The Risk of Overdose With Concomitant Use of Z-Drugs and Prescription Opioids: A Population-Based Cohort Study

Risk of drug-related death associated with co-prescribing of gabapentinoids and Z-drugs among people receiving opioid-agonist treatment: A national retrospective cohort study

BACKGROUND

Prescribing of gabapentinoids and Z-drug-hypnotics has increased in the population and among people receiving opioid-agonist treatment (OAT) for opioid dependence. Evidence is mixed on whether co-prescribing of sedatives such as gabapentinoids and Z-drugs during OAT increases risk of drug-related death (DRD).

METHODS

We conducted a retrospective cohort study of individuals prescribed OAT between 2011 and 2020 in Scotland. Prescribing records were linked to mortality data and other healthcare datasets (sociodemographic, comorbidity). We identified episodes of treatment with gabapentinoids/Z-drugs and used multivariable quasi-Poisson regression to model associations between co-prescription and DRD risk.

RESULTS

Among 46,602 individuals with 304,783 person-years of follow-up, we found that co-prescription was common, with 25 % and 34 % ever being co-prescribed gabapentinoids and Z-drugs, respectively. Gabapentinoid exposure was strongly associated (adjusted hazard ratio (aHR)=2·18, 95 % CI=1·92, 2·46) and Z-drug exposure moderately associated (aHR=1·39, 95 % CI=1·15, 1·66) with elevated risk of DRD. Gabapentinoid exposure was associated with DRD risk on and off OAT; Z-drug exposure was less strongly associated with DRD risk when on OAT.

CONCLUSIONS

Co-prescription of gabapentinoids and Z-drugs is common among OAT patients. However, co-prescription is associated with increased risk of DRD. Alternatives to prescribing sedative medications to OAT patients and/or greater monitoring - if prescribed - are needed.

Total Joint Arthroplasty and Sleep: The State of the Evidence

Background

As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively.

Methods

A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively.

Results

Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids.

Conclusions

Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.

Prevalence and trend of central nervous system-active medication polypharmacy among US commercially insured adults with vs without early-onset dementia: a multi-year cross-sectional study

BACKGROUND

Limited data exist on the prevalence and trend of central nervous system (CNS)-active medication polypharmacy among adults with early-onset dementia (EOD) and whether these estimates differ for adults without EOD but with chronic pain, depression, or epilepsy, conditions managed by CNS-active medications.

METHODS

A multi-year, cross-sectional study using 2012-2021 MarketScan Commercial Claims data was conducted among adults aged 30 to 64 years with EOD and those without EOD but having a diagnosis of chronic pain, depression, or epilepsy as comparison groups. For each disease cohort, the primary outcome was CNS-active medication polypharmacy defined as concurrent use of ≥ 3 CNS-active medications on the US Beers Criteria list that overlapped for > 30 consecutive days during 12 months following a randomly selected medical encounter with the disease diagnosis. A separate multivariate modified Poisson regression model was used to estimate time trends in CNS polypharmacy in each disease cohort. Differences in trend estimates between EOD and non-EOD disease cohorts were examined by an interaction between EOD status and yearly time.

RESULTS

From 2013 to 2020, the annual crude prevalence of CNS polypharmacy was higher among adults with EOD (21.2%-25.0%) than adults with chronic pain (5.1%-5.9%), depression (14.8%-21.7%), or epilepsy (20.0%-22.3%). The adjusted annual prevalence of CNS polypharmacy among patients with EOD did not significantly change between 2013 and 2020 (adjusted prevalence rate ratio [aPRR], 0.94; 95% CI, 0.88-1.01), whereas a significant decreasing trend was observed among non-EOD cohorts with chronic pain (aPRR, 0.66; 95% CI, 0.63-0.69), depression (aPRR, 0.81; 95% CI, 0.77-0.85), and epilepsy (aPRR, 0.86; 95% CI, 0.83-0.89). The interaction analysis indicated that patients with epilepsy and depression (vs with EOD) had a decreasing probability of CNS-active medication polypharmacy over time (aPRR, 0.98 [95% CI, 0.98-0.99]; P < .001 for interaction for both conditions).

CONCLUSIONS

The prevalence of CNS polypharmacy among US commercially insured adults with EOD (vs without) was higher and remained unchanged from 2013 to 2021. Medication reviews of adults with EOD and CNS polypharmacy are needed to ensure that benefits outweigh risks associated with combined use of these treatments.

Impact of 30-day prescribed opioid dose trajectory on fatal overdose risk: A population-based, statewide cohort study

BACKGROUND

Both increases and decreases in patients' prescribed daily opioid dose have been linked to increased overdose risk, but associations between 30-day dose trajectories and subsequent overdose risk have not been systematically examined.

OBJECTIVE

To examine the associations between 30-day prescribed opioid dose trajectories and fatal opioid overdose risk during the subsequent 15 days.

DESIGN

Statewide cohort study using linked prescription drug monitoring program and death certificate data. We constructed a multivariable Cox proportional hazards model that accounted for time-varying prescription-, prescriber-, and pharmacy-level factors.

PARTICIPANTS

All patients prescribed an opioid analgesic in California from March to December, 2013 (5,326,392 patients).

MAIN MEASURES

Dependent variable: fatal drug overdose involving opioids. Primary independent variable: a 16-level variable denoting all possible opioid dose trajectories using the following categories for current and 30-day previously prescribed daily dose: 0-29, 30-59, 60-89, or ≥90 milligram morphine equivalents (MME).

KEY RESULTS

Relative to patients prescribed a stable daily dose of 0-29 MME, large (≥2 categories) dose increases and having a previous or current dose ≥60 MME per day were associated with significantly greater 15-day overdose risk. Patients whose dose decreased from ≥90 to 0-29 MME per day had significantly greater overdose risk compared to both patients prescribed a stable daily dose of ≥90 MME (aHR 3.56, 95%CI 2.24-5.67) and to patients prescribed a stable daily dose of 0-29 MME (aHR 7.87, 95%CI 5.49-11.28). Patients prescribed benzodiazepines also had significantly greater overdose risk; being prescribed Z-drugs, carisoprodol, or psychostimulants was not associated with overdose risk.

CONCLUSIONS

Large (≥2 categories) 30-day dose increases and decreases were both associated with increased risk of fatal opioid overdose, particularly for patients taking ≥90 MME whose opioids were abruptly stopped. Results align with 2022 CDC guidelines that urge caution when reducing opioid doses for patients taking long-term opioid for chronic pain.

Polypharmacy and Healthcare Service Use Among Prescription Opioid Poisoning Cases Age 50

Objectives: To examine relationships between polypharmacy and level of healthcare service use among prescription opioid poisoning cases age 50 and older. Methods: Data came from the American Association of Poison Control Center's National Poison Data System, 2015-2020. We used multinomial logistic regression to examine the study questions. Results: Of the 77 946 cases with prescription opioid exposures, 64.5% were managed at a healthcare facility (HCF). Of HCF-managed cases, 41.2% were treated/evaluated and released and 21.3% and 37.5% were admitted for noncritical care and critical care, respectively. Medications for cardiovascular disease, benzodiazepines, other types of sedatives/hypnotics, antipsychotics, muscle relaxants, acetaminophen, and gabapentin were associated with increased risk of admission to both noncritical and critical care compared to treatment/evaluation and release. Acetaminophen use had the highest relative risk ratios (RRRs) for noncritical care (1.70, 95% CI = 1.51-1.91) and critical care (1.56, 95% CI = 1.39-1.76). Each additional medication/substance used was associated with 1.14 (95% CI = 1.11-1.17) and 1.19 (95% CI = 1.16-1.22) greater risk of noncritical and critical care admissions, respectively. Conclusions: Among older-adult poison control center cases for prescription opioid exposures, co-use of several commonly prescribed/used medicines was associated with increased risk of admissions to both noncritical and critical care units. Careful monitoring of medication use among older adults who use prescription opioids may reduce the risk of unintentional and intentional opioid poisoning.

Prescription high-risk polysubstance use among opioid maintenance treatment patients

BACKGROUND

Among individuals receiving buprenorphine or methadone as opioid maintenance treatment (OMT), concomitant use of other central nervous system depressants, including prescription drugs, can increase risk of overdose. We aimed to 1) determine the prevalence of use of high-risk prescription drugs (opioid analgesics, benzodiazepines, benzodiazepine-related drugs, and gabapentinoids) among OMT patients, 2) calculate its associations with different mental health and pain-related diagnoses, and 3) compare prevalence of concomitant use with the general population.

METHODS

A national sample comprising all individuals filling at least one prescription of OMT drugs in Norway in 2019 was formed. Healthcare registry data were linked to investigate high-risk prescription drug use and different diagnoses. We calculated one-year prevalence of use, amount dispensed in defined daily doses (DDDs), and the number of prescribers for the different high-risk prescription drugs. Logistic regression was used to determine associations (adjusted odds ratios; aOR, 95% confidence intervals (CIs)) between diagnoses and use. Prevalence of use was calculated both in the OMT patient sample and the general population.

RESULTS

Among the OMT patient sample (n=7,299), 47.6% (n=3,476) filled prescriptions for benzodiazepines. For each high-risk prescription drug group, there was a median of 1-2 prescribers. Musculoskeletal diagnoses were the strongest factor for concomitant high-risk prescription drug use for both males (aOR 3.23, CI: 2.72-3.85) and females (aOR 3.07, CI: 2.42- 3.90). The 1-year prevalence of benzodiazepine use was 11.4 times higher for males and 7.1 times higher for females in OMT than the general population. The amount in DDDs was higher for every drug for OMT patients than the general population, particularly for benzodiazepines.

CONCLUSIONS

OMT patients frequently filled prescriptions for high-risk drugs, and in higher dosages than the general population. However, we found little evidence of 'doctor shopping.' Given that these prescription drugs carry overdose risk, particularly when combined with OMT drugs, our findings emphasize the continued need for education and caution to both prescribers and patients on their concomitant use with OMT.

Understanding the rise in overdose deaths involving opioids and non-opioid prescription drugs in the United States

BACKGROUND

Previous studies demonstrate that the reformulation of OxyContin in the U.S. in 2010 induced substitution to illicit opioids, causing illicit opioid markets to grow disproportionately fast in states more exposed to the reformulation. In this paper, we examine if this shift to the illicit market also led to a rise in polysubstance overdose deaths involving non-opioid prescription drugs, including gabapentinoids and "Z-drugs" and, separately, benzodiazepines.

METHODS

Using a difference-in-differences framework, the relationship between exposure to reformulation and overdose death rates including specific substances was studied in each year from 1999 to 2020 while accounting for fixed differences across states, common nationwide shocks, and state-level differences in pain reliever misuse prior to reformulation. Exposure to reformulation was measured as the pre-reformulation rate of OxyContin misuse.

RESULTS

Exposure to reformulation predicted growth in overdose deaths involving gabapentinoids and Z-drugs. There is less evidence that it predicted growth in overdose deaths involving benzodiazepines. However, for all substances, there is strong evidence that pre-reformulation OxyContin misuse rates predicted post-reformulation growth in overdose deaths concurrently involving synthetic opioids.

DISCUSSION

The opioid crisis has changed in radical ways. This study links a major supply-side intervention to the increase in polysubstance overdose deaths involving non-opioid prescription drugs, specifically gabapentinoids and Z-drugs.

Trends in overdose deaths involving gabapentinoids and Z-drugs in the United States

INTRODUCTION

As policies have been implemented to limit access to prescription opioids, other drugs have been prescribed off-label, sometimes concurrently with opioids, to manage pain. There are concerns about the use of gabapentinoids and "Z-drugs" with opioids. As the opioid crisis transitions to illicit opioids and polysubstance use, little work quantifies the concurrent involvement of non-opioid prescription drugs and illicit opioids in overdose deaths.

METHODS

Data from the census of deaths in the United States for 1999-2020 were used to understand trends in deaths involving gabapentinoids/Z-drugs and opioid co-involvement. These trends were studied overall and by sex, race, age, and education.

RESULTS

Per capita overdose deaths involving gabapentinoids/Z-drugs increased almost continuously since 1999, averaging 15.8% annual growth. This rate increased to 32% in 2020, primarily due to overdoses involving synthetic opioids. Women typically had higher rates of overdose deaths involving both opioids and gabapentinoids/Z-drugs, though this disparity disappeared in 2020. White Americans and American Indians/Alaskan Natives historically had higher rates than other racial groups; however, Black Americans experienced over 60% annual growth in recent years. Low education groups have been disproportionately impacted. The age incidence tends to be older than overdoses involving opioids more generally.

CONCLUSION

Overdose deaths involving opioids and gabapentinoids/Z-drugs have tended to disproportionately affect women and older age groups compared to all opioid-involved overdoses. As deaths involving synthetic opioids likely reflect use of illicitly-obtained opioids, there may be less of a role for policies targeting the concurrent prescribing of gabapentinoids/Z-drugs with opioids to reduce these deaths.

Benzodiazepine Use and Dependence in Relation to Chronic Pain Intensity and Pain Catastrophizing

Benzodiazepines (BZDs), a class of sedative-hypnotic medications, generated concern as their popularity grew, with particular alarm regarding elevated rates of BZD use among chronic pain populations. Consistent with negative reinforcement/motivational models of substance use, desire for pain alleviation may motivate BZD use. Yet, little is known about relations between pain and addiction-relevant BZD use processes. This cross-sectional survey study aimed to: a) test associations between pain intensity and clinically relevant BZD use patterns, and b) examine the role of pain catastrophizing in hypothesized pain-BZD relations. Participants included 306 adults with chronic musculoskeletal pain and a current BZD prescription who completed an online survey study (Mage = 38.7, 38.9% female). Results indicated that pain intensity was positively associated with past-month BZD use frequency, BZD dependence severity, and likelihood of endorsing BZD misuse behaviors (ps < .05). Pain catastrophizing was positively associated with BZD dependence/likelihood of BZD misuse, covarying for pain intensity (P < .05). These findings build upon an emerging literature by highlighting positive covariation of pain intensity and pain catastrophizing with addiction-relevant BZD use behaviors. Results underscore the need to further investigate high-risk BZD use among individuals with chronic pain, with and without concurrent opioid use, to inform prevention/intervention efforts. PERSPECTIVE: This article presents findings on cross-sectional associations of pain intensity and pain catastrophizing with clinically relevant benzodiazepine (BZD) use outcomes, including dependence and misuse, among individuals with chronic pain. Findings help elucidate the higher burden of BZD misuse/dependence in chronic pain populations and suggest that pain relief may be a common, yet under recognized, self-reported motivation for taking BZDs.

Association of Benzodiazepine Treatment for Sleep Disorders With Drug Overdose Risk Among Young People

IMPORTANCE

Benzodiazepines are prescribed for the treatment of adolescent sleep disorders; however, benzodiazepine overdoses occur, often in combination with opioids.

OBJECTIVE

To evaluate whether benzodiazepine treatment for sleep disorders, compared with alternative pharmacologic treatments (trazodone, hydroxyzine, zolpidem, zaleplon, and eszopiclone), is associated with increased risk of drug overdose for young people.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included privately insured people 10 to 29 years of age identified from a US commercial claims database (MarketScan), from January 1, 2009, to December 31, 2018. Young people with a sleep disorder diagnosis initiating benzodiazepine (n = 23 084) or comparator pharmacologic treatments (n = 66 706) were included in the study. Statistical analysis was performed from November 1, 2021, to May 16, 2022.

EXPOSURES

New use of benzodiazepine treatment or comparator pharmacologic treatments (defined as ≥1 year without a prescription for benzodiazepine or comparator medications).

MAIN OUTCOMES AND MEASURES

Incident diagnosed drug overdoses were identified from inpatient and emergency department records within 6 months of treatment initiation. The propensity score-adjusted cumulative incidence of overdose and hazard ratios (HRs) were estimated with intention-to-treat (analyzed based on initial treatment) and as-treated analyses (added censoring at treatment discontinuation). Results were stratified by prior prescription opioid fill.

RESULTS

The cohort included 23 084 young people initiating benzodiazepine treatment (14 444 female participants [62.6%]; mean [SD] age, 23 [4.1] years) and 66 706 initiating a comparator treatment (38 446 female participants [57.6%]; mean [SD] age, 22 [4.4] years). Six months after treatment initiation, 9.7% (95% CI, 9.3%-10.1%) of benzodiazepine users and 12.3% (95% CI, 12.1%-12.6%) of the comparator group were still receiving treatment. The crude incidence of drug overdose at 6 months was 0.9% for benzodiazepine initiators and 0.8% for comparator treatment initiators. In adjusted analyses, an increased risk of drug overdose was associated with benzodiazepines vs comparator treatments (intention-to-treat analysis: HR, 1.25 [95% CI, 1.03-1.51]; as-treated analysis: HR, 1.44 [95% CI, 1.14-1.80]). This association was stronger among young people with a recent prescription opioid fill vs those without a recent prescription opioid fill (as-treated analysis: adjusted HR, 2.01 [95% CI, 1.24-3.25] vs adjusted HR, 1.31 [95% CI, 1.00-1.70]).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that benzodiazepines, compared with alternative pharmacologic treatments for common sleep disorders, were associated with an increased risk of drug overdose among young people during the following 6-month period, especially among those with a recent opioid prescription. Drug overdose is an important safety consideration when treating young people with benzodiazepines.

Time trends and associated factors of global burden due to drug use disorders in 204 countries and territories, 1990-2019

BACKGROUND

Drug use disorders (DUDs) have been a public health crisis which strongly impacted community health and socio-economic development. However, there are few studies based on the latest global data to show changes in the disease burden due to DUDs, specifically investigating associations between the country-level socio-economic factors and the burden of DUDs.

METHODS

Data of DUDs were extracted from the Global Burden of Disease Study 2019 database to explore the trends of the disease burden due to DUDs from 1990 to 2019. Univariate linear regression and stepwise multiple linear regression analysis were performed to analyze the correlations between burden due to DUDs and country-level socio-economic factors.

RESULTS

Globally, the number of disability-adjusted life-years (DALYs) caused by DUDs approximately increased by 2.6% yearly from 1990 to 2019, though the age-standardized DALY rate has not changed significantly in the past 30 years. The age-standardized DALY rate of opioid use disorders showed an upward trend during the past 30 years and was highest among 5 types of DUDs in 2019. Inequality-adjusted human development index (β = 15.9, 95% confidence interval [CI]: 12.9-18.9, P < 0.001) was identified as the key risk factor associated with square-root transformed age-standardized DALY rate of DUDs.

CONCLUSIONS

Global burden due to DUDs has increased significantly over the past 30 years. More effective targeted public health policies should be formulated to manage the public health challenge of DUDs, especially in developed countries and territories.

Past-year use or misuse of an opioid is associated with use of a sedative-hypnotic medication: a US National Survey on Drug Use and Health (NSDUH) study

STUDY OBJECTIVES

Prescription use and misuse of opioids are linked to greater sleep disturbance. However, there are limited data on the prevalence of sedative-hypnotic medication use among persons who use opioids. Therefore, this study examined whether past-year sedative-hypnotic use among persons who used/misused opioids was higher than among individuals who did not use opioids.

METHODS

Data were acquired from the US National Survey on Drug Use and Health for 2015-2018. Use of a sedative benzodiazepine (temazepam, flurazepam, triazolam) or a Z-drug (eszopiclone, zaleplon, zolpidem) was examined in relation to use/misuse of an opioid within the past year. Logistic regression models estimated the associations between opioids and sedative-hypnotics using inverse probability of treatment weighting. A secondary machine learning analysis tested 6 binary classifiers to predict sedative-hypnotic use based on opioid use/misuse and other covariates.

RESULTS

Of 171,766 respondents, 24% used a prescription opioid whereas 3.6% misused an opioid in the past year. Among those who used a prescription opioid, 1.9% received a sedative benzodiazepine and 9% received a Z-drug during the same time frame. Use of an opioid was associated with greater odds of sedative benzodiazepine use (odds ratio, 4.4; 95% confidence interval, 3.61-5.4) and Z-drug use (odds ratio, 3.8; 95% confidence interval, 3.51-4.09), and stronger associations were noted for misuse of an opioid. Machine learning models accurately classified sedative-hypnotic medication use for > 70% of respondents based on opioid use/misuse.

CONCLUSIONS

Sedative-hypnotic use is common among persons who use opioids, which is of concern given the elevated mortality risk with concurrent use of these substances.

CITATION

Tubbs AS, Ghani SB, Naps M, Grandner MA, Stein MD, Chakravorty S. Past-year use or misuse of an opiod is associated with use of a sedative-hypnotic medication: a US National Survey on Drug Use and Health (NSDUH) study. J Clin Sleep Med. 2022;18(3):809-816.

Co-utilization of opioids and nonbenzodiazepine hypnotic drugs in U.S. ambulatory care visits, 2006-2016

OBJECTIVE(S)

This study aimed to characterize the co-utilization of non-benzodiazepine sedative 'Z'-drugs with opioids at ambulatory care visits in the United States.

DESIGN

A cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) from 2006 to 2016 was completed.

SETTING AND PARTICIPANTS

Ambulatory care visits in the United States involving adult patients with an opioid prescription were included in the analysis.

OUTCOME MEASURES

The primary outcome was initiation or continuation of a Z-drug (zolpidem, eszopiclone, or zaleplon) in a patient visit in conjunction with an opioid medication.

RESULTS

The authors analyzed 564,090,296 visits (weighted from a sample of 28,773) with a reported opioid prescription. Co-utilization of opioids with Z-drugs fluctuated during the study period beginning at 4.0% in 2006 (95% CI 2.2%-5.7%), 6.3% in 2012 (3.7%-8.9%), and 4.7% in 2016 (2.8%-6.5%). Among all opioid visits in the study period, co-utilization with a Z-drug was not significantly different among female patients compared with male patients (5.26% vs. 4.63%, P = 0.26). Among visits with concomitant opioid and Z-drugs, 7.0% reported new initiation of both medications in the same visit.

CONCLUSION

At ambulatory care visits between 2006 and 2016, co-utilization of opioids and Z-drugs fluctuated with some differences by sex. Major regulatory advisories and policy changes during this period may have contributed to these varying rates of utilization. Additional work is needed to identify predictors of co-utilization and downstream consequences more widely.