Trends In Opioid Prescribing And Self-Reported Pain Among US Adults

Clinical and healthcare use outcomes after cessation of long term opioid treatment due to prescriber workforce exit: quasi-experimental difference-in-differences study

OBJECTIVE

To examine the association between prescriber workforce exit, long term opioid treatment discontinuation, and clinical outcomes.

DESIGN

Quasi-experimental difference-in-differences study SETTING: 20% sample of US Medicare beneficiaries, 2011-18.

PARTICIPANTS

People receiving long term opioid treatment whose prescriber stopped providing office based patient care or exited the workforce, as in the case of retirement or death (n=48 079), and people whose prescriber did not exit the workforce (n=48 079).

MAIN OUTCOMES

Discontinuation from long term opioid treatment, drug overdose, mental health crises, admissions to hospital or emergency department visits, and death. Long term opioid treatment was defined as at least 60 days of opioids per quarter for four consecutive quarters, attributed to the plurality opioid prescriber. A difference-in-differences analysis was used to compare individuals who received long term opioid treatment and who had a prescriber leave the workforce to propensity-matched patients on long term opioid treatment who did not lose a prescriber, before and after prescriber exit.

RESULTS

Discontinuation of long term opioid treatment increased from 132 to 229 per 10 000 patients who had prescriber exit from the quarter before to the quarter after exit, compared with 97 to 100 for patients who had a continuation of prescriber (adjusted difference 1.22 percentage points, 95% confidence interval 1.02 to 1.42). In the first quarter after provider exit, when discontinuation rates were highest, a transient but significant elevation was noted between the two groups of patients in suicide attempts (adjusted difference 0.05 percentage points (95% confidence interval 0.01 to 0.09)), opioid or alcohol withdrawal (0.14 (0.01 to 0.27)), and admissions to hospital or emergency department visits (0.04 visits (0.01 to 0.06)). These differences receded after one to two quarters. No significant change in rates of overdose was noted. Across all four quarters after prescriber exit, an increase was reported in the rate of mental health crises (0.39 percentage points (95% confidence interval 0.08 to 0.69)) and opioid or alcohol withdrawal (0.31 (0.014 to 0.58)), but no change was seen for drug overdose (-0.12 (-0.41 to 0.18)).

CONCLUSIONS

The loss of a prescriber was associated with increased occurrences of discontinuation of long term opioid treatment and transient increases in adverse outcomes, such as suicide attempts, but not other outcomes, such as overdoses. Long term opioid treatment discontinuation may be associated with a temporary period of adverse health impacts after accounting for unobserved confounding.

Association between household opioid prescriptions and risk for overdose among family members not prescribed opioids

BACKGROUND

Prescription opioids have contributed to the rise in opioid-related overdoses and deaths. The presence of opioids within households may increase the risk of overdose among family members who were not prescribed an opioid themselves. Larger quantities of opioids may further increase risk.

OBJECTIVES

To determine the risk of opioid overdose among individuals who were not prescribed an opioid but were exposed to opioids prescribed to other family members in the household, and evaluate the risk in relation to the total morphine milligram equivalents (MMEs) present in the household.

METHODS

We conducted a cohort study using a large database of commercial insurance claims from 2001 to 2021. For inclusion in the cohort, we identified individuals not prescribed an opioid in the prior 90 days from households with two or more family members, and determined the total MMEs prescribed to other family members. Individuals were stratified into monthly enrollment strata defined by household opioid exposure and other confounders. A generalized linear model was used to estimate incidence rate ratios (IRRs) for overdose.

RESULTS

Overall, the incidence of overdose among enrollees in households where a family member was prescribed an opioid was 1.73 (95% confidence interval [CI]: 1.67-1.78) times greater than households without opioid prescriptions. The risk of overdose increased continuously with the level of potential MMEs in the household from an IRR of 1.23 (95% CI: 1.16-1.32) for 1-100 MMEs to 4.67 (95% CI: 4.18-5.22) for >12,000 MMEs. The risk of overdose associated with household opioid exposure was greatest for ages 1-2 years (IRR: 3.46 [95% CI: 2.98-4.01]) and 3-5 years (IRR: 3.31 [95% CI: 2.75-3.99]).

CONCLUSIONS

The presence of opioids in a household significantly increases the risk of overdose among other family members who were not prescribed an opioid. Higher levels of MMEs, either in terms of opioid strength or quantity, were associated with increased levels of risk. Risk estimates may reflect accidental poisonings among younger family members.

Inequitable access to nonpharmacologic pain treatment providers among cancer-free U.S. adults

OBJECTIVE

Using evidence-based nonpharmacologic pain treatments may prevent opioid overuse and associated adverse outcomes. There is limited data on the impact of access-promoting social determinants of health (SDoH: education, income, transportation) on use of nonpharmacologic pain treatments. Our objective was to examine the relationship between SDoH and use of nonpharmacologic pain treatment providers. Our goal was to understand policy-actionable factors contributing to inequity in pain treatment.

METHODS

Based on Andersen's Health Utilization Model, this cross-sectional analysis of 2016-2019 Medical Expenditure Panel Survey data evaluated whether use of outpatient nonpharmacologic pain treatment providers is driven by enabling (i.e., advantageous socioeconomic resources) or need (i.e., perceived disability and diagnosed disease) factors. The study sample (unweighted n = 28,188) represented a weighted N = 81,912,730 noninstitutionalized, cancer-free, U.S. adults with pain interference. The primary outcome measured use of nonpharmacologic providers relative to exclusive prescription opioid use or no treatment (i.e., neither opioids nor nonpharmacologic). To quantify equitable access, we compared the variance-between access-promoting enabling factors versus medical need factors-that explained utilization.

RESULTS

Compared to enabling factors, need factors explained twice the variance predicting pain treatment utilization. Still, the adjusted odds of using nonpharmacologic providers instead of opioids alone were 39% lower among respondents identifying as Black (95% Confidence Interval [CI], 0.49-0.76) and respondents residing in the U.S. South (95% CI, 0.51-0.74). Higher education (95% CI, 1.72-2.79) and income (95% CI, 1.68-2.42) both facilitated using nonpharmacologic providers instead of opioids.

CONCLUSIONS

These findings highlight the substantial influence access-promoting SDoH have on pain treatment utilization.

Opioid prescription rates associated with surgery among adolescents in the United States from 2015 to 2020

INTRODUCTION

The United States currently faces an epidemic of opioid misuse which extends to adolescent surgical populations. Opioid prescriptions after surgery are associated with persistent opioid use and serve as a reservoir for diversion. However, it is unclear what proportion of opioid prescriptions are surgical, and little is known about trends in opioid prescription rates associated with surgery in adolescents in the United States. This study aims to describe national trends in postsurgical opioid prescription rates over time among adolescents in the United States.

METHODS

We conducted a population-based cross-sectional analysis of data captured in the Medical Expenditure Panel Survey (MEPS) from 2015 to 2020. MEPS classified adolescents 10-19 years of age (n = 26 909) as having a surgical procedure if they had any inpatient, outpatient, or emergency department visit during which a surgical procedure was performed.

RESULTS

Mean age (SD) of the sample was 14.4 (0.01) years. Sociodemographic characteristics were representative of the USA adolescent population. In total, 4.7% of adolescents underwent a surgical procedure. The surgery rate remained stable between 2015 (4.3%): and 2020 (4.4%) and was lower among minority populations. The combined rate of opioid prescribing for surgical and nonsurgical indications significantly decreased from 4.1% in 2015 to 1.4% in 2020 among all adolescents, an estimated difference of 2.7% (95% confidence interval (CI): 1.7%-3.7%, p < .0001). However, opioid prescribing for surgery remained relatively stable (1% in 2015 vs. 0.8% in 2020).

DISCUSSION

Opioid prescription rates associated with surgery remained stable between 2015 and 2020 in the United States, despite significant decreases in prescribing among nonsurgical populations. Surgery is now a leading source of medical prescribed opioids among adolescents. Secondary findings included a stable trend in surgery utilization between 2015 and 2020, as well as continued racial disparities, both in terms of surgery utilization and opioid prescribing.

CONCLUSION

The large number of adolescents being prescribed opioids for surgery in the USA each year, suggests there is a need for national guidelines aimed at adolescent opioid use, similar to the recent CDC guidelines aimed at adult opioid use.

Sedative-hypnotic Co-prescribing with Opioids in a Large Network of Community Health Centers

OBJECTIVE

When prescribed with opioids, sedative-hypnotics substantially increase the risk of overdose. The objective of this paper was to describe characteristics and trends in opioid sedative-hypnotic co-prescribing in a network of safety-net clinics serving low-income, publicly insured, and uninsured individuals.

METHODS

This retrospective longitudinal analysis of prescription orders examined opioid sedative-hypnotic co-prescribing rates between 2009 and 2018 in the OCHIN network of safety-net community health centers. Sedative-hypnotics included benzodiazepine and non-benzodiazepine sedatives (eg, zolpidem). Co-prescribing patterns were assessed overall and across patient demographic and co-morbidity characteristics.

RESULTS

From 2009 to 2018, 240 587 patients had ≥1 opioid prescriptions. Most were White (65%), female (59%), and had Medicaid insurance (43%). One in 4 were chronic opioid users (25%). During this period, 55 332 (23%) were co-prescribed a sedative-hypnotic. The prevalence of co-prescribing was highest for females (26% vs 19% for males), non-Hispanic Whites (28% vs 13% for Hispanic to 20% for unknown), those over 44 years of age (25% vs 20% for <44 years), Medicare insurance (30% vs 21% for uninsured to 22% for other/unknown), and among those on chronic opioid therapy (40%). Co-prescribing peaked in 2010 (32%) and declined steadily through 2018 (20%). Trends were similar across demographic subgroups. Co-prescribed sedative-hypnotics remained elevated for those with chronic opioid use (27%), non-Hispanic Whites (24%), females (23%), and those with Medicare (23%) or commercial insurance (22%).

CONCLUSIONS

Co-prescribed sedative-hypnotic use has declined steadily since 2010 across all demographic subgroups in the OCHIN population. Concurrent use remains elevated in several population subgroups.

Demographic and Clinical Correlates of Treatment Completion among Older Adults with Heroin and Prescription Opioid Use Disorders

In this study using 2015-2018 Treatment Episode Data Set-Discharge (TEDS-D) cases age 55+ for heroin (N = 101,524) or prescription opioids (PO; N = 25,510) as the primary substance, we examined treatment completion rates and correlates. We fit separate logistic regression models for heroin and PO cases with treatment completion status (completed vs. discontinued due to dropout/termination/other reasons) for each treatment setting (detoxification, residential rehabilitation, and outpatient) as the dependent variable. Results show that detoxification cases had the highest completion rates and outpatient cases had the lowest (14.8% for heroin and 24.0% for PO cases). A consistently significant correlate of treatment completion was legal system referral for heroin cases and having a bachelor's degree for PO cases. Medication-assisted therapy was associated with higher odds of completing residential treatment for both types of opioids but lower odds of completing detoxification and outpatient treatment. Treatment duration >30 days tended to have higher odds of completion. PO cases age 65+ had higher odds of completing residential treatment than cases age 55-64. Racial/ethnic minorities tended to have lower odds of outpatient treatment completion. Study findings underscore the importance of helping older adults complete treatment, especially those who are racial/ethnic minorities and receiving outpatient treatment.

Trends in the Use of Opioids vs Nonpharmacologic Treatments in Adults With Pain, 2011-2019

IMPORTANCE

Chronic pain prevalence among US adults increased between 2010 and 2019. Yet little is known about trends in the use of prescription opioids and nonpharmacologic alternatives in treating pain.

OBJECTIVES

To compare annual trends in the use of prescription opioids, nonpharmacologic alternatives, both treatments, and neither treatment; compare estimates for the annual use of acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy; and estimate the association between calendar year and pain treatment based on the severity of pain interference.

DESIGN, SETTING, AND PARTICIPANTS

A serial cross-sectional analysis was conducted using the nationally representative Medical Expenditure Panel Survey to estimate the use of outpatient services by cancer-free adults with chronic or surgical pain between calendar years 2011 and 2019. Data analysis was performed from December 29, 2021, to August 5, 2022.

EXPOSURES

Calendar year (2011-2019) was the primary exposure.

MAIN OUTCOMES AND MEASURES

The association between calendar year and mutually exclusive pain treatments (opioid vs nonpharmacologic vs both vs neither treatment) was examined. A secondary outcome was the prevalence of nonpharmacologic treatments (acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy). All analyses were stratified by pain type.

RESULTS

Among the unweighted 46 420 respondents, 9643 (20.4% weighted) received surgery and 36 777 (79.6% weighted) did not. Weighted percentages indicated that 41.7% of the respondents were aged 45 to 64 years and 55.0% were women. There were significant trends in the use of pain treatments after adjusting for demographic factors, socioeconomic status, health conditions, and pain severity. For example, exclusive use of nonpharmacologic treatments increased in 2019 for both cohorts (chronic pain: adjusted odds ratio [aOR], 2.72; 95% CI, 2.30-3.21; surgical pain: aOR, 1.53; 95% CI, 1.13-2.08) compared with 2011. The use of neither treatment decreased in 2019 for both cohorts (chronic pain: aOR, 0.43; 95% CI, 0.37-0.49; surgical pain: aOR, 0.59; 95% CI, 0.46-0.75) compared with 2011. Among nonpharmacologic treatments, chiropractors and physical therapists were the most common licensed healthcare professionals.

CONCLUSIONS AND RELEVANCE

Among cancer-free adults with pain, the annual prevalence of nonpharmacologic pain treatments increased and the prevalent use of neither opioids nor nonpharmacologic therapy decreased for both chronic and surgical pain cohorts. These findings suggest that, although access to outpatient nonpharmacologic treatments is increasing, more severe pain interference may inhibit this access.

Trends in opioid and non-opioid treatment for chronic non-cancer pain and cancer pain among privately insured adults in the United States, 2012–2019

Recent clinical guidelines have emphasized non-opioid treatments in lieu of prescription opioids for chronic non-cancer pain, exempting cancer patients from these recommendations. In this study, we determine trends in opioid and non-opioid treatment among privately insured adults with chronic non-cancer pain (CNCP) or cancer. Using administrative claims data from IBM MarketScan Research Databases, we identified privately-insured adults who were continuously enrolled in insurance for at least one calendar year from 2012 to 2019. We identified individuals with CNCP diagnosis, defined as a diagnosis of arthritis, headache, low back pain, and/or neuropathic pain, and a individuals with cancer diagnosis in a calendar year. Outcomes included receipt of any opioid, non-opioid medication, or non-pharmacologic CNCP therapy and opioid prescribing volume, MME-per-day, and days’ supply. Estimates were regression-adjusted for age, sex, and region. Between 2012 and 2019, the proportion of patients who received any opioid decreased across both groups (CNCP: 49.7 to 30.5%, p<0.01; cancer: 86.0 to 78.7%, p<0.01). Non-opioid pain medication receipt remained steady for individuals with CNCP (66.7 to 66.4%, p<0.01) and increased for individuals with cancer (74.4 to 78.8%, p<0.01), while non-pharmacologic therapy use rose among individuals with CNCP (62.4 to 66.1%, p<0.01). Among those prescribed opioids, there was a decrease in the receipt of at least one prescription with >90 MME/day (CNCP: 13.9% in 2012 to 4.9% in 2019, p<0.01; Cancer: 26.2% to 7.6%, p<0.01); >7 days of supply (CNCP: 56.3% to 30.7%, p <0.01; Cancer: 47.5% to 22.7%, p<0.01), the mean number of opioid prescriptions (CNCP: 5.2 to 3.9, p<0.01; Cancer: 4.0 to 2.7, p<0.01) and mean MME/day (CNCP: 49.9 to 38.0, p<0.01; Cancer: 62.4 to 44.7, p<0.01). Overall, from 2012–2019, opioid prescribing declined for CNCP and cancer, with larger reductions for patients with CNCP. For both groups, reductions in prescribed opioids outpaced increases in non-opioid alternatives.

Comparative Effectiveness of Opioid Tapering or Abrupt Discontinuation vs No Dosage Change for Opioid Overdose or Suicide for Patients Receiving Stable Long-term Opioid Therapy

IMPORTANCE

Opioid dosage tapering has emerged as a strategy to reduce harms associated with long-term opioid therapy; however, evidence supporting this approach is limited.

OBJECTIVE

To identify the association of opioid tapering or abrupt discontinuation with opioid overdose and suicide events among patients receiving stable long-term opioid therapy without evidence of opioid misuse.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness study with a trial emulation approach used a large US claims data set of individuals with commercial insurance or Medicare Advantage who were aged 18 years or older and receiving stable long-term opioid therapy without evidence of opioid misuse between January 1, 2010, and December 31, 2018. Statistical analysis was performed from January 17, 2020, through November 12, 2021.

INTERVENTIONS

Three opioid dosage strategies: stable dosage, tapering (dosage reduction ≥15%), or abrupt discontinuation.

MAIN OUTCOMES AND MEASURES

Time to opioid overdose or suicide event identified from International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes in medical claims over 11 months of follow-up. Inverse probability weighting was used to adjust for baseline confounders. The primary analysis used an intention-to-treat approach; follow-up after assignment regardless of changes in opioid dose was included. A per-protocol analysis was also conducted, in which episodes were censored for lack of adherence to assigned treatment.

RESULTS

A cohort of 199 836 individuals (45.1% men; mean [SD] age, 56.9 [12.4] years; and 57.6% aged 45-64 years) had 415 123 qualifying, long-term opioid therapy episodes; 87.1% of episodes were considered stable, 11.1% were considered a taper, and 1.8% were considered abrupt discontinuation. The adjusted cumulative incidence of opioid overdose or suicide events 11 months after baseline was 0.96% (95% CI, 0.92%-0.99%) with a stable dosage strategy, 1.10% (95% CI, 0.99%-1.22%) with a tapered dosage strategy, and 1.28% (95% CI, 0.93%-1.38%) with an abrupt discontinuation strategy. The risk difference between a taper and a stable dosage was 0.15% (95% CI, 0.03%-0.26%), and the risk difference between abrupt discontinuation and a stable dosage was 0.33% (95% CI, -0.03% to 0.74%). Results were similar using the per-protocol approach.

CONCLUSIONS AND RELEVANCE

This study identified a small absolute increase in risk of harms associated with opioid tapering compared with a stable opioid dosage. These results do not suggest that policies of mandatory dosage tapering for individuals receiving a stable long-term opioid dosage without evidence of opioid misuse will reduce short-term harm via suicide and overdose.

Do Urine Drug Tests Reveal Substance Misuse Among Patients Prescribed Opioids for Chronic Pain?

BACKGROUND

Urine drug testing (UDT) is a recommended risk mitigation strategy for patients prescribed opioids for chronic pain, but evidence that UDT supports identification of substance misuse is limited.

OBJECTIVE

Identify the prevalence of UDT results that may identify substance misuse, including diversion, among patients prescribed opioids for chronic pain.

DESIGN

Retrospective cohort study.

SUBJECTS

Patients (n=638) receiving opioids for chronic pain who had one or more UDTs, examining up to eight substances per sample, during a one 1-year period.

MAIN MEASURES

Experts adjudicated the clinical concern that UDT results suggest substance misuse or diversion as not concerning, uncertain, or concerning.

KEY RESULTS

Of 638 patients, 48% were female and 49% were over age 55 years. Patients had a median of three UDTs during the intervention year. We identified 37% of patients (235/638) with ≥1 concerning UDT and a further 35% (222/638) having ≥1 uncertain UDT. We found concerning UDTs due to non-detection of a prescribed substance in 24% (156/638) of patients and detection of a non-prescribed substance in 23% (147/638). Compared to patients over 65 years, those aged 18-34 years were more likely to have concerning UDT results with an adjusted odds ratio (AOR) of 4.8 (95% confidence interval [CI] 1.9-12.5). Patients with mental health diagnoses (AOR 1.6 [95% CI 1.1-2.3]) and substance use diagnoses (AOR 2.3 [95% CI 1.5-3.7]) were more likely to have a concerning UDT result.

CONCLUSIONS

Expert adjudication of UDT results identified clinical concern for substance misuse in 37% of patients receiving opioids for chronic pain. Further research is needed to determine if UDTs impact clinical practice or patient-related outcomes.

The impact of opioid prescribing report cards in Medicaid

BACKGROUND: Performance feedback has been used for decades to improve health care quality and safety, with varying degrees of success. One example is the use of customized report cards that target inappropriate prescribing of high-risk medications, including opioids. Randomized controlled trials suggest that report cards are an effective tool to change opioid prescribing behavior, but their effectiveness in community settings is unclear. OBJECTIVE: To evaluate the impact of opioid prescribing report cards, which were mailed to Medicaid providers in Philadelphia, Pennsylvania. METHODS: Using a quasi-experimental approach, we compared trends in opioid prescribing by Medicaid providers in Philadelphia, who received a report card in late 2017, with Medicaid providers in surrounding counties, who did not receive report cards. First, we used propensity score matching to balance observed differences in the treatment and comparison groups; matching variables included provider specialty, sex, and selected characteristics of providers' Medicaid patient panels. We then estimated a difference-in-differences model to isolate the impact of report cards on opioid prescribing. RESULTS: The analytical sample included 1,598 providers in Philadelphia and 2,117 providers in surrounding counties, who prescribed opioids to 99,548 Medicaid patients during the study period. Although the number of Medicaid patients receiving opioids and the days supplied of opioids declined in both Philadelphia and surrounding counties during the study period, there was a larger reduction in Philadelphia Medicaid than in surrounding counties after the report cards were mailed. In the 6 months after the report cards were mailed (January 2018 to June 2018) compared with the 6 months before they were mailed (July 2017 to December 2017), we estimate that the reduction in opioid prescribing in Philadelphia Medicaid amounted to nearly 3 fewer Medicaid patients with an opioid prescription per month. CONCLUSIONS: After customized opioid prescribing report cards were mailed to Medicaid providers in Philadelphia, Pennsylvania, there was a statistically significant reduction in opioid prescribing to Medicaid patients relative to surrounding counties. Our findings suggest that opioid prescribing report cards with peer comparison are an effective way to influence opioid prescribing behavior among Medicaid providers. Report cards can complement other initiatives that target inappropriate opioid prescribing, such as prescription drug monitoring programs and prior authorization. DISCLOSURES: Drs Candon and Rothbard and Ms Shen received funding from Community Behavioral Health in Philadelphia, Pennsylvania. Drs Xue, Cole, and Donohue received funding from Pennsylvania Department of Human Services. Neither Community Behavioral Health nor the Pennsylvania Department of Human Services was involved in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication.

Study protocol for a type III hybrid effectiveness-implementation trial to evaluate scaling interoperable clinical decision support for patient-centered chronic pain management in primary care

Background

The US continues to face public health crises related to both chronic pain and opioid overdoses. Thirty percent of Americans suffer from chronic noncancer pain at an estimated yearly cost of over $600 billion. Most patients with chronic pain turn to primary care clinicians who must choose from myriad treatment options based on relative risks and benefits, patient history, available resources, symptoms, and goals. Recently, with attention to opioid-related risks, prescribing has declined. However, clinical experts have countered with concerns that some patients for whom opioid-related benefits outweigh risks may be inappropriately discontinued from opioids. Unfortunately, primary care clinicians lack usable tools to help them partner with their patients in choosing pain treatment options that best balance risks and benefits in the context of patient history, resources, symptoms, and goals. Thus, primary care clinicians and patients would benefit from patient-centered clinical decision support (CDS) for this shared decision-making process.

Methods

The objective of this 3-year project is to study the adaptation and implementation of an existing interoperable CDS tool for pain treatment shared decision making, with tailored implementation support, in new clinical settings in the OneFlorida Clinical Research Consortium. Our central hypothesis is that tailored implementation support will increase CDS adoption and shared decision making. We further hypothesize that increases in shared decision making will lead to improved patient outcomes, specifically pain and physical function. The CDS implementation will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. The evaluation will be organized by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. We will adapt and tailor PainManager, an open source interoperable CDS tool, for implementation in primary care clinics affiliated with the OneFlorida Clinical Research Consortium. We will evaluate the effect of tailored implementation support on PainManager’s adoption for pain treatment shared decision making. This evaluation will establish the feasibility and obtain preliminary data in preparation for a multi-site pragmatic trial targeting the effectiveness of PainManager and tailored implementation support on shared decision making and patient-reported pain and physical function.

Discussion

This research will generate evidence on strategies for implementing interoperable CDS in new clinical settings across different types of electronic health records (EHRs). The study will also inform tailored implementation strategies to be further tested in a subsequent hybrid effectiveness-implementation trial. Together, these efforts will lead to important new technology and evidence that patients, clinicians, and health systems can use to improve care for millions of Americans who suffer from pain and other chronic conditions.

Trial registration

ClinicalTrials.gov, NCT05256394, Registered 25 February 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01217-4.

Trends in Prescriptions for Non-opioid Pain Medications Among U.S. Adults With Moderate or Severe Pain, 2014-2018

As opioid prescribing has declined, it is unclear how the landscape of prescription pain treatment across the U.S. has changed. We used nationally-representative data from the Medical Expenditure Health Survey, 2014 to 2018 to examine trends in prescriptions for opioid and non-opioid pain medications, including acetaminophen, non-steroidal anti-inflammatory drugs, gabapentinoids, and antidepressants among U.S. adults with self-reported pain. Overall, from 2014 to 2018, the percentage of participants receiving a prescription for opioids declined, (38.8% vs 32.8%), remained stable for non-steroidal anti-inflammatory drugs (26.8% vs 27.7%), and increased for acetaminophen (1.6% vs 2.3%), antidepressants (9.6% vs 12.0%) and gabapentinoids (13.2% vs 19.0%). In this period, the adjusted odds of receiving an opioid prescription decreased (aOR = .93, 95% CI = .90-.96), while the adjusted odds of receiving antidepressant, gabapentinoid and acetaminophen prescriptions increased (antidepressants: aOR = 1.08, 95% CI = 1.03-1.13 gabapentinoids: aOR = 1.11, 95% CI = 1.06-1.17; acetaminophen: aOR = 1.10, 95% CI: 1.02-1.20). Secondary analyses stratifiying within the 2014 to 2016 and 2016 to 2018 periods revealed particular increases in prescriptions for gabapentinoids (aOR = 1.13, 95% CI = 1.05-1.21) and antidepressants (aOR = 1.23, 95% CI = 1.12-1.35) since 2016. PERSPECTIVE: These data demonstrate that physicians are increasingly turning to CDC-recommended non-opioid medications for pain management, particularly antidepressants and gabapentinoids. However, evidence for these medications' efficacy in treating numerous common pain conditions, including low back pain, remains limited.

Reducing opioid use disorder and overdose deaths in the United States: A dynamic modeling analysis

Opioid overdose deaths remain a major public health crisis. We used a system dynamics simulation model of the U.S. opioid-using population age 12 and older to explore the impacts of 11 strategies on the prevalence of opioid use disorder (OUD) and fatal opioid overdoses from 2022 to 2032. These strategies spanned opioid misuse and OUD prevention, buprenorphine capacity, recovery support, and overdose harm reduction. By 2032, three strategies saved the most lives: (i) reducing the risk of opioid overdose involving fentanyl use, which may be achieved through fentanyl-focused harm reduction services; (ii) increasing naloxone distribution to people who use opioids; and (iii) recovery support for people in remission, which reduced deaths by reducing OUD. Increasing buprenorphine providers' capacity to treat more people decreased fatal overdose, but only in the short term. Our analysis provides insight into the kinds of multifaceted approaches needed to save lives.

The Effect Of Clinician Feedback Interventions On Opioid Prescribing

An initial opioid prescription with a greater number of pills is associated with a greater risk for future long-term opioid use, yet few interventions have reliably influenced individual clinicians' prescribing. Our objective was to evaluate the effect of feedback interventions for clinicians in reducing opioid prescribing. The interventions included feedback on a clinician's outlier prescribing (individual audit feedback), peer comparison, and both interventions combined. We conducted a four-arm factorial pragmatic cluster randomized trial at forty-eight emergency department (ED) and urgent care (UC) sites in the western US, including 263 ED and 175 UC clinicians with 294,962 patient encounters. Relative to usual care, there was a significant decrease in pills per prescription both for peer comparison feedback (-0.8) and for the combination of peer comparison and individual audit feedback (-1.2). This decrease was sustained during follow-up. There were no significant changes for individual audit feedback alone, and no interventions changed the proportion of encounters with an opioid prescription.

Opioid and non-opioid analgesic prescribing before and after the CDC's 2016 opioid guideline

The U.S. has addressed the opioid crisis using a two-front approach: state regulations limiting opioid prescriptions for acute pain patients, and voluntary federal CDC guidelines on shifting chronic pain patients to lower opioid doses and non-opioids. No opioid policy research to date has accounted for this two-pronged approach in their research design. We develop a theory of physician prescribing behavior under this two-pronged incentive structure. Using the Medical Expenditure Panel Survey, we empirically corroborate the theory: regulations and guidelines have the intended effects of reducing opioid prescriptions for acute and chronic pain, respectively, as well as the predicted unintended effects-income effects cause regulations on acute pain treatment to increase chronic pain opioid prescriptions and the chronic pain treatment guidelines spillover to reduce opioids for acute pain. Moreover, we find that the guidelines worked as intended in terms of the reduced usage, with chronic pain patients shifting to non-opioids and also tapering opioid doses. For those who discontinued opioids under regulations and guidelines, we find no harm in terms of increased work limitations due to pain a year after discontinuing opioids. Finally, we observe an unexplained dichotomy-regulations reduce opioid use by causing fewer new starts, whereas guidelines reduce opioid use by discontinuing current users, with no impact on new starts.

Characterizations of Opioid Prescribing in Community Health Centers in 2018

Objective:

To identify the patient- and clinic-level correlates of any prescription opioid use, chronic use, and high-dose opioid use in a multi-state network of Community Health Centers (CHCs).

Methods:

We used electronic health record data from 337 primary care clinics serving 610 983 patients across 15 states in 2018. The primary outcomes were prescription of any opioid, chronic opioid, and high-dose opioid.

Results:

Overall, 6.5% of patients were prescribed an opioid; of these, 31% were chronic users and 5% were high-dose users. Males had 5% lower odds (Odds Ratio [OR] = 0.95; 95% Confidence Interval = 0.93-0.97) of being prescribed an opioid but 16% higher odds (OR = 1.16; 95% CI = 1.10-1.21) of being chronic users and 48% (OR = 1.48; 95% CI = 1.36-1.64) higher odds of being high-dose users than females. Rural clinics had higher rates of chronic opioid (rate ratio = 1.86; 95% CI = 1.20, 2.88) and high-dose users (rate ratio = 2.95; 95% CI = 1.81-4.81).

Conclusions:

Our study highlights variations in opioid prescribing with regard to patient-level and clinic-level factors. Targeted efforts and resources may be required to support rural CHCs who seek to reduce high-risk opioid prescribing.

Prescription opioid use among women of reproductive age in the United States: NHANES, 2003-2018

Women are prescribed opioids more often than men. Prescription opioid use among women of reproductive age is a public health concern because opioid use during pregnancy is associated with decreased prenatal care and increased risk of adverse perinatal and maternal outcomes. Recent prevalence estimates and correlates of prescription opioid use and long-term use among women of reproductive age are limited. Using the 2003-2018 National Health and Nutrition Examination Survey (NHANES), we estimated the national prevalence, trend, and correlates of prescription opioid use, long-term use (≥ 90 days of use), and use of medications for opioid use disorder (MOUD) among women aged 15-44 (n = 13,558). Prescription opioid use within the last 30 days and prescription duration were collected through interviews and identified using prescription codes. Trend analysis was conducted using the National Cancer Institute Joinpoint Trend Analysis Software. The prevalence of prescription opioid use significantly decreased from 5.2% in 2003-2004 to 3.0% in 2017-2018 (p < .05). MOUD use increased significantly from 0.1% in 2005-2006 to 0.4% in 2011-2012. Long-term opioid use did not significantly change over time. Correlates of prescription opioid use and long-term use included ages 35-44, non-Hispanic White, public insurance, and women with poor or fair health status. As policy makers and clinicians strive to reduce the negative impacts of the opioid epidemic, they should consider the demographic groups most likely to use prescription opioids long-term. Additionally, reductions in opioid prescribing should be balanced with increased availability of nonopioid therapies and monitoring for opioid use disorder.

Trends in prescribing pattern of opioid and benzodiazepine substitutes among Medicare part D beneficiaries from 2013 to 2018: a retrospective study

OBJECTIVE

Opioid and benzodiazepine co-prescribing is associated with a substantial increase in opioid overdose deaths. In this study, we examine the prescribing trends of substitutes of opioids and benzodiazepines alone or in combination, compared with opioids and benzodiazepines.

DESIGN

Retrospective cohort study.

SETTING

Data were collected using a 20% national sample of Medicare beneficiaries from 2013 to 2018.

PARTICIPANTS

4.1-4.3 million enrollees each year from 2013 to 2018.

INTERVENTION

None.

PRIMARY OUTCOME

We employ a generalised linear mixed models to calculate ORs for opioid use, benzodiazepine or Z-drug (benzos/Z-drugs) use, opioid/benzos/Z-drugs 30-day use, gabapentinoid use and (selective serotonin reuptake inhibitors (SSRI) and serotonin norepinephrine reuptake inhibitors (SNRIs)) use, adjusted for the repeated measure of patient. We then created two models to calculate the ORs for each year and comparing to 2013.

RESULTS

Opioid and benzos/Z-drugs use decreased by 2018 (aOR 0.626; 95% CI 0.622 to 0.630) comparing to 2013. We demonstrate a 36.3% and 9.9% increase rate of gabapentinoid and SSRI/SNRI use, respectively. Furthermore, combined gabapentinoid and SSRI/SNRI use increased in 2018 (aOR 1.422; 95% CI 1.412 to 1.431).

CONCLUSION

Little is known about the prescribing pattern and trend of opioid and benzodiazepine alternatives as analgesics. There is a modest shift from prescribing opioid and benzos/Z-drugs (alone or in combination) towards prescribing non-opioid analgesics-gabapentinoids with and without non-benzos/Z-drugs that are indicated for anxiety. It is unclear if this trend towards opioid/benzos/Z-drugs alternatives is associated with fewer drug overdose death, better control of pain and comorbid anxiety, and improved quality of life.

Opioid and non-opioid pain relief after an emergency department acute pain visit

OBJECTIVES

Treatment of acute pain after emergency department (ED) discharge remains a challenge in the opioid crisis context. Our objective was to determine the proportion of patients using opioid vs non-opioid pain medication following discharge from the ED with acute pain, and the association of type of pain medication with average pain intensity before pain medication intake and report of pain relief.

METHODS

This was a prospective cohort study of ED patients aged ≥ 18 years with an acute pain (≤ 2 weeks) who were discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain intensity level before each pain medication intake (0-10 numeric rating scale), type of pain medication use (opioid vs non-opioid), and if pain was relieved by the medication used that day. Multilevel analyses were used to compare the effect of type of analgesic used on pain intensity and relief.

RESULTS

A total of 381 participants completed the 14-day diary; 50% were women and median age was 54 years (IQR = 43-66). Average daily pain intensity before pain medication intake was significantly higher for patients who used opioids (5.9; 95% CI 5.7-6.2) as compared to non-opioid analgesics (4.2; 95% CI 4.0-4.5) or no pain medication (2.2; 95% CI 1.9-2.5). Controlling for pain intensity, patients using opioids were more likely to report a pain relief (OR = 1.3; 95% CI 1.1-1.8) as compared to those who used non-opioid analgesics.

CONCLUSION

Overall, opioids appear to be effective and used as intended by the prescribing physician.

Adolescent and Adult Correlates of Prescription Opioid Use and Misuse in Adulthood: Associations Across Domains of Despair

Objective: Given continued increases in "deaths of despair", there is a need to examine associations of factors across multiple domains of despair (i.e. cognitive, emotional, behavioral, biological) with opioid-related behaviors. An understanding of current and early life correlates of prescription opioid behaviors can help inform clinical care, public health interventions, and future life course research. Methods: Using data from Waves I (1994-1995; participants ages 12-18 years) and V (2016-2018; participants ages 34-42 years) of the National Longitudinal Study of Adolescent to Adult Health (N = 10,685), we examined adolescent and adult demographic, mental and physical health, substance use, and behavioral characteristics associated with past 30-day prescription opioid use only, misuse only, and both use and misuse to no recent use or misuse in adulthood. Results: Overall, 2.3% of adult participants reported past 30-day prescription opioid use only, 6.3% reported past 30-day misuse only, and 1.3% reported both prescribed use and misuse in the past 30 days. Physical health conditions in adolescence and adulthood were most common among those reporting use only and both use and misuse. Mental health conditions, other substance use, and delinquent behaviors in adolescence and adulthood were most common among those reporting misuse only and both use and misuse. Conclusions: Results from this nationally representative sample highlight the prevalence of specific prescription opioid behaviors and underscore the importance of targeting underlying drivers of prescription opioid use and misuse early in the life course. Continued implementation individual- and population-level approaches will be critical to addressing continued demand for opioids.

Chronic Opioid Use Following Lumbar Discectomy: Prevalence, Risk Factors, and Current Trends in the United States

Objective

Lumbar discectomy is commonly performed for symptomatic lumbar disc herniation. We aimed to examine prescribing patterns and risk factors for chronic opioid use following lumbar discectomy.

Methods

Using a private insurance claims database, patients were identified who underwent primary lumbar discectomy from 2010–2015 and had 1-year of continuous enrollment postoperatively. Patients were excluded with spinal fusion. The strength of opioid prescriptions was quantified using morphine milligram equivalents daily (MMED). Univariate and multivariate logistic regression models were built to examine risk factors associated with chronic postoperative opioid use.

Results

A total of 5,315 patients were included in the study (mean age, 59 years; 50% female). 1,198 of patients (23%) used chronic opioids postoperatively. Chronic opioid use declined significantly from 27% in 2010 to 17% in 2015, p < 0.001. In addition, there were significantly fewer patients receiving high and very high-dose opioid prescriptions from 2010–2015, p < 0.001. The median duration that patients used opioids postoperatively was 211 days in 2010 (interquartile range [IQR], 29–356 days), and decreased significantly to 44 days (IQR, 10–294 days) in 2015. The strongest factors associated with chronic opioid use were preoperative opioid use (odds ratio [OR], 4.0), drug abuse (OR, 2.6), depression (OR, 1.6), surgery in the west (OR, 1.6) or south (OR, 1.6), anxiety (OR, 1.5), or 30-day readmission (OR, 1.4).

Conclusion

Chronic opioid use following primary lumbar discectomy has declined from 2010–2015. A variety of factors are associated with chronic opioid use. Preoperative recognition of some of these risk factors may aid in perioperative management and counseling.

Sexual Violence, Mental Health, and Prescription Opioid Use and Misuse

INTRODUCTION

Previous research indicates that sexual violence is associated with prescription opioid use and misuse. However, this literature is limited by a lack of sex-specific analyses, an inability to establish temporality between experiences of sexual violence and prescription opioid outcomes, and little understanding of mechanisms underlying these associations.

METHODS

Data from Waves IV (2008) and V (2016-2018) of the National Longitudinal Study of Adolescent to Adult Health (N=10,685) were analyzed in March 2020. The association of sexual violence with past 30-day prescription opioid use and misuse among women and men and mediation by depression and anxiety diagnoses were examined using generalized structural equation modeling. Temporality was established using self-reported age at the first experience of sexual violence and age at first depression and anxiety diagnoses.

RESULTS

Sexual violence was associated with an increased likelihood of prescription opioid use and misuse among women (OR=1.68, 95% CI=1.19, 2.39 for use; OR=1.18, 95% CI=0.95, 1.55 for misuse) and men (OR=2.37, 95% CI=1.37, 4.12 for use; OR=1.71, 95% CI=1.06, 2.75 for misuse). Among women, depression (p=0.0420) and anxiety (p=0.0450) diagnoses mediated the association with prescription opioid use, and anxiety diagnosis (p=0.0210) mediated the association with prescription opioid misuse. Among men, anxiety diagnosis (p=0.038) mediated the association with prescription opioid use, and depression diagnosis (p=0.0390) mediated the association with prescription opioid misuse.

CONCLUSIONS

Secondary prevention efforts focused on evidence-based, trauma-informed behavioral health treatment among survivors of sexual violence may prevent prescription opioid use and misuse as strategies for coping with the psychological impact of these traumatic experiences.

Assessment of Opioid Prescribing Patterns in a Large Network of US Community Health Centers, 2009 to 2018

IMPORTANCE

Understanding opioid prescribing patterns in community health centers (CHCs) that disproportionately serve low-income patients may help to guide strategies to reduce opioid-related harms.

OBJECTIVE

To assess opioid prescribing patterns between January 1, 2009, and December 31, 2018, in a network of safety-net clinics serving high-risk patients.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of 3 227 459 opioid prescriptions abstracted from the electronic health records of 2 129 097 unique primary care patients treated from 2009 through 2018 at a network of CHCs that included 449 clinic sites in 17 states. All age groups were included in the analysis.

MAIN OUTCOMES AND MEASURES

The following measures were described at the population level for each study year: (1) percentage of patients with at least 1 prescription for an opioid by age and sex, (2) number of opioid prescriptions per 100 patients, (3) number of long-acting opioid prescriptions per 100 patients, (4) mean annual morphine milligram equivalents (MMEs) per patient, (5) mean MME per prescription, (6) number of chronic opioid users, and (7) mean of high-dose opioid users.

RESULTS

The study population included 2 129 097 patients (1 158 413 women [54.4%]) with a mean (SD) age of 32.2 (21.1) years and a total of 3 227 459 opioid prescriptions. The percentage of patients receiving at least 1 opioid prescription in a calendar year declined 67.4% from 15.9% in 2009 to 5.2% in 2018. Over the 10-year study period, a greater percentage of women received a prescription (13.1%) compared with men (10.9%), and a greater percentage of non-Hispanic White patients (18.1%) received an opioid prescription compared with non-Hispanic Black patients (9.5%), non-Hispanic patients who self-identified as other races (8.0%), and Hispanic patients (6.9%). The number of opioid prescriptions for every 100 patients decreased 73.7% from 110.8 in 2009 to 29.1 in 2018. The number of long-acting opioids for every 100 patients decreased 85.5% during the same period, from 22.0 to 3.2. The MMEs per patient decreased from 1682.7 in 2009 to 243.1 in 2018, a decline of 85.6%.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, the opioid prescribing rate in 2009 in the CHC network was higher than national population estimates but began to decline earlier and more precipitously. This finding likely reflects harm mitigation policies and efforts at federal, state, and clinic levels and strong clinical quality improvement strategies within the CHCs.