication. Identifying clinical scenarios in which prescribing cascades are more likely to occur may help determine ways to prevent prescribing cascades. OBJECTIVE To understand the extent to which discordant providers and discordant pharmacies contribute to the dihydropyridine calcium channel blocker (DH CCB)-loop diuretic prescribing cascade. STUDY POPULATION AND DESIGN A retrospective cohort study using Medicare Fee-For-Service data (2011-2018) of adults aged ≥ 66 years. EXPOSURES Patients who initiated DH CCB with subsequent initiation of loop diuretic (DH CCB-loop diuretic dyad) within 90 days or patients who initiated angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) with subsequent initiation of a loop diuretic (ACEI/ARB-loop diuretic dyad; control). MAIN OUTCOMES The primary outcomes were provider and pharmacy discordance for prescribing cascades and control drug pairs. Baseline clinical and socio-demographic characteristics were balanced using inverse probability of treatment weighting with propensity scores. RESULTS Overall, we identified 1987 DH CCB-loop diuretic dyads and 3148 ACEI/ARB-loop diuretic dyads. Discordant providers occurred in 64% of DH CCB-loop diuretic dyads and 55% of ACEI/ARB-loop diuretic dyads, while discordant pharmacies occurred in 19% of DH CCB-loop diuretic dyads and 16% of ACEI/ARB-loop diuretic dyads. After adjustment, the risk of having discordant providers was 20% {Relative Risk (RR) 1.20 [95% confidence interval (CI), 1.14-1.26]} higher in the DH CCB-loop diuretic dyad compared with the ACEI/ARB-loop diuretic dyad. Moreover, pharmacy discordance was 17% (RR 1.17 [95% CI 1.02-1.33]) higher. CONCLUSION Our findings suggest that discordant providers and discordant pharmacies were more commonly involved in the potential prescribing cascade when compared with a similar control dyad of medications. Opportunities for enhanced care coordination and medication reconciliation should be explored to prevent unnecessary polypharmacy.
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Affiliation(s)
- Asinamai M Ndai
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA
| | - Earl J Morris
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA.
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA.
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Sharif L, Gunaseelan V, Lagisetty P, Bicket M, Waljee J, Englesbe M, Brummett CM. High-risk Prescribing Following Surgery Among Payer Types for Patients on Chronic Opioids. Ann Surg 2023; 278:1060-1067. [PMID: 37335197 DOI: 10.1097/sla.0000000000005938] [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: 06/21/2023]
Abstract
OBJECTIVE Among those on chronic opioids, to determine whether patients with Medicaid coverage have higher rates of high-risk opioid prescribing following surgery compared with patients on private insurance. BACKGROUND Following surgery, patients on chronic opioids experience gaps in transitions of care back to their usual opioid prescriber, but differences by payer type are not well understood. This study aimed to analyze how new high-risk opioid prescribing following surgery compares between Medicaid and private insurance. METHODS In this retrospective cohort study through the Michigan Surgical Quality Collaborative, perioperative data from 70 hospitals across Michigan were linked to prescription drug monitoring program data. Patients with either Medicaid or private insurance were compared. The outcome of interest was new high-risk prescribing, defined as a new occurrence of: overlapping opioids or benzodiazepines, multiple prescribers, high daily doses, or long-acting opioids. Data were analyzed using multivariable regressions and a Cox regression model for return to usual prescriber. RESULTS Among 1435 patients, 23.6% (95% CI: 20.3%-26.8%) with Medicaid and 22.7% (95% CI: 19.8%-25.6%) with private insurance experienced new, postoperative high-risk prescribing. New multiple prescribers was the greatest contributing factor for both payer types. Medicaid insurance was not associated with higher odds of high-risk prescribing (odds ratio: 1.067, 95% CI: 0.813-1.402). CONCLUSIONS Among patients on chronic opioids, new high-risk prescribing following surgery was high across payer types. This highlights the need for future policies to curb high-risk prescribing patterns, particularly in vulnerable populations that are at risk of greater morbidity and mortality.
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Affiliation(s)
- Limi Sharif
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
| | - Pooja Lagisetty
- Department of Medicine, Michigan Medicine, Ann Arbor, MI
- Center for Clinical Management and Research, Ann Arbor, MI
- Institute for Healthcare Innovation and Policy, Ann Arbor, MI
| | - Mark Bicket
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Institute for Healthcare Innovation and Policy, Ann Arbor, MI
- School of Public Health, University of Michigan, Ann Arbor, MI
| | - Jennifer Waljee
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Michael Englesbe
- Department of Medicine, Michigan Medicine, Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Chad M Brummett
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
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Soeiro T, Pradel V, Lapeyre-Mestre M, Micallef J. Systematic assessment of non-medical use of prescription drugs using doctor-shopping indicators: A nation-wide, repeated cross-sectional study. Addiction 2023; 118:1984-1993. [PMID: 37203878 DOI: 10.1111/add.16261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 05/04/2023] [Indexed: 05/20/2023]
Abstract
AIMS The aim of this study was to present the first nation-wide, systematic, repeated assessment of doctor-shopping (i.e. visiting multiple physicians to be prescribed the same drug) during 10 years for more than 200 psychoactive prescription drugs in the 67 million inhabitants in France. DESIGN This was a nation-wide, repeated cross-sectional study. SETTING AND PARTICIPANTS Data are from the French National Health Data System in 2010, 2015 and 2019 for 214 psychoactive prescription drugs (i.e. anaesthetics, analgesics, antiepileptics, anti-Parkinson drugs, psycholeptics, psychoanaleptics, other nervous system drugs and antihistamines for systemic use). MEASUREMENTS The detection and quantification of doctor-shopping relied upon an algorithm that detects overlapping prescriptions from repeated visits to different physicians. We used two doctor-shopping indicators aggregated at population level for each drug dispensed to more than 5000 patients: (i) the quantity doctor-shopped, expressed in defined daily doses (DDD), which measures the total quantity doctor-shopped by the study population for a given drug; and (ii) the proportion doctor-shopped, expressed as a percentage, which standardizes the quantity doctor-shopped according to the use level of the drug. FINDINGS The analyses included approximately 200 million dispensings to approximately 30 million patients each year. Opioids (e.g. buprenorphine, methadone, morphine, oxycodone and fentanyl), benzodiazepines and non-benzodiazepine hypnotics (Z-drugs) (e.g. diazepam, oxazepam, zolpidem and clonazepam) had the highest proportions doctor-shopped during the study period. In most cases, the proportion and the quantity doctor-shopped increased for opioids and decreased for benzodiazepines and Z-drugs. Pregabalin had the sharpest increase in the proportion doctor-shopped (from 0.28 to 1.40%), in parallel with a sharp increase in the quantity doctor-shopped (+843%, from 0.7 to 6.6 DDD/100 000 inhabitants/day). Oxycodone had the sharpest increase in the quantity doctor-shopped (+1000%, from 0.1 to 1.1 DDD/100 000 inhabitants/day), in parallel with a sharp increase in the proportion doctor-shopped (from 0.71 to 1.41%). Detailed results for all drugs during the study period can be explored interactively at: https://soeiro.gitlab.io/megadose/. CONCLUSIONS In France, doctor-shopping occurs for many drugs from many pharmacological classes, and mainly involves opioid maintenance drugs, some opioids analgesics, some benzodiazepines and Z-drugs and pregabalin.
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Affiliation(s)
- Thomas Soeiro
- Aix-Marseille Université, Inserm, Marseille, France
- Unité de pharmacoépidémiologie, Service de pharmacologie clinique, Hôpitaux universitaires de Marseille, Marseille, France
- Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Service de pharmacologie clinique, Hôpitaux universitaires de Marseille, Marseille, France
| | - Vincent Pradel
- Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Service de pharmacologie clinique, Hôpitaux universitaires de Marseille, Marseille, France
| | - Maryse Lapeyre-Mestre
- Université de Toulouse, Inserm, Toulouse, France
- Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Service de pharmacologie clinique, Centre hospitalier universitaire de Toulouse, Toulouse, France
| | - Joëlle Micallef
- Aix-Marseille Université, Inserm, Marseille, France
- Unité de pharmacoépidémiologie, Service de pharmacologie clinique, Hôpitaux universitaires de Marseille, Marseille, France
- Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Service de pharmacologie clinique, Hôpitaux universitaires de Marseille, Marseille, France
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Vann MA. The future of ambulatory surgery for geriatric patients. Best Pract Res Clin Anaesthesiol 2023; 37:343-355. [PMID: 37938081 DOI: 10.1016/j.bpa.2022.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/07/2022] [Accepted: 12/28/2022] [Indexed: 01/06/2023]
Abstract
The elderly segment of the population is growing rapidly worldwide. Older patients comprise a disproportionate percentage of the surgical caseload. Physiological changes are inevitable with aging; some may impact a patient's response to anesthesia and surgery. Careful evaluation of an elderly patient preoperatively is vital to proper patient selection for ambulatory surgeries, particularly for complex and lengthy procedures. Cognitive issues, frailty, and geriatric syndromes make a patient vulnerable and sometimes unsuitable for certain ambulatory procedures. Preoperative planning and interventions may improve outcomes for the elderly patient undergoing ambulatory surgery.
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Affiliation(s)
- Mary Ann Vann
- Department of Anesthesia, Pain, and Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA.
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Séguin DJG, Peschken CA, Dolovich C, Grymonpre RE, St John PD, Tisseverasinghe A. Polypharmacy and Potentially Inappropriate Medication Use in Older Adults With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2023; 75:356-364. [PMID: 34369087 DOI: 10.1002/acr.24766] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 06/28/2021] [Accepted: 08/05/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the prevalence and potential risk factors for polypharmacy and prescribing of the potentially inappropriate medications, opioids and benzodiazepines/Z-drugs, in older adults with systemic lupus erythematosus (SLE). METHODS The study population comprised adults age ≥50 years meeting American College of Rheumatology or Systemic Lupus International Collaborating Clinics classification criteria followed at a tertiary care rheumatology clinic. Information on prescriptions filled in the 4 months preceding chart review was obtained from the Manitoba Drug Program Information Network. Clinical data, including age, sex, Charlson Comorbidity Index (CCI) score, Systemic Lupus Erythematosus Disease Activity Index 2000 score, prednisone use, SLE duration, and rural residence were abstracted from electronic medical records. Logistic regression analyses were performed to assess any association between polypharmacy (using 2 definitions: ≥5 and ≥10 medications), potentially inappropriate medication use, and clinical features. RESULTS A total of 206 patients (mean age 62 years, 91% female, 36% rural) were included: 148 (72%) filled ≥5 medications, 71 (35%) filled ≥10 medications, 63 (31%) used benzodiazepines/Z-drugs, and 50 (24%) used opioids. Among the 77 patients age ≥65 years, 57 (74%) filled ≥5 medications, and 26 (34%) filled ≥10 medications, compared to 30% and 4%, respectively, of Manitobans age ≥65 years (National Prescription Drug Utilization Information System, 2016). The odds of polypharmacy were greater with prednisone use (adjusted odds ratio [OR] 3.70 [95% confidence interval (95% CI) 1.40-9.79] for ≥5 medications), CCI score (adjusted OR 1.62 [95% CI 1.20-2.17]), and rural residence (adjusted OR 2.05 [95% CI 1.01-4.18]). Odds of benzodiazepine/Z-drug use were increased with polypharmacy (adjusted OR 4.35 [95% CI 1.69-11.22]), and odds of opioid use were increased with polypharmacy (adjusted OR 6.75 [95% CI 1.93-23.69]) and CCI score (adjusted OR 1.29 [95% CI 1.08-1.54]). CONCLUSION The prevalence of polypharmacy in this SLE cohort was higher than in the general Manitoban population. Polypharmacy is a strong marker for use of prescription benzodiazepines/Z-drugs and opioids.
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Affiliation(s)
- Dale Jean-Guy Séguin
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Christine A Peschken
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Cassandra Dolovich
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ruby E Grymonpre
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Philip D St John
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Olfson M, Waidmann T, King M, Pancini V, Schoenbaum M. Population-Based Opioid Prescribing and Overdose Deaths in the USA: an Observational Study. J Gen Intern Med 2023; 38:390-398. [PMID: 35657466 PMCID: PMC9905341 DOI: 10.1007/s11606-022-07686-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/20/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Rising opioid-related death rates have prompted reductions of opioid prescribing, yet limited data exist on population-level associations between opioid prescribing and opioid-related deaths. OBJECTIVE To evaluate population-level associations between five opioid prescribing measures and opioid-related deaths. DESIGN An ecological panel analysis was performed using linear regression models with year and commuting zone fixed effects. PARTICIPANTS People ≥10 years aggregated into 886 commuting zones, which are geographic regions collectively comprising the entire USA. MAIN MEASURES Annual opioid prescriptions were measured with IQVIA Real World Longitudinal Prescription Data including 76.5% (2009) to 90.0% (2017) of US prescriptions. Prescription measures included opioid prescriptions per capita, percent of population with ≥1 opioid prescription, percent with high-dose prescription, percent with long-term prescription, and percent with opioid prescriptions from ≥3 prescribers. Outcomes were age- and sex-standardized associations of change in opioid prescriptions with change in deaths involving any opioids, synthetics other than methadone, heroin but not synthetics or methadone, and prescription opioids, but not other opioids. KEY RESULTS Change in total regional opioid-related deaths was positively correlated with change in regional opioid prescriptions per capita (β=.110, p<.001), percent with ≥1 opioid prescription (β=.100, p=.001), and percent with high-dose prescription (β=.081, p<.001). Change in total regional deaths involving prescription opioids was positively correlated with change in all five opioid prescribing measures. Conversely, change in total regional deaths involving synthetic opioids was negatively correlated with change in percent with long-term opioid prescriptions and percent with ≥3 prescribers, but not for persons ≥45 years. Change in total regional deaths in heroin was not associated with change in any prescription measure. CONCLUSIONS Regional decreases in opioid prescriptions were associated with declines in overdose deaths involving prescription opioids, but were also associated with increases in deaths involving synthetic opioids (primarily fentanyl). Individual-level inferences are limited by the ecological nature of the analysis.
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Affiliation(s)
- Mark Olfson
- New York State Psychiatric Institute/Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons, 1051 Riverside Drive, New York, NY, USA.
- Columbia University Mailman School of Public Health, New York, NY, USA.
| | | | - Marissa King
- School of Management, Yale University, New Haven, CT, USA
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Kakatkar S, Narayan A, Balkrishnan R. Prescription analgesic overuse in older adults: Can we mitigate this growing problem? Aging Med (Milton) 2022; 5:294-296. [PMID: 36606265 PMCID: PMC9805287 DOI: 10.1002/agm2.12228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
With older adults already on numerous prescription medications to manage their chronic conditions, the addition of pain medications could impose an even greater burden due to dependency issues. We need to understand the use of chronic pain medication, especially opioids, discuss current strategies and gaps, and offer potential solutions to mitigate overuse among older adults.
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Affiliation(s)
- Sara Kakatkar
- Department of Public Health SciencesUniversity of Virginia School of MedicineCharlottesvilleVirginiaUSA
| | - Aditya Narayan
- Department of Public Health SciencesUniversity of Virginia School of MedicineCharlottesvilleVirginiaUSA
| | - Rajesh Balkrishnan
- Department of Public Health SciencesUniversity of Virginia School of MedicineCharlottesvilleVirginiaUSA
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Cen X, Jena AB, Mackey S, Sun EC. Surgeon Variation in Perioperative Opioid Prescribing and Medium- or Long-term Opioid Utilization after Total Knee Arthroplasty: A Cross-sectional Analysis. Anesthesiology 2022; 137:151-162. [PMID: 35503990 PMCID: PMC9991517 DOI: 10.1097/aln.0000000000004259] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Whether a particular surgeon's opioid prescribing behavior is associated with prolonged postoperative opioid use is unknown. This study tested the hypothesis that the patients of surgeons with a higher propensity to prescribe opioids are more likely to utilize opioids long-term postoperatively. METHODS The study identified 612,378 Medicare fee-for-service patients undergoing total knee arthroplasty between January 1, 2011, and December 31, 2016. "High-intensity" surgeons were defined as those whose patients were, on average, in the upper quartile of opioid utilization in the immediate perioperative period (preoperative day 7 to postoperative day 7). The study then estimated whether patients of high-intensity surgeons had higher opioid utilization in the midterm (postoperative days 8 to 90) and long-term (postoperative days 91 to 365), utilizing an instrumental variable approach to minimize confounding from unobservable factors. RESULTS In the final sample of 604,093 patients, the average age was 74 yr (SD 5), and there were 413,121 (68.4%) females. A total of 180,926 patients (30%) were treated by high-intensity surgeons. On average, patients receiving treatment from a high-intensity surgeon received 36.1 (SD 35.0) oral morphine equivalent (morphine milligram equivalents) per day during the immediate perioperative period compared to 17.3 morphine milligram equivalents (SD 23.1) per day for all other patients (+18.9 morphine milligram equivalents per day difference; 95% CI, 18.7 to 19.0; P < 0.001). After adjusting for confounders, receiving treatment from a high-intensity surgeon was associated with higher opioid utilization in the midterm opioid postoperative period (+2.4 morphine milligram equivalents per day difference; 95% CI, 1.7 to 3.2; P < 0.001 [11.4 morphine milligram equivalents per day vs. 9.0]) and lower opioid utilization in the long-term postoperative period (-1.0 morphine milligram equivalents per day difference; 95% CI, -1.4 to -0.6; P < 0.001 [2.8 morphine milligram equivalents per day vs. 3.8]). While statistically significant, these differences are clinically small. CONCLUSIONS Among Medicare fee-for-service patients undergoing total knee arthroplasty, surgeon-level variation in opioid utilization in the immediate perioperative period was associated with statistically significant but clinically insignificant differences in opioid utilization in the medium- and long-term postoperative periods. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Xi Cen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; and National Bureau of Economic Research, Cambridge, Massachusetts
| | - Sean Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Read AJ, Rice MD, Baker JR, Waljee AK, Saini SD. Diffusion of an innovation: growth in video capsule endoscopy in the U.S. Medicare population from 2003 to 2019. BMC Health Serv Res 2022; 22:425. [PMID: 35361221 PMCID: PMC8969398 DOI: 10.1186/s12913-022-07780-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 03/15/2022] [Indexed: 11/12/2022] Open
Abstract
Background Video capsule endoscopy (VCE), approved by the U.S. Food and Drug Administration (FDA) in 2001, represented a disruptive technology that transformed evaluation of the small intestine. Adoption of this technology over time and current use within the U.S. clinical population has not been well described. Methods To assess the growth of capsule endoscopy within the U.S. Medicare provider population (absolute growth and on a population-adjusted basis), characterize the providers performing VCE, and describe potential regional differences in use. Medicare summary data from 2003 to 2019 were used to retrospectively analyze capsule endoscopy use in a multiple cross-sectional design. In addition, detailed provider summary files were used from 2012 to 2018 to characterize provider demographics. Results VCE use grew rapidly from 2003 to 2008 followed by a plateau from 2008 to 2019. There was significant variation in use of VCE between states, with up to 10-fold variation between states (14.6 to 156.1 per 100,000 enrollees in 2018). During this time, the adjusted VCE use on a population-adjusted basis declined, reflecting saturation of growth. Conclusions Growth of VCE use over time follows an S-shaped diffusion of innovation curve demonstrating a successful diffusion of innovation within gastroenterology. The lack of additional growth since 2008 suggests that current levels of use are well matched to overall population need within the constraints of reimbursement. Future studies should examine whether this lack of growth has implications for access and healthcare inequities. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07780-2.
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Affiliation(s)
- Andrew J Read
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Michael D Rice
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Jason R Baker
- Atrium Health, Carolinas Medical Center, Charlotte, NC, USA
| | - Akbar K Waljee
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,VA HSR&D Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Sameer D Saini
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,VA HSR&D Center for Clinical Management Research, Ann Arbor, MI, USA
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Townsend T, Bohnert ASB, Lagisetty P, Haffajee RL. Did prescribing laws disproportionately affect opioid dispensing to Black patients? Health Serv Res 2022; 57:482-496. [PMID: 35243639 PMCID: PMC9108058 DOI: 10.1111/1475-6773.13968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 12/28/2021] [Accepted: 01/09/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate whether pain management clinic laws and prescription drug monitoring program (PDMP) prescriber check mandates, two state opioid policies with relatively rapid adoption across states, reduced opioid dispensing more or less in Black versus White patients. DATA SOURCES Pharmacy claims data, US sample of commercially insured adults, 2007-2018. STUDY DESIGN Stratifying by race, we used generalized estimating equations with an event-study specification to estimate time-varying effects of each policy on opioid dispensing, comparing to the four pre-policy quarters and states without the policy. Outcomes included high-dosage opioids, overlapping opioid prescriptions, concurrent opioid/benzodiazepines, opioids from >3 prescribers, opioids from >3 pharmacies. DATA EXTRACTION METHODS We identified all prescription opioid dispensing to Black and White adults aged 18-64 without a palliative care or cancer diagnosis code. PRINCIPAL FINDINGS Exactly 7,096,592 White and 1,167,310 Black individuals met inclusion criteria. Pain management clinic laws were associated with reductions in two outcomes; their association with high-dosage receipt was larger among White patients. In contrast, reductions due to PDMP mandates appeared limited to, or larger in, Black patients compared with White patients in four of five outcomes. For example, PDMP mandates reduced high-dosage receipt in Black patients by 0.7 percentage points (95% CI: 0.36-1.08 ppt.) over 4 years: an 8.4% decrease from baseline; there was no apparent effect in White patients. Similarly, while there was limited evidence that mandates reduced overlapping opioid receipt in White patients, they appeared to reduce overlapping opioid receipt in Black patients by 1.3 ppt. (95% CI: -1.66--1.01 ppt.) across post-policy years-a 14.4% decrease from baseline. CONCLUSIONS PDMP prescriber check mandates but not pain management clinic laws appeared to reduce opioid dispensing more in Black patients than White patients. Future research should discern the mechanisms underlying these disparities and their consequences for pain management.
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Affiliation(s)
- Tarlise Townsend
- Affiliate, University of Michigan Department of Health Management and Policy; 1415 Washington Heights, Ann Arbor, MI.,Postdoctoral Fellow, Center for Opioid Epidemiology and Policy, NYU Grossman School of Medicine Department of Population Health; 180 Madison Ave, New York, NY.,Postdoctoral Fellow, NYU Rory Meyers College of Nursing; 433 1st Ave, New York, NY
| | - Amy S B Bohnert
- University of Michigan Departments of Anesthesiology, Psychiatry, and Epidemiology; 1500 E. Medical Center Drive, Ann Arbor, MI.,Research Investigator, VA Center for Clinical Management Research; 2215 Fuller Rd, Ann Arbor, MI
| | - Pooja Lagisetty
- Assistant Professor, University of Michigan Department of Internal Medicine; 1500 E. Medical Center Drive, Ann Arbor, MI.,Research Investigator, VA Center for Clinical Management Research; 2215 Fuller Rd, Ann Arbor, MI
| | - Rebecca L Haffajee
- Acting Assistant Secretary for Planning and Evaluation (ASPE) and Principal Deputy ASPE, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Washington, DC
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12
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Ellyson AM, Grooms J, Ortega A. Flipping the script: The effects of opioid prescription monitoring on specialty-specific provider behavior. HEALTH ECONOMICS 2022; 31:297-341. [PMID: 34773311 DOI: 10.1002/hec.4446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 08/20/2021] [Accepted: 10/05/2021] [Indexed: 06/13/2023]
Abstract
Mandatory access Prescription Drug Monitoring Programs (MA-PDMPs) aim to curb the epidemic at a common point of initiation of use, the prescription. However, there is recent concern about whether opioid policies have been too restrictive and reduced appropriate access to patients with the most need for opioid pharmaceuticals. We assess MA-PDMP's effect on specialty-specific opioid prescribing behavior of Medicare providers. Our findings suggest that requiring providers to query a PDMP differentially affects opioid prescribing across provider specialties. We find a three to four percent decrease in prescribing for Primary Care and Internal Medicine providers. This result is driven by healthcare providers at the lower end of the prescribing distribution. There is also suggestive evidence of an increase in opioid use disorder treatment drugs prescribed by these same providers. We also find no evidence for the hypothesis that MA-PDMPs restrict prescribing by providers who treat patients with potentially high levels of pain, few drug substitutes, or urgency for pain treatment (e.g., Oncology/Palliative care). This result is not dependent on whether a state provides exemptions for these providers. Our results indicate that MA-PDMPs may help close provider-patient informational gaps while retaining a provider's ability to supply these drugs to patients with a need for opioids.
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Affiliation(s)
- Alice M Ellyson
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, Washington, USA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jevay Grooms
- Department of Economics, Howard University, Washington, District of Columbia, USA
| | - Alberto Ortega
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana, USA
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13
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Perry BL, Odabaş M, Yang KC, Lee B, Kaminski P, Aronson B, Ahn YY, Oser CB, Freeman PR, Talbert JC. New means, new measures: assessing prescription drug-seeking indicators over 10 years of the opioid epidemic. Addiction 2022; 117:195-204. [PMID: 34227707 PMCID: PMC8664959 DOI: 10.1111/add.15635] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/02/2020] [Accepted: 06/23/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Prescription drug-seeking (PDS) from multiple prescribers is a primary means of obtaining prescription opioids; however, PDS behavior has probably evolved in response to policy shifts, and there is little agreement about how to operationalize it. We systematically compared the performance of traditional and novel PDS indicators. DESIGN Longitudinal study using a de-identified commercial claims database. SETTING United States, 2009-18. PARTICIPANTS A total of 318 million provider visits from 21.5 million opioid-prescribed patients. MEASUREMENTS We applied binary classification and generalized linear models to compare predictive accuracy and average marginal effect size predicting future opioid use disorder (OUD), overdose and high morphine milligram equivalents (MME). We compared traditional indicators of PDS to a network centrality measure, PageRank, that reflects the prominence of patients in a co-prescribing network. Analyses used the same data and adjusted for patient demographics, region, SES, diagnoses and health services. FINDINGS The predictive accuracy of a widely used traditional measure (N + unique doctors and N + unique pharmacies in 90 days) on OUD, overdose and MME decreased between 2009 and 2018, and performed no better than chance (50% accuracy) after 2015. Binarized PageRank measures however exhibited higher predictive accuracy than the traditional binary measures throughout 2009-2018. Continuous indicators of PDS performed better than binary thresholds, with days of Rx performing best overall with 77-93% predictive accuracy. For example, days of Rx had the highest average marginal effects on overdose and OUD: a 1 standard deviation increase in days of Rx was associated with a 6-8% [confidence intervals (CIs) = 0.058-0.061 and 0.078-0.082] increase in the probability of overdose and a 4-5% (CIs = 0.038-0.043 and 0.047-0.053) increase in the probability of OUD. PageRank performed nearly as well or better than traditional indicators of PDS, with predictive performance increasing after 2016. CONCLUSIONS In the United States, network-based measures appear to have increasing promise for identifying prescription opioid drug-seeking behavior, while indicators based on quantity of providers or pharmacies appear to have decreasing utility.
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Affiliation(s)
- Brea L. Perry
- Network Science Institute, Indiana University, 1001 45/46 Bypass, Bloomington, IN, United States of America,Department of Sociology, Indiana University, Bloomington, IN, United States of America
| | - Meltem Odabaş
- Department of Sociology, Indiana University, Bloomington, IN, United States of America
| | - Kai-Cheng Yang
- School of Informatics, Computing, and Engineering, Indiana University, Bloomington, IN, United States of America
| | - Byungkyu Lee
- Department of Sociology, Indiana University, Bloomington, IN, United States of America
| | - Patrick Kaminski
- Department of Sociology, Indiana University, Bloomington, IN, United States of America,School of Informatics, Computing, and Engineering, Indiana University, Bloomington, IN, United States of America
| | - Brian Aronson
- Department of Sociology, Indiana University, Bloomington, IN, United States of America
| | - Yong-Yeol Ahn
- Network Science Institute, Indiana University, 1001 45/46 Bypass, Bloomington, IN, United States of America,School of Informatics, Computing, and Engineering, Indiana University, Bloomington, IN, United States of America
| | - Carrie B. Oser
- Department of Sociology, University of Kentucky, Lexington, KY, United States of America
| | - Patricia R. Freeman
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, KY, United States of America
| | - Jeffrey C. Talbert
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, KY, United States of America
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14
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Soeiro T, Micallef J. Commentary on Perry et al.: New means, new measures-without discarding all the previous ones! Addiction 2022; 117:205-206. [PMID: 34661941 DOI: 10.1111/add.15691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/09/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Thomas Soeiro
- Inserm, Aix-Marseille Université, Marseille, France.,Hôpitaux Universitaires de Marseille, Service de pharmacologie clinique, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Marseille, France
| | - Joëlle Micallef
- Inserm, Aix-Marseille Université, Marseille, France.,Hôpitaux Universitaires de Marseille, Service de pharmacologie clinique, Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Marseille, France
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15
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Delcher C, Bae J, Wang Y, Doung M, Fink DS, Young HW. Defining "Doctor shopping" with Dispensing Data: A Scoping Review. PAIN MEDICINE 2021; 23:1323-1332. [PMID: 34931686 DOI: 10.1093/pm/pnab344] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND "Doctor shopping" typically refers to patients that seek controlled substance prescriptions from multiple providers with the presumed intent to obtain these medications for non-medical use and/or diversion. The purpose of this scoping review is to document and examine the criteria used to identify "doctor shopping" from dispensing data in the United States. METHODS A scoping review was conducted on "doctor shopping" or analogous terminology from January 1, 2000 through December 31, 2020 using the Web of Science Core Collection (7 citation indices). Our search was limited to U.S. only, English-language, peer-reviewed and U.S. federal government studies. Studies without explicit "doctor shopping" criteria were excluded. Key components of these criteria included the number of prescribers and dispensers, dispensing period, and drug class (e.g., opioids). RESULTS Of 9,845 records identified, 95 articles met the inclusion criteria and our pool of studies ranged from years 2003 to 2020. The most common threshold-based or count definition was [≥4 Prescribers (P) AND ≥4 Dispensers (D)] (n = 12). Thirty-three studies used a 365-day detection window. Opioids alone were studied most commonly (n = 69), followed by benzodiazepines and stimulants (n = 5 and n = 2, respectively). Only 39 (41%) studies provided specific drug lists with active ingredients. CONCLUSION Relatively simple P × D criteria for identifying "doctor shopping" are still the dominant paradigm with the need for on-going validation. The value of P × D criteria may change through time with more diverse methods applied to dispensing data emerging.
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Affiliation(s)
- Chris Delcher
- Institute for Pharmaceutical Outcomes & Policy (IPOP), Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA.,Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Jungjun Bae
- Institute for Pharmaceutical Outcomes & Policy (IPOP), Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA.,Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Yanning Wang
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Michelle Doung
- Department of Occupational Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
| | - David S Fink
- Division of Translational Epidemiology, New York State Psychiatric Institute, New York, New York, USA
| | - Henry W Young
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
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16
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Chhibba T, Guizzetti L, Seow CH, Lu C, Novak KL, Ananthakrishnan AN, Bernstein CN, Kaplan GG, Panaccione R, Ma C. Frequency of Opioid Prescription at Emergency Department Discharge in Patients with Inflammatory Bowel Disease: A Nationwide Analysis. Clin Gastroenterol Hepatol 2021; 19:2064-2071.e1. [PMID: 32683099 DOI: 10.1016/j.cgh.2020.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) frequently experience chronic pain. Patients will often seek out care in the emergency department (ED) where short-term opioid use may be associated with potential treatment-related complications. We aimed to assess the rate and factors associated with opioid prescription in IBD patients discharged from the ED. METHODS We conducted a cross-sectional analysis of data collected in the US National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006-2017. We determined the proportion of adult patients (≥18 years) with IBD prescribed an opioid in ED or at ED discharge. Logistic regression was used to evaluate predictors of opioid prescription. Time-trend analysis was performed to evaluate temporal patterns in opioid use. All analyses were adjusted for complex survey design. RESULTS We identified ∼965,000 weighted discharges from the ED for patients with IBD. In total, 51.9% [95% CI: 42.2% -61.6%] of visits resulted in opioid administration in ED and 35.3% [95% CI: 26.5% -45.2%] of IBD-related ED discharges were associated with an opioid prescription. IBD patients with moderate/severe pain (adjusted odds ratio aOR 5.06 [95% CI: 1.72 -14.90], p < 0.01) were more likely to receive opioids whereas older age (aOR 0.73 per decade [95% CI: 0.55 -0.98], p = 0.04) were less likely. In temporal analysis, a trend towards decreasing opioid use in ED and opioid prescriptions at discharge was observed in 2015-2017. CONCLUSIONS More than one third of IBD patients are prescribed an opioid at discharge from ED, highlighting a potential gap in care for accessing effective pain management solutions in this population.
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Affiliation(s)
- Tarun Chhibba
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Leonardo Guizzetti
- Alimentiv (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Lu
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alimentiv (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada.
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17
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Ozturk O, Hong Y, McDermott S, Turk M. Prescription Drug Monitoring Programs and Opioid Prescriptions for Disability Conditions. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2021; 19:415-428. [PMID: 33251552 DOI: 10.1007/s40258-020-00622-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND There are variants of prescription drug monitoring programs (PDMPs) and different groups of patients who are prescribed opioids. Patients with disabilities and those with chronic conditions might have different experiences in physician prescribing practices for opioids, when compared to a comparison group without these conditions. OBJECTIVE To determine differences in opioid prescriptions related to PDMPs for people without cancer-related pain and with disability conditions compared to other adult opioid users without cancer, using a national database. METHOD Opioid users were identified from the US Medical Expenditure Panel Survey. Disability groups were defined by diagnosis codes related to longstanding physical disability and inflammatory conditions. Our analyses used an event study framework and a difference-in-differences approach. RESULTS During a two-year panel period, PDMPs did not reduce opioid prescriptions for individuals with disabilities who use opioids. Our data show that individuals with disabilities who use opioids, on average, have a higher incidence of continuous opioid use and significantly greater amounts prescribed compared to other adults who have opioid prescriptions. CONCLUSION PDMPs do not appear to affect prescribers' initial or ongoing use of opioids for individuals with longstanding physical disabilities and those with inflammatory conditions. Thus, these adults have greater exposure to opioids, compared to other adults who were prescribed opioids.
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Affiliation(s)
- Orgul Ozturk
- Economics Department, Darla Moore School of Business, University of South Carolina, Columbia, 803-4636168, USA.
| | - Yuan Hong
- Department of Epidemiology and Biostatistics Arnold School of Public Health, University of South Carolina University of South Carolina, Columbia, USA
| | - Suzanne McDermott
- Department of Environmental, Occupational, and Geospatial Health Sciences, School of Public Health and Health Policy, City University of New York, New York, USA
| | - Margaret Turk
- Department of Physical Medicine and Rehabilitation, Upstate Medical University, Syracuse, USA
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18
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Carey CM, Meille G, Buchmueller TC. Provider Compliance With Kentucky’s Prescription Drug Monitoring Program’s Mandate To Query Patient Opioid History. Health Aff (Millwood) 2021; 40:461-468. [DOI: 10.1377/hlthaff.2020.01316] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Colleen M. Carey
- Colleen M. Carey is an assistant professor in the Department of Policy Analysis and Management at Cornell University, in Ithaca, New York
| | - Giacomo Meille
- Giacomo Meille is a PhD student in the Stephen M. Ross School of Business, University of Michigan, in Ann Arbor, Michigan
| | - Thomas C. Buchmueller
- Thomas C. Buchmueller is the Waldo O. Hildebrand Professor of Risk Management and Insurance at the Stephen M. Ross School of Business, University of Michigan
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19
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Soeiro T, Pradel V, Lapeyre-Mestre M, Micallef J. Evolution of doctor shopping for oxycodone in the 67 million inhabitants in France as a proxy for potential misuse or abuse. Pain 2021; 162:770-777. [PMID: 33021567 DOI: 10.1097/j.pain.0000000000002093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 09/23/2020] [Indexed: 01/10/2023]
Abstract
ABSTRACT This nationwide study aimed to compare use of oxycodone and doctor shopping for oxycodone in 2010 and 2016, and to quantify doctor shopping for oxycodone by sex, age, formulation, and dosage in 2010 and 2016. This study is a cross-sectional comparative analysis of doctor shopping based on all dispensings of oxycodone in France, in 2010 and 2016. Dispensings of oxycodone were extracted from the Système national des données de santé, which covers the 67 million inhabitants in France. Quantification of doctor shopping relies on an algorithm accounting for overlapping prescriptions, which is a proxy for potential misuse or abuse. The number of subjects who received oxycodone increased by 214% from 67,838 subjects in 2010 to 212,753 subjects in 2016, and the number of subjects with doctor-shopping behavior increased by 197%, from 1066 subjects in 2010 to 3163 subjects in 2016. For 30- to 44-year-old men, the total quantity of oxycodone obtained by doctor shopping increased by 391%, from 4582 defined daily doses in 2010 to 22,517 defined daily doses in 2016. By formulation and dosage, the total quantity of oxycodone obtained by doctor shopping increased with the dosage for both immediate-release and extended-release tablets in 2010 and 2016. The widespread extent of doctor shopping and its 3-fold increase in line with population exposure is a strong signal in the French context. These results are another argument to avoid trivializing oxycodone to prevent misuse, potential abuse, and potential oxycodone-related deaths, but it requires caution to prevent compromising effective treatment of pain.
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Affiliation(s)
- Thomas Soeiro
- Aix-Marseille Université, Inserm, UMR 1106, Assistance publique, Hôpitaux de Marseille, Service de pharmacologie clinique, Centre d'évaluation et d'information sur la pharmacodépendance, Addictovigilance, France
| | - Vincent Pradel
- Aix-Marseille Université, Inserm, UMR 1106, Assistance publique, Hôpitaux de Marseille, Service de pharmacologie clinique, Centre d'évaluation et d'information sur la pharmacodépendance, Addictovigilance, France
| | - Maryse Lapeyre-Mestre
- Université Paul Sabatier, Inserm, UMR 1027, Centre hospitalier universitaire de Toulouse, Service de pharmacologie clinique, Centre d'évaluation et d'information sur la pharmacodépendance, Addictovigilance, France
| | - Joëlle Micallef
- Aix-Marseille Université, Inserm, UMR 1106, Assistance publique, Hôpitaux de Marseille, Service de pharmacologie clinique, Centre d'évaluation et d'information sur la pharmacodépendance, Addictovigilance, France
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20
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Soeiro T, Lacroix C, Pradel V, Lapeyre-Mestre M, Micallef J. Early Detection of Prescription Drug Abuse Using Doctor Shopping Monitoring From Claims Databases: Illustration From the Experience of the French Addictovigilance Network. Front Psychiatry 2021; 12:640120. [PMID: 34079478 PMCID: PMC8165176 DOI: 10.3389/fpsyt.2021.640120] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/29/2021] [Indexed: 12/30/2022] Open
Abstract
Opioid analgesics and maintenance treatments, benzodiazepines and z-drugs, and other sedatives and stimulants are increasingly being abused to induce psychoactive effects or alter the effects of other drugs, eventually leading to dependence. Awareness of prescription drug abuse has been increasing in the last two decades, and organizations such as the International Narcotics Control Board has predicted that, worldwide, prescription drug abuse may exceed the use of illicit drugs. Assessment of prescription drug abuse tackles an issue that is hidden by nature, which therefore requires a specific monitoring. The current best practice is to use multiple detection systems to assess prescription drug abuse by various populations in a timely, sensitive, and specific manner. In the early 2000's, we designed a method to detect and quantify doctor shopping for prescription drugs from the French National Health Data System, which is one of the world's largest claims database, and a first-class data source for pharmacoepidemiological studies. Doctor shopping is a well-known behavior that involves overlapping prescriptions from multiple prescribers for the same drug, to obtain higher doses than those prescribed by each prescriber on an individual basis. In addition, doctor shopping may play an important role in supplying the black market. The paper aims to review how doctor shopping monitoring can improve the early detection of prescription drug abuse within a multidimensional monitoring. The paper provides an in-depth overview of two decades of development and validation of the method as a complementary component of the multidimensional monitoring conducted by the French Addictovigilance Network. The process accounted for the relevant determinants of prescription drug abuse, such as pharmacological data (e.g., formulations and doses), chronological and geographical data (e.g., impact of measures and comparison between regions), and epidemiological and outcome data (e.g., profiles of patients and trajectories of care) for several pharmacological classes (e.g., opioids, benzodiazepines, antidepressants, and methylphenidate).
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Affiliation(s)
- Thomas Soeiro
- Aix-Marseille Université, Inserm, UMR 1106, Hôpitaux Universitaires de Marseille, Service de Pharmacologie Clinique, Centre d'évaluation et d'information sur la Pharmacodépendance - Addictovigilance, Marseille, France
| | - Clémence Lacroix
- Aix-Marseille Université, Inserm, UMR 1106, Hôpitaux Universitaires de Marseille, Service de Pharmacologie Clinique, Centre d'évaluation et d'information sur la Pharmacodépendance - Addictovigilance, Marseille, France
| | - Vincent Pradel
- Aix-Marseille Université, Inserm, UMR 1106, Hôpitaux Universitaires de Marseille, Service de Pharmacologie Clinique, Centre d'évaluation et d'information sur la Pharmacodépendance - Addictovigilance, Marseille, France
| | - Maryse Lapeyre-Mestre
- Université Paul Sabatier, Inserm, CIC 1436, Centre Hospitalier Universitaire de Toulouse, Service de Pharmacologie Clinique, Centre d'évaluation et d'information sur la Pharmacodépendance - Addictovigilance, Toulouse, France
| | - Joëlle Micallef
- Aix-Marseille Université, Inserm, UMR 1106, Hôpitaux Universitaires de Marseille, Service de Pharmacologie Clinique, Centre d'évaluation et d'information sur la Pharmacodépendance - Addictovigilance, Marseille, France
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21
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Abstract
There is tremendous interpatient variability in the response to analgesic therapy
(even for efficacious treatments), which can be the source of great frustration
in clinical practice. This has led to calls for “precision
medicine” or personalized pain therapeutics (ie, empirically based
algorithms that determine the optimal treatments, or treatment combinations, for
individual patients) that would presumably improve both the clinical care of
patients with pain and the success rates for putative analgesic drugs in phase 2
and 3 clinical trials. However, before implementing this approach, the
characteristics of individual patients or subgroups of patients that increase or
decrease the response to a specific treatment need to be identified. The
challenge is to identify the measurable phenotypic characteristics of patients
that are most predictive of individual variation in analgesic treatment
outcomes, and the measurement tools that are best suited to evaluate these
characteristics. In this article, we present evidence on the most promising of
these phenotypic characteristics for use in future research, including
psychosocial factors, symptom characteristics, sleep patterns, responses to
noxious stimulation, endogenous pain-modulatory processes, and response to
pharmacologic challenge. We provide evidence-based recommendations for core
phenotyping domains and recommend measures of each domain.
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22
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Maciejewski ML, Zepel L, Hale SL, Wang V, Diamantidis CJ, Blaz JW, Olin S, Wilson-Frederick SM, James CV, Smith VA. Opioid Prescribing in the 2016 Medicare Fee-for-Service Population. J Am Geriatr Soc 2020; 69:485-493. [PMID: 33216957 DOI: 10.1111/jgs.16911] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/02/2020] [Accepted: 10/02/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Opioid use and misuse are prevalent and remain a national crisis. This study identified beneficiary characteristics associated with filling opioid prescriptions, variation in opioid dosing, and opioid use with average daily doses (ADDs) equal to 120 morphine milligram equivalents (MMEs) or more in the 100% Medicare fee-for-service (FFS) population. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS In a cohort of FFS beneficiaries with 12 months of Medicare Part D coverage in 2016, we examined patient factors associated with filling an opioid prescription (n = 20,880,490) and variation in ADDs (n = 7,325,031) in a two-part model. Among those filling opioids, we also examined the probability of ADD equal to 120 MMEs or more via logistic regression. RESULTS About 35% of FFS beneficiaries had one or more opioid prescription fills in 2016 and 1.5% had ADDs equal to 120 MMEs or more. Disability-eligible beneficiaries and beneficiaries with multiple chronic conditions were more likely to fill opioids, to have higher ADDs or were more likely to have ADD equal to 120 MMEs or more. Beneficiaries with chronic obstructive pulmonary disease (COPD) were more likely to fill opioids (odds ratio (OR) = 1.47, 95% confidence interval (CI) = 1.46-1.47), have higher ADDs (rate ratio = 1.06, 95% CI = 1.06-1.06) when filled and were more likely to have ADD equal to 120 MMEs or more (OR = 1.23, 95% CI = 1.21-1.24). Finally, black and Hispanic beneficiaries were less likely to fill opioids, had lower overall doses and were less likely to have ADDs equal to 120 MMEs or more compared to white beneficiaries. CONCLUSION Several beneficiary subgroups have underappreciated risk of adverse events associated with ADD equal to 120 MMEs or more that may benefit from opioid optimization interventions that balance pain management and adverse event risk, especially beneficiaries with COPD who are at risk for respiratory depression.
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Affiliation(s)
- Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lindsay Zepel
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah L Hale
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Clarissa J Diamantidis
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jacquelyn W Blaz
- National Committee for Quality Assurance, Washington, District of Columbia, USA
| | - Serene Olin
- National Committee for Quality Assurance, Washington, District of Columbia, USA
| | - Shondelle M Wilson-Frederick
- Office of Minority Health, Centers for Medicare & Medicaid Services, U.S. Department of Health & Human Services, Baltimore, Maryland, USA
| | - Cara V James
- Office of Minority Health, Centers for Medicare & Medicaid Services, U.S. Department of Health & Human Services, Baltimore, Maryland, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Stakeholder Perspective on Opioid Stewardship After Prostatectomy: Evaluating Barriers and Facilitators From the Pennsylvania Urology Regional Collaborative. Urology 2020; 145:120-126. [DOI: 10.1016/j.urology.2020.05.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/25/2020] [Accepted: 05/28/2020] [Indexed: 02/01/2023]
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24
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Burgstaller JM, Held U, Signorell A, Blozik E, Steurer J, Wertli MM. Increased risk of adverse events in non-cancer patients with chronic and high-dose opioid use-A health insurance claims analysis. PLoS One 2020; 15:e0238285. [PMID: 32925928 PMCID: PMC7489518 DOI: 10.1371/journal.pone.0238285] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 06/04/2020] [Indexed: 11/29/2022] Open
Abstract
Background Chronic and high dose opioid use may result in adverse events. We analyzed the risk associated with chronic and high dose opioid prescription in a Swiss population. Methods Using insurance claims data covering one-sixth of the Swiss population, we analyzed recurrent opioid prescriptions (≥2 opioid claims with at least 1 strong opioid claim) between 2006 and 2014. We calculated the cumulative dose in milligrams morphine equivalents (MED) and treatment duration. Excluded were single opioid claims, opioid use that was cancer treatment related, and opioid use in substitution programs. We assessed the association between the duration of opioid use, prescribed opioid dose, and benzodiazepine use with emergency department (ED) visits, urogenital and pulmonary infections, acute care hospitalization, and death at the end of the episode. Results In 63,642 recurrent opioid prescription episodes (acute 38%, subacute 7%, chronic 25.8%, very chronic (>360 days) episodes 29%) 18,336 ED visits, 30,209 infections, 19,375 hospitalizations, and 9,662 deaths occurred. The maximum daily MED dose was <20 mg in 15.8%, 20−<50 mg in 16.6%, 50−<100 mg in 21.6%, and ≥100 mg in 46%. Compared to acute episodes (<90 days), episode duration was an independent predictor of ED visits (chronic OR 1.09 (95% CI 1.03–1.15), very chronic (>360 days) OR 1.76 (1.67–1.86)) for adverse effects; infections (chronic OR 1.74 (1.66–1.82), very chronic 4.16 (3.95–4.37)), and hospitalization (chronic: OR 1.22 (1.16–1.29), very chronic OR 1.82 (1.73–1.93)). The risk of death decreased over time (very chronic OR 0.46 (0.43–0.50)). A dose dependent increased risk was observed for ED visits, hospitalization, and death (≥100mg daily MED OR 1.21 (1.13–1.29), OR 1.29 (1.21–1.38), and OR 1.67, 1.50–1.85, respectively). A concomitant use of benzodiazepines increased the odds for ED visits by 46% (OR 1.46, 1.41–1.52), infections by 44% (OR 1.44, 1.41–1.52), hospitalization by 12% (OR 1.12, 1.07–1.1), and death by 45% (OR 1.45, 1.37–1.53). Conclusion The length of opioid use and higher prescribed morphine equivalent dose were independently associated with an increased risk for ED visits and hospitalizations. The risk for infections, ED visits, hospitalizations, and death also increased with concomitant benzodiazepine use.
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Affiliation(s)
- Jakob M. Burgstaller
- Department of Internal Medicine, Horten Center for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
- Institute of Primary Care, University and University Hospital Zürich, Zürich, Switzerland
| | - Ulrike Held
- Department of Internal Medicine, Horten Center for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zurich, Switzerland
| | - Andri Signorell
- Department of Health Sciences, Helsana, Dübendorf, Switzerland
| | - Eva Blozik
- Institute of Primary Care, University and University Hospital Zürich, Zürich, Switzerland
- Department of Health Sciences, Helsana, Dübendorf, Switzerland
| | - Johann Steurer
- Department of Internal Medicine, Horten Center for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Maria M. Wertli
- Department of Internal Medicine, Horten Center for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
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25
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Buchmueller TC, Carey CM, Meille G. How well do doctors know their patients? Evidence from a mandatory access prescription drug monitoring program. HEALTH ECONOMICS 2020; 29:957-974. [PMID: 32790943 DOI: 10.1002/hec.4020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 02/11/2020] [Accepted: 03/16/2020] [Indexed: 06/11/2023]
Abstract
Many opioid control policies target the prescribing behavior of health care providers. In this paper, we study the first comprehensive state-level policy requiring providers to access patients' opioid history before making prescribing decisions. We compare prescribers in Kentucky, which implemented this policy in 2012, to those in a control state, Indiana. Our main difference-in-differences analysis uses the universe of prescriptions filled in the two states to assess how the information provided affected prescribing behavior. We find that a significant share of low-volume providers stopped prescribing opioids altogether after the policy was implemented, though this change accounted for a small share of the reduction in total volume. The most important margin of response was to prescribe opioids to fewer patients. Although providers disproportionately discontinued treating patients whose opioid histories showed the use of multiple providers, there were also economically meaningful reductions for patients without multiple providers and single-use acute patients.
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Affiliation(s)
| | - Colleen M Carey
- Department of Policy Analysis and Management, Cornell University, Ithaca, New York, USA
| | - Giacomo Meille
- Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
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Opioids, Polypharmacy, and Drug Interactions: A Technological Paradigm Shift Is Needed to Ameliorate the Ongoing Opioid Epidemic. PHARMACY 2020; 8:pharmacy8030154. [PMID: 32854271 PMCID: PMC7559875 DOI: 10.3390/pharmacy8030154] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 12/17/2022] Open
Abstract
Polypharmacy is a common phenomenon among adults using opioids, which may influence the frequency, severity, and complexity of drug–drug interactions (DDIs) experienced. Clinicians must be able to easily identify and resolve DDIs since opioid-related DDIs are common and can be life-threatening. Given that clinicians often rely on technological aids—such as clinical decision support systems (CDSS) and drug interaction software—to identify and resolve DDIs in patients with complex drug regimens, this narrative review provides an appraisal of the performance of existing technologies. Opioid-specific CDSS have several system- and content-related limitations that need to be overcome. Specifically, we found that these CDSS often analyze DDIs in a pairwise manner, do not account for relevant pharmacogenomic results, and do not integrate well with electronic health records. In the context of polypharmacy, existing systems may encourage inadvertent serious alert dismissal due to the generation of multiple incoherent alerts. Future technological systems should minimize alert fatigue, limit manual input, allow for simultaneous multidrug interaction assessments, incorporate pharmacogenomic data, conduct iterative risk simulations, and integrate seamlessly with normal workflow.
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27
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Lagisetty P, Bohnert A, Goesling J, Hu HM, Lagisetty K, Brummett C, Englesbe M, Waljee J. Care Coordination for Patients on Chronic Opioid Therapy Following Surgery: A Cohort Study. Ann Surg 2020; 272:304-310. [PMID: 32675543 PMCID: PMC7197041 DOI: 10.1097/sla.0000000000003235] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe if patients with chronic opioid use with a consistent usual prescriber (UP) prior to surgery and if early return to that UP (<30 d) would be associated with fewer high risk prescribing events in the postoperative period. SUMMARY BACKGROUND DATA Over 10 million people each year are prescribed opioids for chronic pain. There is little evidence regarding coordination of opioid management and best practices for patients on long-term opioid therapy patients following surgery. METHODS The study design is a retrospective cohort study. We identified 5749 commercially insured patients aged 18 to 64 with chronic opioid use who underwent elective surgery between January 2008 and March 2015. The predictors were presence of a UP and early return (<30 d from surgery) to a UP. The primary outcome was new high-risk opioid prescribing in the 90-day postoperative period (multiple prescribers, overlapping opioid and/or benzodiazepine prescriptions, new long acting opioid prescriptions, or new dose escalations to > 100 mg OME). RESULTS In this cohort, 73.8% of patients were exposed to high risk prescribing postoperatively. Overall, 10% of patients did not have a UP preoperatively, and were more likely to have prescriptions from multiple prescribers (OR 2.23 95% CI 1.75-2.83) and new long acting opioid prescriptions (OR 1.69, 95% CI 1.05-2.71). Among patients with a UP, earlier return was associated with decreased odds of receiving prescriptions from multiple prescribers (OR 0.80, 95% CI 0.68-0.95). CONCLUSION Patients without a UP prior to surgery are more likely to be exposed to high-risk opioid prescribing following surgery. Among patients who have a UP, early return visits may enhance care coordination with fewer prescribers.
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Affiliation(s)
- Pooja Lagisetty
- Department of Medicine, University of Michigan, School of Medicine, Ann Arbor, MI
- Center for Clinical Management and Research, Ann Arbor, MI
- Institute for Health Policy and Innovation, Ann Arbor, MI
| | - Amy Bohnert
- Center for Clinical Management and Research, Ann Arbor, MI
- Institute for Health Policy and Innovation, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, School of Medicine
| | - Jenna Goesling
- Department of Anesthesiology, University of Michigan, School of Medicine
| | - Hsou Mei Hu
- Department of Anesthesiology, University of Michigan, School of Medicine
| | - Kiran Lagisetty
- Department of Surgery, University of Michigan, School of Medicine
| | - Chad Brummett
- Department of Anesthesiology, University of Michigan, School of Medicine
| | - Mike Englesbe
- Department of Surgery, University of Michigan, School of Medicine
| | - Jennifer Waljee
- Institute for Health Policy and Innovation, Ann Arbor, MI
- Department of Surgery, University of Michigan, School of Medicine
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28
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Kan WC, Kuo SC, Chien TW, Lin JCJ, Yeh YT, Chou W, Chou PH. Therapeutic Duplication in Taiwan Hospitals for Patients With High Blood Pressure, Sugar, and Lipids: Evaluation With a Mobile Health Mapping Tool. JMIR Med Inform 2020; 8:e11627. [PMID: 32716306 PMCID: PMC7418019 DOI: 10.2196/11627] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 03/06/2019] [Accepted: 03/23/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Cardiovascular disease causes approximately half of all deaths in patients with type 2 diabetes. Duplicative prescriptions of medication in patients with high blood pressure (hypertension), high blood sugar (hyperglycemia), and high blood lipids (hyperlipidemia) have attracted substantial attention regarding the abuse of health care resources and to implement preventive measures for such abuse. Duplicative prescriptions may occur by patients receiving redundant medications for the same condition from two or more sources such as doctors, hospitals, and multiple providers, or as a result of the patient's wandering among hospitals. OBJECTIVE We evaluated the degree of duplicative prescriptions in Taiwanese hospitals for outpatients with three types of medications (antihypertension, antihyperglycemia, and antihyperlipidemia), and then used an online dashboard based on mobile health (mHealth) on a map to determine whether the situation has improved in the recent 25 fiscal quarters. METHODS Data on duplicate prescription rates of drugs for the three conditions were downloaded from the website of Taiwan's National Health Insurance Administration (TNHIA) from the third quarter of 2010 to the third quarter of 2016. Complete data on antihypertension, antihyperglycemia, and antihyperlipidemia prescriptions were obtained from 408, 414, and 359 hospitals, respectively. We used scale quality indicators to assess the attributes of the study data, created a dashboard that can be traced using mHealth, and selected the hospital type with the best performance regarding improvement on duplicate prescriptions for the three types of drugs using the weighted scores on an online dashboard. Kendall coefficient of concordance (W) was used to evaluate whether the performance rankings were unanimous. RESULTS The data quality was found to be acceptable and showed good reliability and construct validity. The online dashboard using mHealth on Google Maps allowed for easy and clear interpretation of duplicative prescriptions regarding hospital performance using multidisciplinary functionalities, and showed significant improvement in the reduction of duplicative prescriptions among all types of hospitals. Medical centers and regional hospitals showed better performance with improvement in the three types of duplicative prescriptions compared with the district hospitals. Kendall W was 0.78, indicating that the performance rankings were not unanimous (Chi square2=4.67, P=.10). CONCLUSIONS This demonstration of a dashboard using mHealth on a map can inspire using the 42 other quality indicators of the TNHIA by hospitals in the future.
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Affiliation(s)
- Wei-Chih Kan
- Department of Nephrology, Chi Mei Medical Center, Tainan, Taiwan.,Department of Biological Science and Technology, Chung Hwa University of Medical Technology, Tainan, Taiwan
| | - Shu-Chun Kuo
- Department of Ophthalmology, Chi Mei Medical Center, Tainan, Taiwan.,Department of Optometry, Chung Hwa University of Medical Technology, Tainan, Taiwan
| | | | | | - Yu-Tsen Yeh
- Medical School, St George's, University of London, London, United Kingdom
| | - Willy Chou
- Department of Physical Medicine and Rehabilitation, Chiali Chi Mei Hospital, Tainan, Taiwan.,Department of Physical Medicine and Rehabilitation, Chung Shan Medical University, Taichung, Taiwan
| | - Po-Hsin Chou
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
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29
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Powell D, Pacula RL, Taylor E. How increasing medical access to opioids contributes to the opioid epidemic: Evidence from Medicare Part D. JOURNAL OF HEALTH ECONOMICS 2020; 71:102286. [PMID: 32193022 PMCID: PMC7231644 DOI: 10.1016/j.jhealeco.2019.102286] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 10/08/2019] [Accepted: 12/31/2019] [Indexed: 05/19/2023]
Abstract
Drug overdoses involving opioid analgesics have increased dramatically since 1999, representing one of the United States' top public health crises. Opioids have legitimate medical functions, but they are often diverted, suggesting a tradeoff between improving medical access and nonmedical abuse. We provide causal estimates of the relationship between the medical opioid supply and drug overdoses using Medicare Part D as a differential shock to the geographic distribution of opioids. Our estimates imply that a 10% increase in opioid medical supply leads to a 7.1% increase in opioid-related deaths among the Medicare-ineligible population, suggesting substantial diversion from medical markets.
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30
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Stephenson JJ, Cepeda MS, Zhang J, Dinh J, Hall K, Esposito DB, Kern DM. The Association Between Doctor and Pharmacy Shopping and Self-Reported Misuse and Abuse of Prescription Opioids: A Survey Study. J Pain Res 2020; 13:689-701. [PMID: 32308468 PMCID: PMC7140905 DOI: 10.2147/jpr.s232409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/19/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND/RATIONALE Little is known about the reasons for visiting multiple doctors/pharmacies, known as doctor/pharmacy shopping, to obtain opioids. OBJECTIVE To investigate patients' self-reported reasons for doctor/pharmacy shopping and assess whether doctor/pharmacy shopping behavior can be used as a surrogate measure of opioid abuse/misuse. METHODS We conducted a cross-sectional web-based survey among adult patients with ≥2 pharmacy claims for immediate-release or extended-release/long-acting opioids between 7/1/2015 and 12/31/2016, identified from a large United States (US) commercial claims database. Patients were classified into no, mild, moderate, or severe shopping categories based on their claims. Reasons for doctor/pharmacy shopping and opioid abuse/misuse were determined from patient responses to the Prescription Opioid Misuse and Abuse Questionnaire. RESULTS A random sample of 10,081 patients was invited to participate in the survey and 1085 (11%) completed surveys. The most frequently reported reasons for doctor/pharmacy shopping were convenience, availability, price, and multiple morbidities requiring pain management. Among patients in the no, minimal, moderate, and severe shopping categories, only 7.8%, 8.5%, 11.8% and 12.6% reported opioid abuse/misuse, respectively. CONCLUSION In this commercially-insured population, patient-reported reasons for doctor/pharmacy shopping do not suggest opioid abuse/misuse. Less than 15% of patients with shopping behavior in the past 3 months reported any reasons attributable to opioid abuse/misuse, indicating that shopping behavior in this population may not be a good surrogate for abuse/misuse.
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Affiliation(s)
| | - M Soledad Cepeda
- Epidemiology, Janssen Research and Development, Titusville, NJ, USA
| | - Jie Zhang
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
- Safety and Epidemiology, HealthCore, Inc., Wilmington, DE, USA
| | - Jade Dinh
- Safety and Epidemiology, HealthCore, Inc., Wilmington, DE, USA
| | - Kelsey Hall
- Safety and Epidemiology, HealthCore, Inc., Wilmington, DE, USA
| | - Daina B Esposito
- Safety and Epidemiology, HealthCore, Inc., Wilmington, DE, USA
- Ciconia, Inc, Westford, MA, USA
- Epidemiology, Boston University, Boston, MA, USA
| | - David M Kern
- Epidemiology, Janssen Research and Development, Titusville, NJ, USA
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Baker LC, Bundorf MK, Kessler DP. The effects of medicare advantage on opioid use. JOURNAL OF HEALTH ECONOMICS 2020; 70:102278. [PMID: 31972536 PMCID: PMC7181702 DOI: 10.1016/j.jhealeco.2019.102278] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 12/10/2019] [Accepted: 12/14/2019] [Indexed: 06/10/2023]
Abstract
Despite a vast literature on the determinants of prescription opioid use, the role of health insurance plans has received little attention. We study how the form of Medicare beneficiaries' drug coverage affects the volume of opioids they consume. We find that enrollment in Medicare Advantage, which integrates drug coverage with other medical benefits, significantly reduces beneficiaries' likelihood of filling an opioid prescription, as compared to enrollment in a stand-alone drug plan. Approximately half of this effect was due to fewer fills from prescribers who write a very large number of opioid prescriptions.
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Yang J, Bauer BA, Wahner-Roedler DL, Chon TY, Xiao L. The Modified WHO Analgesic Ladder: Is It Appropriate for Chronic Non-Cancer Pain? J Pain Res 2020; 13:411-417. [PMID: 32110089 PMCID: PMC7038776 DOI: 10.2147/jpr.s244173] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/30/2020] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION From 1986, the World Health Organization (WHO) analgesic ladder has been used as the simple and valuable pain-relieving guidance in the pharmaceutical pain management, however, with the development of medical history, notions about pain physiology and pain management have already updated. Is the analgesic ladder still appropriate for chronic non-cancer pain (CNCP) patients? This study aims to analyse the current usage of the analgesic ladder in patients with CNCP by evaluating previously published pertinent studies. METHODS Literature published in English from January 1980 to April 2019 and cited on PubMed database was included. Analysis on the analgesic ladder, current status of CNCP management, and a new revised ladder model were developed based on relevant literature. RESULTS The WHO analgesic ladder for cancer pain is not appropriate for current CNCP management. It is revised into a four-step ladder: the integrative therapies being adopted at each step for reducing or even stopping the use of opioid analgesics; interventional therapies being considered as step 3 before upgrading to strong opioids if non-opioids and weak opioids failed in CNCP management. DISCUSSION A simple and valuable guideline in past years, the WHO analgesic ladder is inappropriate for the current use of CNCP control. A revised four-step analgesic ladder aligned with integrative medicine principles and minimally invasive interventions is recommended for control of CNCP.
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Affiliation(s)
- Juan Yang
- Department of Pain Medicine, Shenzhen Nanshan People’s Hospital, Shenzhen518052, People’s Republic of China
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN55905, USA
| | - Brent A Bauer
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN55905, USA
| | | | - Tony Y Chon
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN55905, USA
| | - Lizu Xiao
- Department of Pain Medicine, Shenzhen Nanshan People’s Hospital, Shenzhen518052, People’s Republic of China
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Cuthbert CA, Xu Y, Kong S, Boyne DJ, Hemmelgarn BR, Cheung WY. Patient-level factors associated with chronic opioid use in cancer: a population-based cohort study. Support Care Cancer 2020; 28:4201-4209. [PMID: 31900614 DOI: 10.1007/s00520-019-05224-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/28/2019] [Indexed: 01/12/2023]
Abstract
PURPOSE Concerns around chronic opioid use (COU), misuse, and harms have led to increased scrutiny of opioid prescribing in oncology. There is lack of research examining patient-level factors associated with COU. Our aim was to examine patient-level factors associated with COU in newly diagnosed cancer patients. METHODS Population-based retrospective cohort study using administrative health data of patients in Alberta, Canada, diagnosed between February 2016 and October 2017. Adult cancer patients who completed a symptom survey within ± 60 days of diagnosis were included. Patients were divided into two groups: COU (defined as continuous opioid prescriptions for at least 90 days post-diagnosis) and non-chronic opioid use (NCOU). Logistic regression was used to evaluate factors associated with COU. RESULTS We included 694 patients (mean age 65 years; 51% female). Most had breast (20%), colorectal (13%), and lung (33%) cancers. Of the 14% with COU, 79% were opioid naïve at diagnosis. Those in the COU group were more often diagnosed with advanced cancer (66% versus 40%), had lung cancer (47%), and were opioid tolerant (> 90 days of continuous opioids within one-year pre-diagnosis). A total of 64% of COU versus 27% of NCOU had moderate to severe pain at diagnosis (p < 0.001). Irrespective of treatment type or stage, those with moderate to severe pain, were opioid tolerant at diagnosis, or had multiple prescribers were at greater risk for COU. CONCLUSIONS Specific patient groups were at increased risk of COU and should be the focus of adaptive prescribing approaches to ensure that opioid use is appropriate.
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Affiliation(s)
- Colleen A Cuthbert
- Faculty of Nursing, University of Calgary, PF 2294, 2500 University Drive N.W, Calgary, AB, T2N 1N4, Canada.
| | - Yuan Xu
- Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Shiying Kong
- Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Devon J Boyne
- Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Brenda R Hemmelgarn
- Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Canada.,Department of Medicine, University of Calgary, Calgary, Canada
| | - Winson Y Cheung
- Alberta Health Services Cancer Control, Calgary, Alberta, Canada.,Cumming School of Medicine, Department of Oncology, University of Calgary, Calgary, Canada
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Anoushiravani AA, Kim KY, Roof M, Chen K, O’Connor CM, Vigdorchik J, Schwarzkopf R. Risk factors associated with persistent chronic opioid use following THA. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:681-688. [DOI: 10.1007/s00590-019-02618-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/19/2019] [Indexed: 01/20/2023]
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Henche Ruiz AI. [Transmucosal fentanyl and breakthrough pain: The other side of the coin]. Rev Esp Geriatr Gerontol 2020; 55:56-57. [PMID: 31307779 DOI: 10.1016/j.regg.2019.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/02/2019] [Accepted: 02/08/2019] [Indexed: 06/10/2023]
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Meisel ZF, Lupulescu-Mann N, Charlesworth CJ, Kim H, Sun BC. Conversion to Persistent or High-Risk Opioid Use After a New Prescription From the Emergency Department: Evidence From Washington Medicaid Beneficiaries. Ann Emerg Med 2019; 74:611-621. [PMID: 31229392 PMCID: PMC6864746 DOI: 10.1016/j.annemergmed.2019.04.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/05/2019] [Accepted: 04/08/2019] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE We describe the overall risk and factors associated with transitioning to persistent opioid or high-risk use after an initial emergency department (ED) opioid prescription. METHODS A retrospective cohort study of Washington Medicaid beneficiaries was performed with linked Medicaid and prescription drug monitoring program files. We identified adults who had no record of opioid prescriptions in the previous 12 months, and who filled a new opioid prescription within 1 day of an ED discharge in 2014. We assessed the risk of persistent opioid use or high-risk prescription fills within 12 months after the index visit. Logistic regression was used to assess the association between pertinent variables and conversion to persistent or high-risk use. RESULTS Among 202,807 index ED visits, 23,381 resulted in a new opioid prescription. Of these, 13.7% led to persistent or high-risk opioid prescription fills within 12 months compared with 3.2% for patients who received no opioids at the index visit. Factors associated with increased likelihood of persistent opioid or high-risk prescription fills included a history of skeletal or connective-tissue disorder; neck, back, or dental pain; and a history of prescribed benzodiazepines. The highest conversion rates (37.3%) were observed among visits in which greater than or equal to 350 morphine milligram equivalents were prescribed. Conversion rates remained greater than 10% even among visits resulting in lower-dose opioid prescriptions. CONCLUSION Medicaid recipients are at moderate risk for conversion to persistent or high-risk opioid use after a new ED prescription. Longer or higher-dose prescriptions are associated with increased risk for conversion; however, even visits that lead to guideline-concordant prescriptions bear some risk for long-term or high-risk use.
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Affiliation(s)
- Zachary F Meisel
- Center for Emergency Care Policy Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, and the Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA; Center for Health Economics for Treatment Interventions of Substance Use Disorder, HIV, HCV.
| | | | | | - Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR
| | - Benjamin C Sun
- Center for Emergency Care Policy Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, and the Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA; Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR
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Perry BL, Yang KC, Kaminski P, Odabas M, Park J, Martel M, Oser CB, Freeman PR, Ahn YY, Talbert J. Co-prescription network reveals social dynamics of opioid doctor shopping. PLoS One 2019; 14:e0223849. [PMID: 31652266 PMCID: PMC6814254 DOI: 10.1371/journal.pone.0223849] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 09/30/2019] [Indexed: 01/04/2023] Open
Abstract
This paper examines network prominence in a co-prescription network as an indicator of opioid doctor shopping (i.e., fraudulent solicitation of opioids from multiple prescribers). Using longitudinal data from a large commercially insured population, we construct a network where a tie between patients is weighted by the number of shared opioid prescribers. Given prior research suggesting that doctor shopping may be a social process, we hypothesize that active doctor shoppers will occupy central structural positions in this network. We show that network prominence, operationalized using PageRank, is associated with more opioid prescriptions, higher predicted risk for dangerous morphine dosage, opioid overdose, and opioid use disorder, controlling for number of prescribers and other variables. Moreover, as a patient's prominence increases over time, so does their risk for these outcomes, compared to their own average level of risk. Results highlight the importance of co-prescription networks in characterizing high-risk social dynamics.
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Affiliation(s)
- Brea L. Perry
- Network Science Institute, Indiana University, 1001 45/46 Bypass, Bloomington, IN, United States of America
- Department of Sociology, Indiana University, Bloomington, IN, United States of America
| | - Kai Cheng Yang
- School of Informatics, Computing, and Engineering, Indiana University, Bloomington, IN, United States of America
| | - Patrick Kaminski
- Department of Sociology, Indiana University, Bloomington, IN, United States of America
- School of Informatics, Computing, and Engineering, Indiana University, Bloomington, IN, United States of America
| | - Meltem Odabas
- Department of Sociology, Indiana University, Bloomington, IN, United States of America
| | - Jaehyuk Park
- School of Informatics, Computing, and Engineering, Indiana University, Bloomington, IN, United States of America
| | - Michelle Martel
- Department of Psychology, University of Kentucky, Lexington, KY, United States of America
| | - Carrie B. Oser
- Department of Sociology, University of Kentucky, Lexington, KY, United States of America
| | - Patricia R. Freeman
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, KY, United States of America
| | - Yong-Yeol Ahn
- Network Science Institute, Indiana University, 1001 45/46 Bypass, Bloomington, IN, United States of America
- School of Informatics, Computing, and Engineering, Indiana University, Bloomington, IN, United States of America
| | - Jeffery Talbert
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, KY, United States of America
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Raman SR, Bush C, Karmali RN, Greenblatt LH, Roberts AW, Skinner AC. Characteristics of New Opioid Use Among Medicare Beneficiaries: Identifying High-Risk Patterns. J Manag Care Spec Pharm 2019; 25:966-972. [PMID: 31456497 PMCID: PMC7121919 DOI: 10.18553/jmcp.2019.25.9.966] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Opioid prescription patterns, including long-term use, multiple prescribers, and high opioid doses, increase the risk for adverse outcomes; however, previous research in older adult populations has primarily described opioid dose patterns using average daily dose measures or using very high thresholds (i.e., > 100 morphine milligram equivalents [MME] per day). OBJECTIVE To describe prescription patterns by peak dose among older adults who have newly initiated opioid use in 2014 and describe long-term opioid use and the use of multiple pharmacies and prescribers among those with peak opioid doses over 50 and over 90 MME per day. METHODS This was a retrospective cohort study of Medicare Part D prescription claims data (5% sample) for beneficiaries aged 65 years and older who were prescribed ≥ 1 opioid prescription in 2014 and did not have an opioid prescription in the preceding 180 days. Within a 1-year period of follow-up, we used prescription claims to characterize individuals' opioid exposure, measuring long-term opioid use (≥ 90 days of continuous opioid supply), unique opioid prescribers, and unique opioid-dispensing pharmacies. Peak MME was defined as the maximum daily MME received across all overlapping opioid prescriptions in the observation period. RESULTS 144,127 beneficiaries without an opioid prescription in the previous 6 months filled ≥ 1 opioid prescription in 2014. During the 1-year follow-up period, 6.5% of beneficiaries transitioned to long-term opioid use; 39.5% received opioid prescriptions from > 1 prescriber; 18.1% filled opioid prescriptions from > 1 pharmacy; and 21.8% had a peak MME of 50-89. Among the 28.1% of beneficiaries exposed to a peak MME > 50, 8.6% developed long-term opioid use; 7.0% had 3 or more opioid dispensing pharmacies; and 28.0% had 3 or more opioid prescribers. Among the 6.2% of beneficiaries exposed to a peak MME ≥ 90, 18.5% developed long-term opioid use; 13.0% had 3 or more opioid dispensing pharmacies; and 39.6% had 3 or more opioid prescribers. CONCLUSIONS High doses of opioids were prescribed for about one quarter (28%) of Medicare beneficiaries with new opioid use in 2014. Having multiple opioid prescribers or multiple opioid dispensing pharmacies was common, especially among those prescribed higher doses. These prescription patterns can be particularly helpful to identify older adults with increased opioid-related risk. DISCLOSURES No funding supported this study. Raman reports research grants from GlaxoSmithKline not related to this study. Roberts was supported by a CTSA grant from NCATS awarded to the University of Kansas Medical Center for Frontiers: The Heartland Institute for Clinical and Translational Research (#KL2TR000119). The other authors have no potential conflicts to report.
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Affiliation(s)
- Sudha R. Raman
- Department of Population Health Sciences, Duke University School of Medicine, and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Christopher Bush
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Ruchir N. Karmali
- Department of Population Health Sciences, Duke University School of Medicine and Duke Clinical Research Institute, Duke University, Durham, North Carolina, and Division of Research, Kaiser Permanente Northern California, Oakland
| | - Lawrence H. Greenblatt
- Department of Medicine and Department of Community and Family Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Andrew W. Roberts
- Department of Population Health and Department of Anesthesiology, University of Kansas Medical Center, Kansas City
| | - Asheley C. Skinner
- Department of Population Health Sciences, Duke University School of Medicine, and Duke Clinical Research Institute, Duke University, Durham, North Carolina
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Abstract
IMPORTANCE Time pressure to provide a quick fix is commonly cited as a reason why opioids are frequently prescribed in the United States, but there is little evidence of an association between appointment timing and clinical decision-making. As the workday progresses and appointments run behind schedule, physicians may be more likely to prescribe opioids. OBJECTIVE To estimate whether characteristics of appointment timing are associated with clinical decision-making about pain treatment. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of physician behavior used data from electronic health record systems in primary care offices in the United States to analyze primary care appointments occurring in 2017 for patients with a new painful condition who had not received an opioid prescription within the past year. MAIN OUTCOMES AND MEASURES The association between treatment decisions and 2 dimensions of appointment timing (order of appointment occurrence and delay relative to scheduled start time) were assessed. The rates of opioid prescribing were measured and compared with rates of nonopioid pain medication (ie, nonsteroidal anti-inflammatory drugs) prescribing and referral to physical therapy. All rates were estimated within the same physician using physician fixed effects, adjusting for patient, appointment, and seasonal characteristics. RESULTS Among 678 319 primary care appointments (642 262 patients; 392 422 [61.1%] women) with 5603 primary care physicians, the likelihood that an appointment resulted in an opioid prescription increased by 33% as the workday progressed (1st to 3rd appointment, 4.0% [95% CI, 3.9%-4.1%] vs 19th to 21st appointment, 5.3% [95% CI. 5.1%-5.6%]; P < .001) and by 17% as appointments ran behind schedule (0-9 minutes late, 4.4% [95% CI, 4.3%-4.6%] vs ≥60 minutes late, 5.2% [95% CI, 5.0%-5.4%]; P < .001). Prescribing of nonsteroidal anti-inflammatory drugs and referral to physical therapy did not display similar patterns. CONCLUSIONS AND RELEVANCE These findings suggest that, even within an individual physician's schedule, clinical decision-making for opioid prescribing varies by the timing and lateness of appointments.
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Affiliation(s)
- Hannah T. Neprash
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Michael L. Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Barnett ML, Zhao X, Fine MJ, Thorpe CT, Sileanu FE, Cashy JP, Mor MK, Radomski TR, Hausmann LRM, Good CB, Gellad WF. Emergency Physician Opioid Prescribing and Risk of Long-term Use in the Veterans Health Administration: an Observational Analysis. J Gen Intern Med 2019; 34:1522-1529. [PMID: 31144281 PMCID: PMC6667564 DOI: 10.1007/s11606-019-05023-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/05/2019] [Accepted: 03/21/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Treatment by high-opioid prescribing physicians in the emergency department (ED) is associated with higher rates of long-term opioid use among Medicare beneficiaries. However, it is unclear if this result is true in other high-risk populations such as Veterans. OBJECTIVE To estimate the effect of exposure to high-opioid prescribing physicians on long-term opioid use for opioid-naïve Veterans. DESIGN Observational study using Veterans Health Administration (VA) encounter and prescription data. SETTING AND PARTICIPANTS Veterans with an index ED visit at any VA facility in 2012 and without opioid prescriptions in the prior 6 months in the VA system ("opioid naïve"). MEASUREMENTS We assigned patients to emergency physicians and categorized physicians into within-hospital quartiles based on their opioid prescribing rates. Our primary outcome was long-term opioid use, defined as 6 months of days supplied in the 12 months subsequent to the ED visit. We compared rates of long-term opioid use among patients treated by high versus low quartile prescribers, adjusting for patient demographic, clinical characteristics, and ED diagnoses. RESULTS We identified 57,738 and 86,393 opioid-naïve Veterans managed by 362 and 440 low and high quartile prescribers, respectively. Patient characteristics were similar across groups. ED opioid prescribing rates varied more than threefold between the low and high quartile prescribers within hospitals (6.4% vs. 20.8%, p < 0.001). The frequency of long-term opioid use was higher among Veterans treated by high versus low quartile prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%; adjusted OR 1.11, 95% CI 0.997-1.24, p = 0.056). In subgroup analyses, there were significant associations for patients with back pain (adjusted OR 1.25, 95% CI 1.01-1.55, p = 0.04) and for those with a history of depression (adjusted OR 1.28, 95% CI 1.08-1.51, p = 0.004). CONCLUSIONS ED physician opioid prescribing varied by over 300% within facility, with a statistically non-significant increased rate of long-term use among opioid-naïve Veterans exposed to the highest intensity prescribers.
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Affiliation(s)
- Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
| | - John P Cashy
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for High Value Health Care, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA.
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Frequency and Risk Factors for Prolonged Opioid Prescriptions After Surgery for Brachial Plexus Injury. J Hand Surg Am 2019; 44:662-668.e1. [PMID: 31078338 PMCID: PMC7193763 DOI: 10.1016/j.jhsa.2019.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 02/07/2019] [Accepted: 04/02/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE We hypothesized that patients with preoperative opioid prescriptions and diagnoses of depression and anxiety would be at increased risk for prolonged opioid prescriptions after surgery for brachial plexus injury (BPI). METHODS Using an administrative database of privately insured patients, we assembled a cohort of BPI surgery patients and a control group of non-BPI patients, matching for age, sex, and year. Pharmacy claims for prescriptions filled for opioids and neuropathic pain medications were examined 12 months before surgery to 180 days after surgery. The primary outcome was prolonged opioid prescription, defined as receiving a prescription 90 to 180 days after the index (BPI surgery or randomly selected date of service for controls). Multivariable regression was used to examine risk factors for postoperative opioid use, including diagnoses of depression, anxiety, drug abuse, tobacco use, and preoperative use of opioids and neuropathic pain medications. A subgroup analysis was performed for opioid-naive BPI patients between 30 days to 1 year before surgery. RESULTS Among BPI surgery patients (n = 1,936), 27.7% had prolonged opioid prescriptions. Among opioid-naive BPI patients (n = 911), 10.8% had prolonged opioid prescriptions. In controls (n = 19,360), frequency of prolonged opioid prescriptions was 0.11%. Among all BPI patients, after adjustment for age and sex, predictors of prolonged postoperative opioid prescriptions in BPI patients were preoperative opioids, preoperative neuropathic pain medication use, histories of drug abuse, tobacco use, and anxiety. CONCLUSIONS Prolonged postoperative opioids prescriptions after BPI reconstruction are higher than previous estimates among other surgical patients. In addition to establishing normative data among this population, our findings serve to increase awareness of risk factors for prolonged opioids after BPI reconstruction and encourage coordinated multidisciplinary care. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Bixler FR, Radomski TR, Zickmund SL, Roman KM, Hausmann LRM, Thorpe CT, Hale JA, Sileanu FE, Gellad WF. Primary care physicians' perspectives on Veterans who obtain prescription opioids from multiple healthcare systems. J Opioid Manag 2019; 15:183-191. [PMID: 31343720 DOI: 10.5055/jom.2019.0502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To characterize primary care physicians' (PCPs') perceptions of the reasons patients receive opioid medications from both VA and non-VA healthcare systems. DESIGN Qualitative. SETTING Department of Veterans Affairs (VA). PARTICIPANTS Forty-two VA PCPs who prescribed opioids to at least 15 patients and who practiced in Massachusetts, Illinois, or Pennsylvania. METHODS Thirty-minute, semistructured telephone interviews were conducted in 2016, addressing topics regarding PCPs' experiences and perspectives on patients who use both VA and non-VA healthcare systems to obtain prescription opioids. The analysis focused on two questions: attributes that PCPs believe characterize dual-use patients and reasons that PCPs believe patients obtain opioids from both VA and non-VA sources. RESULTS PCPs identified multiple attributes of, and reasons for, patients obtaining opioid medications from both VA and non-VA healthcare systems, including pain issues, opioid misuse, having healthcare managed through multiple healthcare systems, and transferring care between systems. More than half of the PCPs identified addiction and diversion as key attributes and reasons why patients obtain prescription opioids from multiple sources. PCPs also identified several behavioral and psychological factors as attributes of these patients. CONCLUSIONS PCPs within the VA have varying perceptions of patients obtaining opioid medications from multiple healthcare systems, with pain complaints and opioid misuse as the primary themes. This knowledge about PCPs' perceptions can be incorporated into interventions to better manage pain and prescription opioid use by VA patients.
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Affiliation(s)
- Felicia R Bixler
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, Illinois
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Susan L Zickmund
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - KatieLynn M Roman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Schneeweiss S, Rassen JA, Brown JS, Rothman KJ, Happe L, Arlett P, Dal Pan G, Goettsch W, Murk W, Wang SV. Graphical Depiction of Longitudinal Study Designs in Health Care Databases. Ann Intern Med 2019; 170:398-406. [PMID: 30856654 DOI: 10.7326/m18-3079] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pharmacoepidemiologic and pharmacoeconomic analysis of health care databases has become a vital source of evidence to support health care decision making and efficient management of health care organizations. However, decision makers often consider studies done in nonrandomized health care databases more difficult to review than randomized trials because many design choices need to be considered. This is perceived as an important barrier to decision making about the effectiveness and safety of medical products. Design flaws in longitudinal database studies are avoidable but can be unintentionally obscured in the convoluted prose of methods sections, which often lack specificity. We propose a simple framework of graphical representation that visualizes study design implementations in a comprehensive, unambiguous, and intuitive way; contains a level of detail that enables reproduction of key study design variables; and uses standardized structure and terminology to simplify review and communication to a broad audience of decision makers. Visualization of design details will make database studies more reproducible, quicker to review, and easier to communicate to a broad audience of decision makers.
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Affiliation(s)
- Sebastian Schneeweiss
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.S., S.V.W.)
| | | | - Jeffrey S Brown
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts (J.S.B.)
| | | | - Laura Happe
- Journal of Managed Care and Specialty Pharmacy, Alexandria, Virginia (L.H.)
| | - Peter Arlett
- European Medicines Agency, London, United Kingdom (P.A.)
| | - Gerald Dal Pan
- U.S. Food and Drug Administration, Silver Spring, Maryland (G.D.)
| | - Wim Goettsch
- The National Health Care Institute, Diemen, and Utrecht University, Utrecht, the Netherlands (W.G.)
| | | | - Shirley V Wang
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.S., S.V.W.)
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Zhu W, Chernew ME, Sherry TB, Maestas N. Initial Opioid Prescriptions among U.S. Commercially Insured Patients, 2012-2017. N Engl J Med 2019; 380:1043-1052. [PMID: 30865798 PMCID: PMC6487883 DOI: 10.1056/nejmsa1807069] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The United States is undergoing a crippling opioid epidemic, spurred in part by overuse of prescription opioids by adults 25 to 64 years of age. Of concern are long-duration and high-dose initial prescriptions, which place the patients and their friends and relatives at heightened risk for long-term opioid use, misuse, overdose, and death. METHODS We estimated the incidence of initial opioid prescriptions in each month between July 2012 and December 2017 using administrative-claims data from across the United States (accessed through Blue Cross-Blue Shield [BCBS] Axis); monthly incidence was estimated as the percentage of enrollees who received an initial opioid prescription among those who had not used opioids (i.e., no opioid prescription or a diagnosis of opioid use disorder in the 6 months before a given month). We then estimated the percentage of enrollees initiating opioid therapy who received a long-duration or high-dose initial opioid prescription in each month during this period. We also calculated the number of providers who initiated opioid therapy in any patient who had not used opioids in each month and examined monthly trends in the duration and dose of initial opioid prescriptions in prescriber and patient subgroups. Our study sample included 63,817,512 enrollees who had not used opioids (mean, 15,897,673 per month). RESULTS The monthly incidence of initial opioid prescriptions among enrollees who had not used opioids declined by 54%, from 1.63% in July 2012 to 0.75% in December 2017. This decline was accompanied by a decreasing number of providers (from 114,043 in July 2012 to 80,462 in December 2017) who initiated opioid therapy in any patient who had not used opioids. Nonetheless, among the shrinking subgroup of physicians who initiated opioid therapy in such patients, high-risk prescribing (i.e., prescriptions for more than a 3-day supply or for a dose of 50 morphine milligram equivalents per day or higher) persisted at a monthly rate of 115,378 prescriptions per 15,897,673 enrollees who had not used opioids. CONCLUSIONS As the opioid crisis progressed between July 2012 and December 2017, many providers stopped initiating opioid therapy. Although the number of initial opioid prescriptions declined, a subgroup of providers continued to write high-risk initial opioid prescriptions. (Funded by the National Institute on Aging and a gift from Owen and Linda Robinson.).
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Affiliation(s)
- Wenjia Zhu
- From the Department of Health Care Policy, Harvard Medical School (W.Z., M.E.C., N.M.), RAND (T.B.S.), and the Department of Medicine, Brigham and Women's Hospital (T.B.S.) - all in Boston
| | - Michael E Chernew
- From the Department of Health Care Policy, Harvard Medical School (W.Z., M.E.C., N.M.), RAND (T.B.S.), and the Department of Medicine, Brigham and Women's Hospital (T.B.S.) - all in Boston
| | - Tisamarie B Sherry
- From the Department of Health Care Policy, Harvard Medical School (W.Z., M.E.C., N.M.), RAND (T.B.S.), and the Department of Medicine, Brigham and Women's Hospital (T.B.S.) - all in Boston
| | - Nicole Maestas
- From the Department of Health Care Policy, Harvard Medical School (W.Z., M.E.C., N.M.), RAND (T.B.S.), and the Department of Medicine, Brigham and Women's Hospital (T.B.S.) - all in Boston
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Impact of community pharmacist intervention on concurrent benzodiazepine and opioid prescribing patterns. J Am Pharm Assoc (2003) 2019; 59:238-242. [DOI: 10.1016/j.japh.2018.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/02/2018] [Accepted: 10/07/2018] [Indexed: 11/18/2022]
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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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Zhang Y, Johnson P, Jeng PJ, Reid MC, Witkin LR, Schackman BR, Ancker JS, Bao Y. First Opioid Prescription and Subsequent High-Risk Opioid Use: a National Study of Privately Insured and Medicare Advantage Adults. J Gen Intern Med 2018; 33:2156-2162. [PMID: 30206790 PMCID: PMC6258623 DOI: 10.1007/s11606-018-4628-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/24/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Yongkang Zhang
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - Phyllis Johnson
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - Philip J Jeng
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - M Carrington Reid
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Lisa R Witkin
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA.,Division of Pain Medicine, New York-Presbyterian/Lower Manhattan Hospital, New York, NY, USA
| | - Bruce R Schackman
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA.,Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Jessica S Ancker
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - Yuhua Bao
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA. .,Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA.
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Bushnell G, Stürmer T, Mack C, Pate V, Miller M. Who diagnosed and prescribed what? Using provider details to inform observational research. Pharmacoepidemiol Drug Saf 2018; 27:1422-1426. [PMID: 30379369 PMCID: PMC6407693 DOI: 10.1002/pds.4685] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 08/03/2018] [Accepted: 10/02/2018] [Indexed: 11/06/2022]
Abstract
PURPOSE To describe how often patients with depression initiating antidepressants receive their depression diagnosis and prescriptions from the same provider and, when simultaneously initiating benzodiazepines, how often both prescriptions come from the same provider. METHODS Using a US healthcare claims database, we created a cohort of adults (18-64 years) with a depression diagnosis who initiated antidepressants. We examined concordance by provider specialty and provider identifier between (a) the first antidepressant prescription fill and most proximal depression diagnosis, and (b) the initial antidepressant and benzodiazepine prescription fills among simultaneous benzodiazepine and antidepressant initiators. RESULTS Among 245 166 antidepressant initiators with a recent depression diagnosis (female = 67%; median age = 39), the specialty of the provider assigning the depression diagnosis matched the antidepressant prescriber's specialty in 94% of cases with known provider details (provider identifier concordance = 93%). Concordance was higher for adults diagnosed by a general practitioner (98%) or psychiatrist (92%) than for those diagnosed by a psychologist (74%). In simultaneous new users of antidepressants and benzodiazepines (n = 19 371), both prescriptions were issued by the same provider specialty and provider identifier 94% and 93% of the time, respectively. CONCLUSIONS The vast majority of patients who received antidepressant prescriptions and depression diagnoses appear to have received both diagnosis and antidepressants from the same provider, suggesting that when antidepressants are issued around the time a patient is diagnosed with depression, the antidepressant was likely prescribed for depression. In addition, the great majority of patients who simultaneously initiate benzodiazepines appear to do so under the direction of one provider.
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Affiliation(s)
- Greta Bushnell
- Department of Epidemiology, University of North Carolina at Chapel Hill
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina at Chapel Hill
| | | | - Virginia Pate
- Department of Epidemiology, University of North Carolina at Chapel Hill
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Chui PW, Bastian LA, DeRycke E, Brandt CA, Becker WC, Goulet JL. Dual Use of Department of Veterans Affairs and Medicare Benefits on High-Risk Opioid Prescriptions in Veterans Aged 65 Years and Older: Insights from the VA Musculoskeletal Disorders Cohort. Health Serv Res 2018; 53 Suppl 3:5402-5418. [PMID: 30298672 DOI: 10.1111/1475-6773.13060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To examine the association of dual use of both Veterans Health Administration (VHA) and Medicare benefits with high-risk opioid prescriptions among Veterans aged 65 years and older with a musculoskeletal disorder diagnosis. DATA SOURCES/STUDY SETTING Data were obtained from the VA Musculoskeletal Disorder (MSD) cohort and national Medicare claims data from 2008 to 2010. STUDY DESIGN We conducted a retrospective analysis of Veterans enrolled in Medicare to examine the association of dual use with long-term opioid use (>90 days of prescription opioids/year) and overlapping opioid prescriptions. Multivariable logistic regression was performed adjusting for demographic and clinical characteristics. DATA COLLECTION/EXTRACTION METHODS We identified 21,111 Veterans enrolled in Medicare who entered the MSD cohort in 2008 and received an opioid prescription in 2010. We linked VHA data with Medicare claims data to identify opioid prescriptions for these Veterans in 2010. PRINCIPAL FINDINGS As compared to Veterans who used only VHA or Medicare, Veterans with dual use of VHA and Medicare were significantly more likely to be prescribed long-term opioid therapy (OR = 4.61 (95 percent CI 4.05-5.25) and were also found to have higher median number of opioid prescriptions and higher odds of overlapping opioid prescriptions in 1 year. Patients reporting moderate-to-severe pain, non-white-race/ethnicity, and higher scoring on the Charlson comorbidity index had significantly higher odds of long-term opioid prescriptions. CONCLUSIONS Among Veterans aged 65 years or older, dual use of both VHA and Medicare was associated with higher odds of long-term opioid therapy. Our findings suggest there may be benefit to combining VHA and non-VHA electronic health record data to minimize exposure to high-risk opioid prescribing.
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Affiliation(s)
- Philip W Chui
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Lori A Bastian
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Eric DeRycke
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT
| | - Cynthia A Brandt
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - William C Becker
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Joseph L Goulet
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT
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50
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Abstract
OBJECTIVE To determine characteristics and trends in opioid use, questionable use, and prescribing in Medicare. STUDY SETTING Opioid prescriptions filled through Medicare Part D for beneficiaries with full-year, fee-for-service Medicare coverage during 2006 to 2012. STUDY DESIGN Retrospective analysis of a 20 percent sample of Medicare claims data. Estimates are adjusted using multivariable regression analysis. DATA COLLECTION Opioid use, opioid abuse, questionable opioid use, and opioid prescribing by specialty. PRINCIPAL FINDINGS Opioid use in Medicare was stable from 2006 to 2012 on average. More than 1 in 3 beneficiaries filled an opioid prescription annually; about 1 in 10 were chronic opioid users. The distribution of opioid users shifted in favor of diagnoses often associated with chronic pain. Opioid users were increasingly likely to abuse opioids or display patterns of questionable use from 2006 to 2010, with a slowdown in later years. Average outcomes mask significant variation as the distribution of opioid use widened over the analysis period. Prescribing quantity and intensity varied by specialty. The largest quantity increases were among nurse practitioners and physician assistants. CONCLUSIONS Opioid utilization and prescribing are increasingly heterogeneous from 2006 to 2012. Future research should focus on explaining differential trends in utilization and prescribing.
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Affiliation(s)
- Sarah Axeen
- Keck School of Medicine, Department of Emergency MedicineSchaeffer Center for Health Policy and EconomicsUniversity of Southern CaliforniaLos AngelesCA
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