Impact of triplicate prescription program on psychotropic prescribing patterns in long-term care facilities

ORIGINS OF THE OPIOID CRISIS AND ITS ENDURING IMPACTS

Overdose deaths involving opioids have increased dramatically since the 1990s, leading to the worst drug overdose epidemic in U.S. history, but there is limited empirical evidence about the initial causes. In this article, we examine the role of the 1996 introduction and marketing of OxyContin as a potential leading cause of the opioid crisis. We leverage cross-state variation in exposure to OxyContin's introduction due to a state policy that substantially limited the drug's early entry and marketing in select states. Recently unsealed court documents involving Purdue Pharma show that state-based triplicate prescription programs posed a major obstacle to sales of OxyContin and suggest that less marketing was targeted to states with these programs. We find that OxyContin distribution was more than 50% lower in "triplicate states" in the years after the drug's launch. Although triplicate states had higher rates of overdose deaths prior to 1996, this relationship flipped shortly after the launch and triplicate states saw substantially slower growth in overdose deaths, continuing even 20 years after OxyContin's introduction. Our results show that the introduction and marketing of OxyContin explain a substantial share of overdose deaths over the past two decades.

A systematic review of regulatory and educational interventions to reduce the burden associated with the prescriptions of sedative-hypnotics in adults treated for sleep disorders

BACKGROUND

The burden of Sedative-Hypnotics (SHs) has been known since the 1980s. Yet, their consumption remains high. A systematic review of the literature should help to assess efficient interventions to improve the appropriate use of SHs in sleep disorders.

OBJECTIVES

To identify and assess regulatory and educational interventions designed to improve the appropriate use of SHs for insomnia treatment.

METHODS

We conducted a systematic review of the literature according to PRISMA guidelines. A systematic search covering the period 1980-2015 was carried out in Medline, Web of Science, Embase and PsycInfo. We included studies reporting the implementation of regulatory or educational strategies directed towards patients and/or healthcare professionals to improve the appropriate use of SHs to treat insomnia in the community, hospitals and nursing homes.

RESULTS

Thirty-one studies were included: 23 assessed educational interventions (recommendations by mail/email, computer alerts, meetings, mass media campaigns, prescription profile), 8 assessed regulatory interventions (prescription rule restriction, end of reimbursement). The most recent was implemented in 2009. Restrictive prescription rules were effective to reduce the consumption of targeted SHs but led to a switch to other non-recommended SHs. Among educational interventions, only 3 studies out of 7 reported positive results of mono-faceted interventions; whereas, 13 out of the 16 multi-faceted interventions were reported as efficient: particularly, the active involvement of healthcare professionals and patients and the spread of information through mass media were successful. The risk of bias was high for 24 studies (mainly due to the design), moderate for 3 studies and weak for 4 studies.

CONCLUSION

Educational multifaceted studies are presented as the most efficient. But further better designed studies are needed to make evidence-based results more generalizable.

Feasibility of discontinuing chronic benzodiazepine use in nursing home residents: a pilot study

PURPOSE

Guidelines discourage chronic benzodiazepines and related Z drugs (BZD/Zs) for sleep problems. However, prevalence among nursing home residents remains high. Discontinuing these drugs is widely recommended but seems difficult to implement. The aim of our study was to evaluate the overall feasibility in the nursing home, in terms of willingness towards discontinuation and success rate at 8 months, together with the impact on withdrawal symptoms, change in sleep quality, quality of life and medication use.

METHODS

In a convenience sample of five nursing homes (823 residents), we included cognitively competent residents with chronic BZD/Z use for insomnia. We investigated sleep quality [with Pittsburgh Sleep Quality Index (PSQI)], quality of life (EQ-5D) and withdrawal symptoms [Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ)]. Success rate was analysed with survival analysis.

RESULTS

Of the 135 eligible residents, both general physician (GP) and resident were willing to initiate discontinuation in 38 residents. Reasons for refusing to initiate discontinuation among GPs was the unmotivated patient and among residents the reluctance towards change. At 8 months, 66.0% were successful discontinuers, with the subjective PSQI component evolving favourably (p = 0.013) and a decreasing number of midnight awakenings (p = 0.041). In the relapse group (n = 13), the quality of life decreased (p = 0.012), with mainly an increase of problems with activities and pain/discomfort. In both groups, the withdrawal symptoms, functionality and medication use did not change.

CONCLUSION

Discontinuation of chronic BZD/Z use is feasible in the nursing home setting without noticeable withdrawal symptoms, without a switch in medication use, without detrimental effect on quality of life and with a positive effect on the self-perceived sleep quality.

Time series analysis of California's prescription monitoring program: impact on prescribing and multiple provider episodes

Prescription monitoring programs (PMPs) are designed to reduce medication diversion by identifying individuals obtaining the same medication from multiple providers (termed multiple provider episodes [MPEs]). This study determined whether recent changes to California's PMP influenced: 1) the extent that practitioners issue prescriptions for a variety of Schedule II opioids; and 2) the incidence of MPEs involving these opioids. Intervention time series of California's PMP data was used to determine the effect of requiring practitioners to transition from using triplicate prescription forms for Schedule II medications to security forms for all controlled substances. Outcome measures included changes in number of prescriptions issued for Schedule II long-acting or short-acting (SA) opioids and the MPEs involving these medications. Requiring a security form was associated with a sustained prescribing increase for SA hydromorphone, meperidine, and SA oxycodone; no prescribing changes were found for SA fentanyl, methadone, and SA morphine, or for any long-acting opioids. The same policy change, however, increased MPEs involving all opioids. Further effort is required to determine how California's PMP can continue to ensure availability of prescription opioids for medical use while better mitigating their diversion.

PERSPECTIVE

Statistical model-building was used to evaluate the influence of changes to California's prescription monitoring program. The extent that practitioners prescribe Schedule II opioids and the incidence of people receiving prescriptions from multiple providers were measured. Such research illustrates the viability of evaluating drug control program impact on prescribing practice and potential diversion behaviors.

How is medication prescribing ceased? A systematic review

BACKGROUND

Medication prescribing is a complex process where the focus tends to be on starting new medication, changing a drug regimen, and continuing a drug regimen. On occasion, a prudent approach to prescribing may necessitate ending an ongoing course of medication, either because it should not have been started in the first place; because its continued use would cause harm; or because the medication is no longer effective.

OBJECTIVE

To identify effective strategies for stopping pre-existing prescribing in situations where continued prescribing may no longer be clinically warranted.

RESEARCH DESIGN

Systematic searches for English-language reports of experimental and quasi-experimental research were conducted in PubMed (1951-November 2009), EMBASE (1966-September 2008), and International Pharmaceutical Abstract b (1970-September 2008). A manual search for relevant review articles and a keyword search of a local database produced by a previous systematic search for prescribing influence and intervention research were also conducted.

STUDY SELECTION AND DATA EXTRACTION

Following initial title screening for relevance 2 reviewers, using formal assessment and data extraction tools, independently assessed abstracts for relevance and full studies for quality before extracting data from studies selected for inclusion.

RESULTS

Of 1306 articles reviewed, 12 were assessed to be of relevant, high-quality research. A variety of drugs were examined in the included studies with benzodiazepines the most common. Studies included in the review tested 9 different types of interventions. Effective interventions included patient-mediated interventions, manual reminders to prescribers, educational materials given to patients, a face-to-face intervention with prescribers, and a case of regulatory intervention. Partially effective interventions included audit and feedback, electronic reminders, educational materials alone sent to prescribers, and distance communication combined with educational materials sent to prescribers.

CONCLUSIONS

It appears possible to stop the prescribing of a variety of medications with a range of interventions. A common theme in effective interventions is the involvement of patients in the stopping process. However, prescribing at the level of individual patients was rarely reported, with data often aggregated to number of doses or number of drugs per unit population, attributing any reduction to cessation. Such studies are not measuring the actual required outcome (stopping prescribing), and this may reflect the broader ambiguity about when or why it might be important to end a prescription. Much more research is required into the process of stopping pre-existing prescribing, paying particular attention to improving the outcomes that are measured.

Prescriptions for schedule II opioids and benzodiazepines increase after the introduction of computer-generated prescriptions

BACKGROUND

Prescriptions for controlled substances decrease when regulatory barriers are put in place. The converse has not been studied.

OBJECTIVES

The objective was to determine whether a less complicated prescription writing process is associated with a change in the prescribing patterns of controlled substances in the emergency department (ED).

METHODS

The authors conducted a retrospective nonconcurrent cohort study of all patients seen in an adult ED between April 19, 2005, and April 18, 2007, who were discharged with a prescription. Prior to April 19, 2006, a specialized prescription form stored in a locked cabinet was obtained from the nursing staff to write a prescription for benzodiazepines or Schedule II opioids. After April 19, 2006, New York State mandated that all prescriptions, regardless of schedule classification, be generated on a specialized bar-coded prescription form. The main outcome of the study was to compare the proportion of Schedule III-V opioids to Schedule II opioids and benzodiazepines prescribed in the ED before and after the introduction of a less cumbersome prescription writing process.

RESULTS

Of the 26,638 charts reviewed, 2.1% of the total number of prescriptions generated were for a Schedule II controlled opioid before the new system was implemented compared to 13.6% after (odds ratio [OR] = 7.3, 95% confidence interval [CI] = 6.4 to 8.4). The corresponding percentages for Schedule III-V opioids were 29.9% to 18.1% (OR = 0.52, 95% CI = 0.49 to 0.55) and for benzodiazepines 1.4% to 3.9% (OR = 2.8, 95% CI = 2.4 to 3.4).

CONCLUSIONS

Patients were more likely to receive a prescription for a Schedule II opioid or a benzodiazepine after a more streamlined computer-generated prescription writing process was introduced in this ED.

Factors Associated with Reductions in Patients' Analgesia at Hospital Discharge

OBJECTIVE

To describe the patterns of opioid prescribing and the factors associated with reductions in the potency of patients' analgesic medications at the time of hospital discharge.

DESIGN

Prospective cohort.

SETTING

Two hundred forty-four patients (171 surgical and 73 nonsurgical) hospitalized in an urban academic medical center who have experienced moderate or severe pain and who are taking opioid analgesics prior to discharge.

OUTCOME

Step-down (or reduction) in the potency of patients' analgesic medication at the time of discharge. A step-down is defined as the analgesic medication that a patient is prescribed for outpatient analgesia at the time of discharge being less potent then the last pain medication administered to that patient just prior to hospital discharge.

RESULTS

Thirty-three percent of all patients had reductions in the potency of their opioid pain medication at the time of discharge (36% for surgical and 26% for nonsurgical patients). For nonsurgical patients, we found a trend toward Hispanic ethnicity being an independent risk factor for having a step-down in analgesic potency at discharge (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 0.9-14.9).

CONCLUSION

Physicians frequently reduce the potency of hospitalized patients' pain medications at discharge and Hispanic patients may be at increased risk of this occurring. Further research is needed to determine if the reductions in analgesic potency we observed are associated with poor posthospital pain outcomes.

Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis

OBJECTIVE

To identify and evaluate studies of interventions in primary care aimed at reducing medication related adverse events that result in morbidity, hospital admission, and/or mortality.

METHODS

Fourteen electronic databases were systematically searched for published and unpublished data. Bibliographies of retrieved papers were searched and experts and first authors contacted in an attempt to locate additional studies. There were no restrictions on language of publication. All interventions applied in primary care settings which aimed to improve patient safety by reducing adverse events resulting from medication overuse or misuse were considered. Randomised controlled trials, controlled trials, controlled before and after studies, and interrupted time series studies were eligible for inclusion. Study quality assessment and data extraction were undertaken using the Cochrane Effective Practice and Organisation of Care data collection checklist and template. Meta-analysis was performed using a random effects model.

RESULTS

159 studies were initially identified, of which 38 satisfied our inclusion criteria. These were categorised as follows: 17 pharmacist-led interventions (of which 15 reported hospital admissions as an outcome); eight interventions led by other primary healthcare professionals that reported preventable drug related morbidity as an outcome; and 13 complex interventions that included a component of medication review aimed at reducing falls in the elderly (the outcome being falls). Meta-analysis found that pharmacist-led interventions are effective at reducing hospital admissions (OR 0.64 (95% CI 0.43 to 0.96)), but restricting analysis to the randomised controlled trials failed to demonstrate significant benefit (OR 0.92 (95% CI 0.81 to 1.05)). Pooling the results of studies in the other categories did not demonstrate any significant effect.

CONCLUSIONS

There is relatively weak evidence to indicate that pharmacist-led medication reviews are effective in reducing hospital admissions. There is currently no evidence for the effectiveness of other interventions which aim at reducing admissions or preventable drug related morbidity. More randomised controlled trials of primary care based pharmacist-led interventions are needed to decide whether or not this intervention is effective in reducing hospital admissions.

Effect of triplicate prescription policy on benzodiazepine administration in nursing home residents

OBJECTIVE

To estimate the effect of a triplicate prescription policy on administration of benzodiazepines and possible substitute drugs in nursing home residents during 1994-1995.

DESIGN

Retrospective cross-sectional study

SETTING

Medicare- and Medicaid-certified nursing homes in five states: New York, which has a policy requiring triplicate prescription forms for certain drugs, and four states without such a policy.

SUBJECTS

A total of 211,177 nursing home residents.

MEASUREMENTS AND MAIN RESULTS

Data were collected using the Minimum Data Set; logistic regression provided an estimated effect of the policy on prescribing benzodiazepines. We also estimated possible substitute drugs for benzodiazepines (e.g., barbiturates, antidepressants, antipsychotics, and miscellaneous sedative-hypnotics) while adjusting simultaneously for potential confounders. New York nursing home residents were less likely to be receiving benzodiazepine therapy than those in nonpolicy states (odds ratio 0.42; 95% confidence interval 0.41-0.44). No increases occurred in administration of benzodiazepine substitute drugs in New York versus states without a triplicate prescription policy.

CONCLUSION

Policy did affect prescription and administration of benzodiazepines in nursing homes in states with versus without a triplicate prescription policy Lack of substitution with other drugs makes it unclear whether overprescribing occurred in states without a policy, or undertreatment occurred in the state with a policy.

Regulatory issues in pain management

Patients commonly are left to suffer from pain that affects their daily lives. The prevalence of undertreated, moderate to severe pain is a public health problem in many countries, including the United States. In many cases, opioids should be the mainstay for the treatment of this level of pain, but they often are not used or are underdosed. One of the reasons for this underuse most cited by health care professionals is their fear of sanctions by their governing boards, law enforcement, or their misunderstanding of the laws and regulations governing the use of these controlled substances. This article reviews some of the relevant issues of the regulation of controlled substances, updates the reader about the laws, and provides guidance to practitioners about the appropriate use of controlled substances, especially opioids, to manage pain.

Balancing diversion control and medical necessity: the case of prescription drugs with abuse potential

Narcotics and other prescription drugs play a significant and legitimate role in medical practice. The illicit use of prescribed medicines, however, remains a major problem. This paper examines the effectiveness of two drug diversion control programs, multiple copy prescriptions programs (MCPP) and electronic data transfer (EDT) systems, and their impact on medical practice. Current evidence demonstrates that these programs decrease prescription drug use, with much of the decrease due to declines in inappropriate use. MCPPs appear more effective than EDT in preventing diversion. More research is needed. however, to assess their effects on medical practice, particularly patient quality of care.

Current benzodiazepine issues

This article deals with some of the recent evidence bearing on the issues of the liability of benzodiazepines to lead to abuse, dependence, and adverse behavioral effects. Reviews of epidemiological, clinical and experimental literature indicated that the previous conclusion about abuse of these drugs still holds: the vast majority of the use of benzodiazepines is appropriate. Problems of nonmedical use arise nearly exclusively among people who abuse other drugs. Nevertheless, there are reasons for concern about patients who take benzodiazepines regularly for long periods of time. These drugs can produce physiological dependence when taken chronically, and although this does not appear to result in dose escalation or other evidence of "psychological dependence," physiological dependence can result in patient discomfort if drug use is abruptly discontinued. Also, physicians are currently prescribing shorter-acting benzodiazepines in preference to longer-acting benzodiazepines. The shorter-acting drugs can produce a more intense withdrawal syndrome following chronic administration. Furthermore, rates of use of benzodiazepines increase with age, and elderly patients are more likely than younger ones to take the drug chronically. The clearest adverse effect of benzodiazepines is impairment of memory. This, too, may be particular concern in older patients whose recall in the absence of drug is typically impaired relative to younger individuals, and who are more compromised following drug administration.

Abuse potential of various opioid medications

The abuse potentials of various narcotic medications were assessed by surveying 130 hospital patients who admitted to having abused prescription narcotics within the preceding six months. 85% of the subjects surveyed reported having tried controlled-release narcotic preparations for abuse purposes and 60% reported that they were of little or no use. To obtain another index of abuse potential, the author asked the subjects to estimate the street prices of various medications. The street prices of controlled-release formulations were lower than those of other narcotic medications and those of some uncontrolled nonnarcotic medications. These results suggest that controlled-release narcotic formulations may have a lower potential for abuse than do other narcotic medications. In situations where there is concern about potential abuse or diversion of prescribed narcotics, controlled-release preparations may be an appropriate alternative to high-peaking, rapid-onset opioid formulations.