Launching injury epidemiology

Impact of State Opioid Regulation on Postoperative Opioid Prescribing Patterns for Total Knee Arthroplasty: A Retrospective Analysis

BACKGROUND

Limited studies have assessed the impact of state regulations on opioid prescribing patterns for patients undergoing total knee arthroplasty (TKA). This study evaluates how Florida House Bill 21 (FL-HB21) affected postoperative opioid prescribing for patients after TKA.

METHODS

Institutional review board approval was obtained to retrospectively review all patients who underwent TKA during 3 months of 2017 (pre-law) and 2018 (post-law) by five arthroplasty surgeons in Florida. Prescribed opioid quantity in morphine milligram equivalents (MME), quantity of refills, and number of prescribers were recorded for each patient's 90-day postsurgical episode. The differences between pre-law and post-law prescription data and short-term postoperative pain levels were compared.

RESULTS

The average total MME was notably reduced by over 30% for all time periods for the post-law group. The average MME per patient decreased by 169 MME at the time of discharge, by 245 MME during subsequent postoperative visits, and by 414 MME for the 90-day postsurgical episode ( P < 0.001 for all). The quantity of refills was unchanged (1.6 vs. 1.6, P = 0.885). The total number of prescribers per patient for the 90-day postsurgical episode was unchanged (1.31 vs. 1.24 prescribers/patient, P = 0.16). Postoperative pain levels were similar at discharge (3.6 pre-law vs. 3.3 post-law, P = 0.272).

DISCUSSION

Restrictive opioid legislation was associated with notably reduced postoperative opioid (MME) prescribed per patient after TKA at the time of discharge and for the entire 90-day postsurgical episode. There was no increase in the number of prescribers or refills required by patients.

LEVEL OF EVIDENCE

Level III retrospective cohort.

Measuring Relationships Between Proactive Reporting State-level Prescription Drug Monitoring Programs and County-level Fatal Prescription Opioid Overdoses

BACKGROUND

Prescription drug monitoring programs (PDMPs) that collect and distribute information on dispensed controlled substances have been adopted by nearly all US states. We know little about program characteristics that modify PDMP impact on prescription opioid (PO) overdose deaths.

METHODS

We measured associations between adoption of any PDMP and changes in fatal PO overdoses in 2002-2016 across 3109 counties in 49 states and D.C. We then measured changes related to the adoption of "proactive PDMPs," which report outlying prescribing/dispensing patterns and provide broader access to PDMP data by law enforcement. Comparisons were made within 3 time intervals that broadly represent the evolution of PDMPs (2002-2004, 2005-2009, and 2010-2016). We modeled overdoses using Bayesian space-time models.

RESULTS

Adoption of electronic PDMP access was associated with 9% lower rates of fatal PO overdoses after three years (rate ratio [RR] = 0.91, 95% credible interval [CI]: 0.88-0.93) with well-supported effects for methadone (RR = 0.86,95% CI: 0.82-0.90) and other synthetic opioids (RR = 0.82, 95% CI: 0.77-0.86). Compared with states with no/weak PDMPs, proactive PDMPs were associated with fewer deaths attributed to natural/semi-synthetic opioids (2002-2004: RR = 0.72 [0.66-0.78]; 2005-2009: RR = 0.93 [0.90-0.97]; 2010-2016: 0.89 [0.86-0.92]) and methadone (2002-2004: RR = 0.77 [0.69-0.85]; 2010-2016: RR = 0.90 [0.86-0.94]). Unintended effects were observed for synthetic opioids other than methadone (2005-2009: RR = 1.29 [1.21-1.38]; 2010-2016: RR = 1.22 [1.16-1.29]).

CONCLUSIONS

State adoption of PDMPs was associated with fewer PO deaths overall while proactive PDMPs alone were associated with fewer deaths related to natural/semisynthetic opioids and methadone, the specific targets of these programs. See video abstract at, http://links.lww.com/EDE/B619.

How well do doctors know their patients? Evidence from a mandatory access prescription drug monitoring program

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.

Prescription drug monitoring programs in the US: A systematic literature review on its strength and weakness

Prescription Drug Monitoring Program (PDMP) is an electronic database that tracks the prescriptions of controlled drugs with its aims to combat the incidence of drug abuse. Although the establishment of PDMP in the US was since 2003, evidence of the impact of PDMP's strength and weakness towards its implementation is still scarce. A systematic literature review according to Preferred Reporting Items for Systematic Review (PRISMA) standard was conducted to investigate the influence of PDMP's strength in combating the incidence of drug abuse and also to review the weaknesses of PDMP that prohibit its implementation. Results from this study reveal that the implementation of PDMP has mitigated the issue of drug abuse and has increased work efficiency among healthcare practitioners. However, the implementation rate of this system is low due to its weaknesses such as limited internet access and limited access to the PDMP system. Therefore, efforts to overcome the weaknesses of PDMP need to be instituted to ensure the healthcare system could fully optimize PDMP's benefits.

Implementation and enforcement of state opioid prescribing laws

BACKGROUND

In response to the role overprescribing has played in the U.S. opioid crisis, in the past decade states have enacted four main types of laws to curb opioid prescribing: mandatory prescription drug monitoring program (PDMP) enrollment laws requiring clinicians to register with a PDMP; mandatory PDMP query laws requiring clinicians to check a PDMP prior to prescribing opioids; pill mill laws regulating pain management clinics; and opioid prescribing cap laws limiting the dose/duration of opioid prescriptions. While 47 states now have one or more of these laws in place, little is known about implementation and enforcement strategies, facilitators, and barriers.

METHODS

From November 2017 to February 2019, we interviewed 114 professionals involved in state opioid prescribing law implementation and enforcement in 20 states and identified common themes.

RESULTS

Implementation efforts focused on awareness campaigns and targeted training of key front-line implementers. Enforcement strategies included active, complaint-based, and automated strategies. Collaboration across agencies and stakeholders, particularly health agencies and law enforcement, was identified as an important facilitator of implementation and enforcement. Two key interrelated barriers were identified: the complexity of state opioid prescribing laws in terms of which providers, patients, and prescriptions they applied to, and IT infrastructure.

CONCLUSION

Despite differing approaches, our findings suggest similar barriers to implementation and enforcement across state opioid prescribing laws. Strategies are needed to ease implementation and enforcement of laws that apply only to specific sub-sets of providers, patients, or prescriptions and address issues of access and data utilization of the PDMP.

The effectiveness of prescription drug monitoring programs at reducing opioid-related harms and consequences: a systematic review

BACKGROUND

In order to address the opioid crisis in North America, many regions have adopted preventative strategies, such as prescription drug monitoring programs (PDMPs). PDMPs aim to increase patient safety by certifying that opioids are prescribed in appropriate quantities. We aimed to synthesize the literature on changes in opioid-related harms and consequences, an important measure of PDMP effectiveness.

METHODS

We completed a systematic review. We conducted a narrative synthesis of opioid-related harms and consequences from PDMP implementation. Outcomes were grouped into categories by theme: opioid dependence, opioid-related care outcomes, opioid-related adverse events, and opioid-related legal and crime outcomes.

RESULTS

We included a total of 22 studies (49 PDMPs) in our review. Two studies reported on illicit and problematic use but found no significant associations with PDMP status. Eight studies examined the association between PDMP status and opioid-related care outcomes, of which two found that treatment admissions for prescriptions opioids were lower in states with PDMP programs (p < 0.05). Of the thirteen studies that reported on opioid-related adverse events, two found significant (p < 0.001 and p < 0.05) but conflicting results with one finding a decrease in opioid-related overdose deaths after PDMP implementation and the other an increase. Lastly, two studies found no statistically significant association between PDMP status and opioid-related legal and crime outcomes (crime rates, identification of potential dealers, and diversion).

CONCLUSION

Our study found limited evidence to support overall associations between PDMPs and reductions in opioid-related consequences. However, this should not detract from the value of PDMPs' larger role of improving opioid prescribing.

Sport-Related Concussion and Mental Health Outcomes in Elite Athletes: A Systematic Review

Background

Elite athletes can experience a diverse range of symptoms following post-concussive injury. The impact of sport-related concussion on specific mental health outcomes is unclear in this population.

Objective

The aim was to appraise the evidence base regarding the association between sport-related concussion and mental health outcomes in athletes competing at elite and professional levels.

Methods

A systematic search of PubMed, EMBASE, SPORTDiscus, PsycINFO, Cochrane, and Cinahl databases was conducted.

Results

A total of 27 studies met inclusion criteria for review. Most of the included studies (67%, n = 18) were published in 2014 or later. Study methodology and reporting varied markedly. The extant research has been conducted predominantly in North America (USA, n = 23 studies; Canada, n = 3), often in male only (44.4%, n = 12) and college (70.4%, n = 19) samples. Depression is the most commonly studied mental health outcome (70.4%, n = 19 studies). Cross-sectional retrospective studies and studies including a control comparison tend to support an association between concussion exposure and depression symptoms, although several studies report that these symptoms resolved in the medium term (i.e. 1 month) post-concussion. Evidence for anxiety is mixed. There are insufficient studies to draw conclusions for other mental health domains.

Conclusion

Consistent with current recommendations to assess mood disturbance in post-concussive examinations, current evidence suggests a link between sports-related concussion and depression symptoms in elite athletes. Causation cannot be determined at this stage of enquiry because of the lack of well-designed, prospective studies. More research is required that considers a range of mental health outcomes in diverse samples of elite athletes/sports.

Electronic supplementary material

The online version of this article (10.1007/s40279-017-0810-3) contains supplementary material, which is available to authorized users.

Association Between Prescription Drug Monitoring Programs and Nonfatal and Fatal Drug Overdoses: A Systematic Review

Background

Prescription drug monitoring programs (PDMPs) are a key component of the president's Prescription Drug Abuse Prevention Plan to prevent opioid overdoses in the United States.

Purpose

To examine whether PDMP implementation is associated with changes in nonfatal and fatal overdoses; identify features of programs differentially associated with those outcomes; and investigate any potential unintended consequences of the programs.

Data Sources

Eligible publications from MEDLINE, Current Contents Connect (Clarivate Analytics), Science Citation Index (Clarivate Analytics), Social Sciences Citation Index (Clarivate Analytics), and ProQuest Dissertations indexed through 27 December 2017 and additional studies from reference lists.

Study Selection

Observational studies (published in English) from U.S. states that examined an association between PDMP implementation and nonfatal or fatal overdoses.

Data Extraction

2 investigators independently extracted data from and rated the risk of bias (ROB) of studies by using established criteria. Consensus determinations involving all investigators were used to grade strength of evidence for each intervention.

Data Synthesis

Of 2661 records, 17 articles met the inclusion criteria. These articles examined PDMP implementation only (n = 8), program features only (n = 2), PDMP implementation and program features (n = 5), PDMP implementation with mandated provider review combined with pain clinic laws (n = 1), and PDMP robustness (n = 1). Evidence from 3 studies was insufficient to draw conclusions regarding an association between PDMP implementation and nonfatal overdoses. Low-strength evidence from 10 studies suggested a reduction in fatal overdoses with PDMP implementation. Program features associated with a decrease in overdose deaths included mandatory provider review, provider authorization to access PDMP data, frequency of reports, and monitoring of nonscheduled drugs. Three of 6 studies found an increase in heroin overdoses after PDMP implementation.

Limitation

Few studies, high ROB, and heterogeneous analytic methods and outcome measurement.

Conclusion

Evidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses is largely insufficient, as is evidence regarding positive associations between specific administrative features and successful programs. Some evidence showed unintended consequences. Research is needed to identify a set of "best practices" and complementary initiatives to address these consequences.

Primary Funding Source

National Institute on Drug Abuse and Bureau of Justice Assistance.

Geographic Variation in Opioid and Heroin Involved Drug Poisoning Mortality Rates

INTRODUCTION

An important barrier to formulating effective policies to address the rapid rise in U.S. fatal overdoses is that the specific drugs involved are frequently not identified on death certificates. This analysis supplies improved estimates of state opioid and heroin involved drug fatality rates in 2014, and changes from 2008 to 2014.

METHODS

Reported mortality rates were calculated directly from death certificates and compared to corrected rates that imputed drug involvement when no drug was specified. The analysis took place during 2016-2017.

RESULTS

Nationally, corrected opioid and heroin involved mortality rates were 24% and 22% greater than reported rates. The differences varied across states, with particularly large effects in Pennsylvania, Indiana, and Louisiana. Growth in corrected opioid mortality rates, from 2008 to 2014, were virtually the same as reported increases (2.5 deaths per 100,000 people) whereas changes in corrected heroin death rates exceeded reported increases (2.7 vs 2.3 per 100,000). Without corrections, opioid mortality rate changes were considerably understated in Pennsylvania, Indiana, New Jersey, and Arizona, but dramatically overestimated in South Carolina, New Mexico, Ohio, Connecticut, Florida, and Kentucky. Increases in heroin death rates were understated in most states, and by large amounts in Pennsylvania, Indiana, New Jersey, Louisiana, and Alabama.

CONCLUSIONS

The correction procedures developed here supply a more accurate understanding of geographic differences in drug poisonings and supply important information to policymakers attempting to reduce or slow the increase in fatal drug overdoses.

Trends in Prescription Opioids Detected in Fatally Injured Drivers in 6 US States: 1995-2015

OBJECTIVES

To assess the time trends in prescription opioids detected in fatally injured drivers.

METHODS

We analyzed 1995 to 2015 Fatality Analysis Reporting System data from California, Hawaii, Illinois, New Hampshire, Rhode Island, and West Virginia of toxicological tests for drivers fatally injured within 1 hour of a crash (n = 36 729). We used the Cochran-Armitage test for trend to assess the statistical significance of changes in the prevalence of prescription opioids detected in these drivers over time.

RESULTS

The prevalence of prescription opioids detected in fatally injured drivers increased from 1.0% (95% confidence interval [CI] = 0.5, 1.4) in 1995 to 7.2% (95% CI = 5.7, 8.8) in 2015 (Z = -9.04; P < .001). Prescription opioid prevalence was higher in female than in male drivers (4.4% vs 2.9%; P < .001). Of the drivers testing positive for prescription opioids, 30.0% had elevated blood alcohol concentrations (≥ 0.01 g/dL), and 66.9% tested positive for other drugs.

CONCLUSIONS

The prevalence of prescription opioids detected in fatally injured drivers has increased in the past 2 decades. The need to assess the effect of increased prescription opioid use on traffic safety is urgent.

Pathways linking car transport for young adults and the public health in Northern Ireland: a qualitative study to inform the evaluation of graduated driver licensing

Background

Novice drivers are at relatively high risk of road traffic injury. There is good evidence that Graduated Driving Licensing (GDL) schemes reduce collisions rates, by reducing exposure to risk and by extending learning periods. Legislation for a proposed scheme in Northern Ireland was passed in 2016, providing an opportunity for future evaluation of the full public health impacts of a scheme in a European context within a natural experiment. This qualitative study was designed to inform the logic model for such an evaluation, and provide baseline qualitative data on the role of private cars in health and wellbeing.

Methods

Nine group interviews with young people aged 16–23 (N = 43) and two group interviews with parents of young people (N = 8) were conducted in a range of settings in Northern Ireland in 2015. Data were analysed using thematic content analysis.

Results

Informal car-pooling within and beyond households led to routine expectations of lift provision and uptake. Experiences of risky driving situations were widespread. In rural areas, extensive use of farm vehicles for transport needs meant many learner drivers had both early driving experience and expectations that legislation may have to be locally adapted to meet social needs. Cars were used as a site for socialising, as well as essential means of transport. Alternative modes (public transport, walking and cycling) were held in low esteem, even where available. Recall of other transport-related public health messages and parents’ existing use of GDL-type restrictions suggested GDL schemes were acceptable in principle. There was growing awareness and use of in-car technologies (telematics) used by insurance companies to reward good driving.

Conclusions

Key issues to consider in evaluating the broader public health impact of GDL will include: changes in injury rates for licensed car occupants and other populations and modes; changes in exposure to risk in the licensed and general population; and impact on transport exclusion. We suggest an important pathway will be change in social norms around offering and accepting lifts and to risk-taking. The growing adoption of in-car telematics will have implications for future GDL programmes and for evaluation.

Orchard Sports Injury Classification System 10.1 Plus: An End-User Study

The purpose of this study was to establish the level of ease of use and effectiveness of the Orchard Sport Injury Classification System (OSICS) 10.1 Plus for recording injuries and interventions. Three hundred and forty-two (males=148, females=192, no response=2; age=30.9±9.5y; experience=9.1±10.5y) athletic trainers (ATs) in the United States completed the survey. Participants were primarily employed in the secondary school (n=135) or collegiate setting (n=171). Participants entered system includes the OSICS 10.1 to catalog injuries and Current Procedural Terminology (CPT) codes to document interventions. Participants completed an 18-item end-user evaluation to assess the ease of use and effectiveness of the OSICS 10.1 Plus (5-point Likert scale). Participants indicated that the OSICS 10.1 Plus is overall easy to use (4.1±0.7pts), easy to enter an injury (4.1±0.8pts), and easy to enter the associated interventions (3.9±0.8pts). Respondents were neutral about whether the OSICS 10.1 Plus matched their current injury (3.5±1.0pts) or intervention (3.5±0.9pts) records. A majority of participants indicated that they could find the injury (281/342, 82.2%) and interventions (225/342, 65.8%) of interest. A majority of respondents (205/342, 60.0%) indicated they would consider using OSICS 10.1 Plus for injury surveillance in clinical practice. The OSICS 10.1 Plus could serve as an effective and useful mechanism for injury surveillance with minor modifications; however, we, as professionals in sports healthcare, need to improve regular medical documentation first so that we are better able to conduct injury surveillance among our patients.

The effects of the lower ignition propensity cigarettes standard in Estonia: time-series analysis

Background

In 2011, the lower ignition propensity (LIP) standard for cigarettes was implemented in the European Union. Evidence about the impact of that safety measure is scarce.

Objective

The aim of this paper is to examine the effects of the LIP standard on fire safety in Estonia.

Methods

The absolute level of smoking-related fire incidents and related deaths was modelled using dynamic time-series regression analysis. The data about house fire incidents for the 2007–2013 period were obtained from the Estonian Rescue Board.

Results

Implementation of the LIP standard has reduced the monthly level of smoking-related fires by 6.2 (p<0.01, SE=1.95) incidents and by 26% (p<0.01, SE=9%) when estimated on the log scale. Slightly weaker evidence was found about the fatality reduction effects of the LIP regulation. All results were confirmed through counterfactual models for non-smoking-related fire incidents and deaths.

Conclusions

This paper indicates that implementation of the LIP cigarettes standard has improved fire safety in Estonia.

Social norms theory and concussion education

Secondary prevention of harm from sport-related concussion is contingent on immediate removal from play post-injury. To-date, educational efforts to reduce the prevalent risk behavior of continued play while symptomatic have been largely ineffective. Social norms theory may hold promise as a foundation for more effective concussion education aimed at increasing concussion reporting. The primary objective of this study was to assess whether perceived team concussion reporting norms would be less supportive of an individual's safe concussion symptom reporting behavior than objective team norms. Participants were 328 male and female US collegiate athletes. Written surveys were completed in person during the spring of 2014. Among both male and female athletes, team concussion reporting norms were significantly misperceived, with athletes tending to think that they themselves have safer attitudes about concussion reporting than their teammates. Perceived norms were associated with symptom reporting intention, independent of the team's objective reporting norm. A social norms approach to concussion education, in which misperceived group norms are corrected and shifted in the direction of safety, is an important avenue for program development and evaluation research aimed at the secondary prevention of harm from concussion. Implications for the design of this type of educational programming are discussed.

Long-Term Caregiver Mental Health Outcomes Following a Predominately Online Intervention for Adolescents With Complicated Mild to Severe Traumatic Brain Injury

OBJECTIVE

To examine the efficacy of counselor-assisted problem solving (CAPS) in improving long-term caregiver psychological functioning following traumatic brain injury (TBI) in adolescents.

METHODS

This randomized clinical trial compared CAPS (n = 65), a predominantly online problem-solving intervention, with an Internet resource comparison (n = 67) program. Families of adolescents with TBI completed a baseline assessment and follow-up assessments 6, 12, and 18 months later. General linear mixed models were used to examine longitudinal changes in caregiver global psychological distress, depressive symptoms, and caregiving self-efficacy. Family income and injury severity were examined as moderators of treatment efficacy.

RESULTS

Family income moderated long-term changes in caregiver psychological distress. For lower-income caregivers, the CAPS intervention was associated with lower levels of psychological distress at 6, 12, and 18 months post baseline.

CONCLUSIONS

These findings support the utility of Web-based interventions in improving long-term caregiver psychological distress, particularly for lower-income families.