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Weleff J, Anand A, Squeri M, Sieke R, Thompson NR, Barnett BS. An Analysis of Benzodiazepine Prescribing to Primary Care Patients in a Large Healthcare System from 2019-2020. J Psychoactive Drugs 2024; 56:245-256. [PMID: 36940298 DOI: 10.1080/02791072.2023.2191610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/04/2023] [Indexed: 03/22/2023]
Abstract
We sought to quantify benzodiazepine prescribing by primary care providers from 2019 to 2020 and identify correlates of prescribing. We hypothesized prescribing would increase post-COVID-19 lockdown. We conducted a retrospective cohort study of adult patients with primary care visits in 2019 or 2020 in a large Ohio healthcare system. Demographics, diagnosis codes, and receipt of benzodiazepine prescriptions were collected. Using multivariable logistic regression, we examined factors associated with benzodiazepine prescription receipt during the whole study period and post-lockdown. 455,537 adult patients had 1,643,473 visits. Benzodiazepines were prescribed in 3.2% (53,049/1,643,473) of visits. Effect sizes for positive associations with benzodiazepine prescription were largest for anxiety disorders. For negative associations, they were largest for Black patients and patients with cocaine use disorder. Benzodiazepine prescribing was positively associated with multiple groups having contraindications, though effect sizes were small. Contrary to our hypothesis, odds of receiving a prescription were 8.8% lower post-lockdown. Benzodiazepine prescribing rates in our system compared favorably to national rates. Year over year odds of receiving a prescription were slightly lower post-lockdown. Racial disparities were present and deserve further study. Strategies to reduce benzodiazepine prescribing to patients with anxiety may yield the largest reductions for benzodiazepine prescribing in primary care settings.
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Affiliation(s)
- Jeremy Weleff
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Akhil Anand
- Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- EC-10 Cleveland Clinic, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA
| | - Michael Squeri
- Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rachel Sieke
- Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nicolas R Thompson
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
- Neurological Institute, Center for Outcomes Research & Evaluation, Cleveland Clinic, Cleveland, OH, USA
| | - Brian S Barnett
- Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- EC-10 Cleveland Clinic, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA
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El-Solh AA, Lawson Y, Wilding GE. Association Between Hypnotic Use and All-Cause Mortality in Patients with Chronic Obstructive Pulmonary Disease and Insomnia. Int J Chron Obstruct Pulmon Dis 2023; 18:2393-2404. [PMID: 37942297 PMCID: PMC10629458 DOI: 10.2147/copd.s430609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023] Open
Abstract
Purpose Hypnotics are commonly prescribed in patients with COPD to manage insomnia. Given the considerable risks associated with these drugs, the aim of the study was to evaluate the risk of all-cause mortality associated with hypnotics in a cohort of veterans with COPD presenting with insomnia. Methods We conducted a retrospective cohort study that used Veterans Health Administration Corporate Data Warehouse with data supplemented by linkage to Medicare, Medicaid, and National Death Index data from 2010 through 2019. The primary outcome was all-cause mortality. Analyses were conducted using propensity score 1:1 matching to balance baseline characteristics. Results Of the 5759 veterans with COPD (mean [SD] age, 71.7 [11.2]; 92% men), 3585 newly initiated hypnotic agents during the study period. During a mean follow-up of 7.4 (SD, 2.7) years, a total of 2301 deaths occurred, with 65.2 and 48.7 total deaths per 1000 person-years among hypnotic users and nonusers, respectively. After propensity matching, hypnotic use was associated with a 22% increased risk of mortality compared with hypnotic nonusers (hazard ratio [HR] 1.22; 95% confidence interval [CI],1.11-1.35). The benzodiazepine receptor agonists (BZRAs) group experienced a higher incidence rate of all-cause mortality compared to hypnotic nonusers (Incidence rate ratio [IRR] 1.27; 95% CI, 1.14-1.43). Conversely, the mortality rate of non-BZRA hypnotics decreased after the first 2 years and was not significantly different for hypnotic nonusers (IRR 1.04; 95% CI, 0.82-1.11). Conclusion Among patients with COPD and insomnia, treatment with hypnotics was associated with a higher risk of all-cause mortality. The association was observed in patients prescribed BZRAs. The risk of mortality for non-BZRAs moderated after the first 2 years, indicating a class effect.
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Affiliation(s)
- Ali A El-Solh
- Research Department, VA Western New York Healthcare System, Buffalo, NY, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine; Jacobs School of Medicine, Buffalo, NY, USA
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions; University at Buffalo, Buffalo, NY, USA
| | - Yolanda Lawson
- Research Department, VA Western New York Healthcare System, Buffalo, NY, USA
| | - Gregory E Wilding
- Department of Biostatistics, School of Public Health and Health Professions; University at Buffalo, Buffalo, NY, USA
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Turner AP, Arewasikporn A, Hawkins EJ, Suri P, Burns SP, Leipertz SL, Haselkorn JK. Risk Factors for Chronic Prescription Opioid Use in Multiple Sclerosis. Arch Phys Med Rehabil 2023; 104:1850-1856. [PMID: 37137460 DOI: 10.1016/j.apmr.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 01/31/2023] [Accepted: 04/10/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To characterize patterns of prescription opioid use among individuals with multiple sclerosis (MS) and identify risk factors associated with chronic use. DESIGN Retrospective longitudinal cohort study examining US Department of Veterans Affairs electronic medical record data of Veterans with MS. The annual prevalence of prescription opioid use by type (any, acute, chronic, incident chronic) was calculated for each study year (2015-2017). Multivariable logistic regression was used to identify demographics and medical, mental health, and substance use comorbidities in 2015-2016 associated with chronic prescription opioid use in 2017. SETTING US Department of Veterans Affairs, Veteran's Health Administration. PARTICIPANTS National sample of Veterans with MS (N=14,974). MAIN OUTCOME MEASURE Chronic prescription opioid use (≥90 days). RESULTS All types of prescription opioid use declined across the 3 study years (chronic opioid use prevalence=14.6%, 14.0%, and 12.2%, respectively). In multivariable logistic regression, prior chronic opioid use, history of pain condition, paraplegia or hemiplegia, post-traumatic stress disorder, and rural residence were associated with greater risk of chronic prescription opioid use. History of dementia and psychotic disorder were both associated with lower risk of chronic prescription opioid use. CONCLUSION Despite reductions over time, chronic prescription opioid use remains common among a substantial minority of Veterans with MS and is associated with multiple biopsychosocial factors that are important for understanding risk for long-term use.
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Affiliation(s)
- Aaron P Turner
- VA Puget Sound Health Care System, Seattle, WA; VA MS Center of Excellence West, Seattle, WA; Center of Excellence in Substance Addiction Treatment and Education, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
| | | | - Eric J Hawkins
- VA Puget Sound Health Care System, Seattle, WA; Center of Excellence in Substance Addiction Treatment and Education, Seattle, WA; Health Services Research & Development (HSR&D), Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| | - Pradeep Suri
- VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA; Clinical Learning, Evidence, and Research Center (CLEAR), University of Washington, Seattle, WA
| | - Stephen P Burns
- VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Steve L Leipertz
- VA Puget Sound Health Care System, Seattle, WA; VA MS Center of Excellence West, Seattle, WA
| | - Jodie K Haselkorn
- VA Puget Sound Health Care System, Seattle, WA; VA MS Center of Excellence West, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
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Syed O, Jancic P, Fink AB, Knezevic NN. Drug Safety and Suicidality Risk of Chronic Pain Medications. Pharmaceuticals (Basel) 2023; 16:1497. [PMID: 37895968 PMCID: PMC10609967 DOI: 10.3390/ph16101497] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/13/2023] [Accepted: 10/15/2023] [Indexed: 10/29/2023] Open
Abstract
Chronic pain is one of the main leading causes of disability in the world at present. A variety in the symptomatology, intensity and duration of this phenomenon has led to an ever-increasing demand of pharmacological treatment and relief. This demand for medication, ranging from well-known groups, such as antidepressants and benzodiazepines, to more novel drugs, was followed by a rise in safety concerns of such treatment options. The validity, frequency, and diversity of such concerns are discussed in this paper, as well as their possible effect on future prescription practices. A specific caution is provided towards the psychological safety and toll of these medications, regarding suicidality and suicidal ideation. Most significantly, this paper highlights the importance of pharmacovigilance and underscores the necessity of surveillance programs when considering chronic pain medication.
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Affiliation(s)
- Osman Syed
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, IL 60657, USA; (O.S.); (P.J.); (A.B.F.)
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL 60515, USA
| | - Predrag Jancic
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, IL 60657, USA; (O.S.); (P.J.); (A.B.F.)
| | - Adam B. Fink
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, IL 60657, USA; (O.S.); (P.J.); (A.B.F.)
- Harborview Medical Center, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA
| | - Nebojsa Nick Knezevic
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, IL 60657, USA; (O.S.); (P.J.); (A.B.F.)
- Department of Anesthesiology, University of Illinois, Chicago, IL 60612, USA
- Department of Surgery, University of Illinois, Chicago, IL 60612, USA
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Wolitzky-Taylor K, Mooney LJ, Otto MW, Metts A, Parsons EM, Hanano M, Ram R. Augmenting the efficacy of benzodiazepine taper with telehealth-delivered cognitive behavioral therapy for anxiety disorders in patients using prescription opioids: A pilot randomized controlled trial. Contemp Clin Trials 2023; 133:107334. [PMID: 37730196 PMCID: PMC10960249 DOI: 10.1016/j.cct.2023.107334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/07/2023] [Accepted: 09/15/2023] [Indexed: 09/22/2023]
Abstract
The risks of concomitant benzodiazepine (BZ) and opioid use are significant. Despite the urgent need to reduce BZ use among patients taking opioids, no treatment intervention research to our knowledge has addressed treatment for this concurrent, high-risk use. The current study will evaluate the efficacy of augmenting BZ taper procedures with CBT for anxiety disorders that has been adapted specifically for patients with concomitant BZ and opioid use (either use as prescribed or misuse), a high-risk patient population. Research combining rapidly scalable behavioral interventions ancillary to pharmacological approaches delivered via telehealth in primary care settings is innovative and important given concerning trends in rising prevalence of BZ/opioid co-prescription, BZ-associated overdose deaths, and known barriers to implementation of behavioral health interventions in primary care. CBT delivery using telehealth has the potential to aid adherence and promote access and dissemination of procedures in primary care. Lastly, the current study will utilize an experimental therapeutics approach to preliminarily explore the mechanism of action for the proposed interventions. The overall aim of the present pilot randomized controlled trial is to examine the feasibility and preliminary efficacy of a BZ taper with CBT for anxiety disorders adapted for patients with concomitant BZ (BZT + CBT) and opioid use to a BZ taper with a control health education program (BZT + HE) in a sample of individuals (N = 54) who have been prescribed and are taking benzodiazepines and opioids for at least 3 months prior to baseline and experience anxious distress. Screening and outcome measures, methods, and implications are described. Trial Registration: ClinicalTrials.gov (NCT05573906).
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Affiliation(s)
| | - Larissa J Mooney
- UCLA Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, USA
| | - Michael W Otto
- Boston University, Department of Psychological and Brain Sciences, Boston, MA, USA
| | | | - E Marie Parsons
- Boston University, Department of Psychological and Brain Sciences, Boston, MA, USA
| | - Maria Hanano
- UCLA Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA, USA
| | - Reuben Ram
- UCLA Toluca Lake Clinic, Los Angeles, CA, USA
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El-Solh AA, Lawson Y, Wilding GE. The risk of major adverse cardiovascular events associated with the use of hypnotics in patients with insomnia. Sleep Health 2023; 9:717-725. [PMID: 37393143 DOI: 10.1016/j.sleh.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/19/2023] [Accepted: 05/05/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVES To examine whether hypnotic use in patients with insomnia reduces major adverse cardiovascular events, including all-cause mortality and nonfatal major adverse cardiovascular events. METHODS Using the Veterans Affairs Corporate Data Warehouse, we conducted a retrospective cohort study of 16,064 patients who were newly diagnosed with insomnia between January 1, 2010, and December 31, 2019. A pair of 3912 hypnotic users and nonusers were selected based on a 1:1 propensity score methodology. The primary outcome was extended major adverse cardiovascular events, a composite of the first occurrence of all-cause mortality or nonfatal major adverse cardiovascular events. RESULTS During the median follow-up of 4.8 years, a total of 2791 composite events occurred, including 2033 deaths and 762 nonfatal major adverse cardiovascular events. Although the incidence rates of major adverse cardiovascular events were comparable between hypnotic users and nonusers in the propensity-matched cohort, users of benzodiazepines and Z-drugs had a higher risk of all-cause mortality (hazard ratio 1.47 [95% CI, 1.17-1.88] and 1.20 [95% CI, 1.03-1.39], respectively), while serotonin antagonist and reuptake inhibitors users had a survival advantage (hazard ratio 0.79 [95% CI, 0.69-0.91]) compared with nonusers. There were no differences in the risk of nonfatal major adverse cardiovascular events between all classes of hypnotics. Male patients and those aged 60 years or younger who were using benzodiazepines or Z-drugs experienced higher major adverse cardiovascular events than their counterparts. CONCLUSIONS In patients with newly diagnosed insomnia, treatment with hypnotics resulted in higher extended major adverse cardiovascular events but not nonfatal major adverse cardiovascular events with benzodiazepine and Z-drug users compared with nonusers. The use of serotonin antagonist and reuptake inhibitors agents had a protective effect against major adverse cardiovascular events warranting further investigation.
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Affiliation(s)
- Ali A El-Solh
- The Veterans Affairs Western New York Healthcare System, Western New York Respiratory Research Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Buffalo, NY, USA; Department of Medicine, Jacobs School of Medicine and Biomedical Sciences and School of Public Health and Health Professions, Buffalo, NY, USA; Department of Epidemiology and Environmental Health, Jacobs School of Medicine and Biomedical Sciences and School of Public Health and Health Professions, Buffalo, NY, USA.
| | - Yolanda Lawson
- The Veterans Affairs Western New York Healthcare System, Western New York Respiratory Research Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Buffalo, NY, USA.
| | - Gregory E Wilding
- Department of Biostatistics; Jacobs School of Medicine and Biomedical Sciences and School of Public Health and Health Professions, Buffalo, CY, USA.
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Wang Y, Wilson DL, Fernandes D, Adkins LE, Bantad A, Copacia C, Dharma N, Huang PL, Joseph A, Park TW, Budd J, Meenrajan S, Orlando FA, Pennington J, Schmidt S, Shorr R, Uphold CR, Lo-Ciganic WH. Deprescribing Strategies for Opioids and Benzodiazepines with Emphasis on Concurrent Use: A Scoping Review. J Clin Med 2023; 12:jcm12051788. [PMID: 36902574 PMCID: PMC10002935 DOI: 10.3390/jcm12051788] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 02/25/2023] Open
Abstract
While the Food and Drug Administration's black-box warnings caution against concurrent opioid and benzodiazepine (OPI-BZD) use, there is little guidance on how to deprescribe these medications. This scoping review analyzes the available opioid and/or benzodiazepine deprescribing strategies from the PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library databases (01/1995-08/2020) and the gray literature. We identified 39 original research studies (opioids: n = 5, benzodiazepines: n = 31, concurrent use: n = 3) and 26 guidelines (opioids: n = 16, benzodiazepines: n = 11, concurrent use: n = 0). Among the three studies deprescribing concurrent use (success rates of 21-100%), two evaluated a 3-week rehabilitation program, and one assessed a 24-week primary care intervention for veterans. Initial opioid dose deprescribing rates ranged from (1) 10-20%/weekday followed by 2.5-10%/weekday over three weeks to (2) 10-25%/1-4 weeks. Initial benzodiazepine dose deprescribing rates ranged from (1) patient-specific reductions over three weeks to (2) 50% dose reduction for 2-4 weeks, followed by 2-8 weeks of dose maintenance and then a 25% reduction biweekly. Among the 26 guidelines identified, 22 highlighted the risks of co-prescribing OPI-BZD, and 4 provided conflicting recommendations on the OPI-BZD deprescribing sequence. Thirty-five states' websites provided resources for opioid deprescription and three states' websites had benzodiazepine deprescribing recommendations. Further studies are needed to better guide OPI-BZD deprescription.
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Affiliation(s)
- Yanning Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Department of Health Outcome and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Debbie L. Wilson
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Deanna Fernandes
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL 32601, USA
| | - Lauren E. Adkins
- Health Science Center Libraries, University of Florida, Gainesville, FL 32610, USA
| | - Ashley Bantad
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Clint Copacia
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Nilay Dharma
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Pei-Lin Huang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Amanda Joseph
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Tae Woo Park
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jeffrey Budd
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL 32611, USA
| | - Senthil Meenrajan
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL 32611, USA
| | - Frank A. Orlando
- Department of Community Heath and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - John Pennington
- Department of Community Heath and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Siegfried Schmidt
- Department of Community Heath and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Ronald Shorr
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL 32601, USA
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Constance R. Uphold
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL 32601, USA
- Department of Physiology and Aging, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Correspondence:
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Barrett AK, Sandbrink F, Mardian A, Oliva EM, Torrise V, Zhang R, Bukowski K, Burk M, Cunningham FE. Medication Use Evaluation of High-Dose Long-Term Opioid De-prescribing in Multiple Veterans Affairs Medical Centers. J Gen Intern Med 2022; 37:4037-4046. [PMID: 36219305 PMCID: PMC9708996 DOI: 10.1007/s11606-022-07807-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/13/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND The Opioid Safety Initiative (OSI) was implemented in 2013 to enhance the safe and appropriate use of opioids in the Veterans Health Administration (VA). Opioid use decreased nationally in subsequent years, but characterization of opioid de-prescribing practices has not been well established. OBJECTIVES To describe changes in patient characteristics and patterns of de-prescribing since OSI implementation for opioid users at > 90 morphine equivalent daily dose for at least 90 days for those that discontinued opioids within the VA. DESIGN Retrospective observational pre-post intervention medication use evaluation using VA data and electronic health records to identify differences in opioid de-prescribing between fiscal year 2013 (FY13; early OSI) and FY17 (late OSI). Reviewers' insights for local opioid management and de-prescribing practices collected through web-based post-data collection survey. PARTICIPANTS Veterans prescribed high-dose long-term opioid therapy in FY13 and FY17 who subsequently discontinued opioids at 27 VA medical centers. MAIN MEASURES Chart review data from local facility reviewers identified socioeconomic characteristics, opioid de-prescribing rationale (e.g., risk-benefit, diversion) and practices (e.g., rate of opioid discontinuation, taper monitoring activities, withdrawal monitoring), and outcomes following discontinuation. KEY RESULTS Among 315 patients in FY13 and 322 patients in FY17 with opioid discontinuation, discontinuation rationale focused on diversion in FY13 and risk-benefit in FY17. Clinical pharmacists and pain management specialists had increased involvement in FY17 opioid discontinuations (36% versus 16%). Of all discontinuations, 56% of patients were tapered in FY13 versus 70% of patients in FY17. Tapering plans were longer in FY17 than in FY13 (163 days versus 65 days). Transitions to non-opioid pain therapy following opioid discontinuation were higher in FY17 compared to FY13 (70% versus 60%). CONCLUSIONS Veterans discontinued from high-dose long-term opioids in FY17 were more optimally managed compared to those in FY13. Findings suggest improvements in opioid de-prescribing following OSI implementation, but interpretation is limited by study design.
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Affiliation(s)
- Alexis K Barrett
- VA Pharmacy Benefits Management Services and Center for Medication Safety, Hines VA, Hines, IL, USA.
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C) Building 30, Pittsburgh, PA, 15240, USA.
| | | | | | - Elizabeth M Oliva
- VA Program Evaluation and Resource Center, Menlo Park, CA, USA
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Virginia Torrise
- VA Pharmacy Benefits Management Services, United States Department of Veterans Affairs, Washington, DC, USA
| | - Rongping Zhang
- VA Pharmacy Benefits Management Services and Center for Medication Safety, Hines VA, Hines, IL, USA
| | - Kenneth Bukowski
- VA Pharmacy Benefits Management Services and Center for Medication Safety, Hines VA, Hines, IL, USA
| | - Muriel Burk
- VA Pharmacy Benefits Management Services and Center for Medication Safety, Hines VA, Hines, IL, USA
| | - Francesca E Cunningham
- VA Pharmacy Benefits Management Services and Center for Medication Safety, Hines VA, Hines, IL, USA
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Barrett AK, Cashy JP, Thorpe CT, Hale JA, Suh K, Lambert BL, Galanter W, Linder JA, Schiff GD, Gellad WF. Latent Class Analysis of Prescribing Behavior of Primary Care Physicians in the Veterans Health Administration. J Gen Intern Med 2022; 37:3346-3354. [PMID: 34993865 PMCID: PMC9550922 DOI: 10.1007/s11606-021-07248-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Benzodiazepines, opioids, proton-pump inhibitors (PPIs), and antibiotics are frequently prescribed inappropriately by primary care physicians (PCPs), without sufficient consideration of alternative options or adverse effects. We hypothesized that distinct groups of PCPs could be identified based on their propensity to prescribe these medications. OBJECTIVE To identify PCP groups based on their propensity to prescribe benzodiazepines, opioids, PPIs, and antibiotics, and patient and PCP characteristics associated with identified prescribing patterns. DESIGN Retrospective cohort study using VA data and latent class regression analyses to identify prescribing patterns among PCPs and examine the association of patient and PCP characteristics with class membership. PARTICIPANTS A total of 2524 full-time PCPs and their patient panels (n = 2,939,636 patients), from January 1, 2017, to December 31, 2018. MAIN MEASURES We categorized PCPs based on prescribing volume quartiles for the four drug classes, based on total days' supply dispensed of each medication by the PCP to their patients (expressed as days' supply per 1000 panel patient-days). We used latent class analysis to group PCPs based on prescribing and used multinomial logistic regression to examine patient and PCP characteristics associated with latent class membership. KEY RESULTS PCPs were categorized into four groups (latent classes): low intensity (23% of cohort), medium-intensity overall/high-intensity PPI (36%), medium-intensity overall/high-intensity opioid (20%), and high intensity (21%). PCPs in the high-intensity group were predominantly in the highest quartile of prescribers for all four drugs (68% in the highest quartile for benzodiazepine, 86% opioids, 64% PPIs, 62% antibiotics). High-intensity PCPs (vs. low intensity) were substantially less likely to be female (OR: 0.30, 95% CI: 0.21-0.42) or practice in the northeast versus other census regions (OR: 0.10, 95% CI: 0.06-0.17). CONCLUSIONS VA PCPs can be classified into four clearly differentiated groups based on their prescribing of benzodiazepines, opioids, PPIs, and antibiotics, suggesting an underlying typology of prescribing. High-intensity PCPs were more likely to be male.
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Affiliation(s)
- Alexis K Barrett
- VA Center for Medication Safety/Pharmacy Benefits Management Services, U.S. Department of Veteran Affairs, Hines, IL, USA.
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, USA.
| | - John P Cashy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, USA
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, USA
| | - Kangho Suh
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bruce L Lambert
- Department of Communication Studies, Center for Communication and Health, Northwestern University, Evanston, IL, USA
| | - William Galanter
- Department of Medicine, Department of Pharmacy Systems, Outcomes & Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gordon D Schiff
- Center for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston, MA, USA
- Center for Primary Care, Harvard Medical School, Boston, MA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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10
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Sprunger JG, Johnson K, Lewis D, Kaelber DC, Winhusen TJ. Five-year incidence of substance use and mental health diagnoses following exposure to opioids or opioids with benzodiazepines during an emergency department encounter for traumatic injury. Drug Alcohol Depend 2022; 238:109584. [PMID: 35933891 PMCID: PMC9680036 DOI: 10.1016/j.drugalcdep.2022.109584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Benzodiazepines and opioids are used alone or in conjunction in certain care settings, but each have the potential for misuse. OBJECTIVE This longitudinal observational study evaluated substance use and mental health outcomes associated with providing opioids with or without benzodiazepine to treat traumatic injury in the emergency department (ED) setting. METHODS We analyzed a limited dataset obtained through the IBM Watson Health Explorys. Matched cohorts were defined for: 1) patients treated with opioids during the ED encounter (ED-Opioid) vs. neither opioid or benzodiazepine treatment (No medication) (n = 5372); 2) patients treated with opioids and benzodiazepines during the ED encounter (ED-Opioid+Benzodiazepines) vs. No Medication (n = 2454); and 3) ED-Opioid+Benzodiazepines vs. ED-Opioid (n = 2454). Patients consisted of adults with an emergency department encounter in the MetroHealth System (Cleveland, Ohio) with a chief complaint of traumatic injury and medical records for five years following the encounter. Control patients for each cohort were matched to the exposure patients on demographics, body mass index, and residential zip code median income. Outcomes were five-year incidence rates for alcohol, substance use, depression, and anxiety-related diagnoses. RESULTS Our results indicate that, although receiving opioids during the ED visit predicted a relatively lower likelihood of subsequent substance use and mental health diagnoses, the brief co-use of benzodiazepines was strongly associated with poorer outcomes. CONCLUSIONS Even brief exposure to co-prescribed opioids and benzodiazepines during emergency traumatic injury care may be associated with negative substance use and mental health consequences in the years following the event.
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Affiliation(s)
- Joel G. Sprunger
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA;,Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH 45229
| | - Keilan Johnson
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA
| | - Daniel Lewis
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA
| | - David C. Kaelber
- Department of Information Services, The MetroHealth System, Cleveland, Ohio, USA,Departments of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA;,The Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, Ohio, USA
| | - T. John Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA;,Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH 45229
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11
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Concomitant opioid and benzodiazepine use and risk of suicide attempt and intentional self-harm: Pharmacoepidemiologic study. Drug Alcohol Depend 2021; 228:109046. [PMID: 34592702 PMCID: PMC8595792 DOI: 10.1016/j.drugalcdep.2021.109046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Overdose due to concomitant use of opioids and benzodiazepines has been raised as a major public health concern, although little research has examined whether this risk extends to intentional overdose or other self-harm. This study examined whether prescription opioids and benzodiazepines interact to increase the rate of suicide attempt and intentional self-harm. METHODS The study analyzed 4,762,438 users of opioids, benzodiazepines, both drugs concomitantly, or neither drug from the MarketScan Commercial Claims and Encounters databases (2014-2016). The four groups were matched using inverse probability of treatment weighting and a difference in difference design was used to examine associations with risk of suicide attempt, intentional self-harm and drug overdose, including suicide death resulting in a medical claim. RESULTS There was a small association for opioids (HR=1.23; 95% CI 1.06-1.43) but a larger association for benzodiazepines (HR=2.55; 95% CI 2.12-3.05) with suicide attempt, intentional self-harm, and drug overdose. The medication interaction was opposite to the expected direction (HR=0.70; 95% CI 0.55-0.89), indicating that risk associated with concomitant use was lower than would be expected on an additive basis. Sensitivity analyses found no evidence of increased risk due to interaction between the two drug classes. CONCLUSIONS Increased risk of suicide attempt, intentional self-harm and drug overdose for concomitant use of opioids and benzodiazepines is in large part attributable to benzodiazepine use alone. In typically prescribed quantities, opioids and benzodiazepines may not represent a drug interaction in terms of yielding increased risk of suicide attempt and intentional self-harm resulting in medical care.
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12
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Tseregounis IE, Henry SG. Assessing opioid overdose risk: a review of clinical prediction models utilizing patient-level data. Transl Res 2021; 234:74-87. [PMID: 33762186 PMCID: PMC8217215 DOI: 10.1016/j.trsl.2021.03.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/24/2021] [Accepted: 03/16/2021] [Indexed: 12/23/2022]
Abstract
Drug, and specifically opioid-related, overdoses remain a major public health problem in the United States. Multiple studies have examined individual risk factors associated with overdose risk, but research developing clinical risk prediction tools for overdose has only emerged in the last few years. We conducted a comprehensive review of the literature on patient-level factors associated with opioid-related overdose risk, with an emphasis on clinical risk prediction models for opioid-related overdose in the United States. Studies that developed and/or validated clinical prediction models were closely reviewed and evaluated to determine the state of the field. We identified 12 studies that reported risk prediction models for opioid-related overdose risk. Published models were developed from a variety of data sources, including Veterans Health Administration data, Medicare data, commercial insurance data, and statewide linked datasets. Studies reported model performance using measures of discrimination, usually at good-to-excellent levels, though they did not always assess calibration. C-statistics were better for models that included clinical predictors (c-statistics: 0.75-0.95) compared to models without them (c-statistics: 0.69-0.82). External validation of models was rare, and we found no studies evaluating implementation of models or risk prediction tools into clinical practice. A common feature of these models was a high rate of false positives, largely because opioid-related overdose is rare in the general population. Thus, efforts to implement prediction models into practice should take into account that published models overestimate overdose risk for many low-risk patients. Future prediction models assessing overdose risk should employ external validation and address model calibration. In order to translate findings from prediction models into clinical public health benefit, future studies should focus on developing clinical prediction tools based on prediction models, implementing these tools into clinical practice, and evaluating the impact of these models on treatment decisions, patient outcomes, and, ultimately, opioid overdose rates.
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Affiliation(s)
- Iraklis Erik Tseregounis
- Center for Healthcare Policy and Research, University of California Davis, Sacramento, California, USA
| | - Stephen G Henry
- Center for Healthcare Policy and Research, University of California Davis, Sacramento, California, USA; Department of Internal Medicine, University of California Davis, Sacramento, California, USA.
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13
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Ball SJ, Simpson K, Zhang J, Marsden J, Heidari K, Moran WP, Mauldin PD, McCauley JL. High-Risk Opioid Prescribing Trends: Prescription Drug Monitoring Program Data From 2010 to 2018. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 27:379-384. [PMID: 32956292 PMCID: PMC7940459 DOI: 10.1097/phh.0000000000001203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Deaths due to opioids have continued to increase in South Carolina, with 816 opioid-involved overdose deaths reported in 2018, a 9% increase from the prior year. The objective of the current study is to examine longitudinal trends (quarter [Q] 1 2010 through Q4 2018) of opioid prescribing volume and high-risk opioid prescribing behaviors in South Carolina using comprehensive dispensing data available in the South Carolina Prescription Drug Monitoring Program (SC PDMP). DESIGN Retrospective analyses of SC PDMP data were performed using general linear models to assess quarterly time trends and change in rate of each outcome Q1 2010 through Q4 2018. PARTICIPANTS Opioid analgesic prescription fills from SC state residents between Q1 2010 and Q4 2018. MAIN OUTCOME MEASURES High-risk prescribing behaviors included (1) opioid prescribing rate; (2) percentage of patients receiving opioids dispensed 90 or more average morphine milligram equivalents daily; (3) percentage of opioid prescribed days with overlapping opioid and benzodiazepine prescriptions; (4) rate per 100 000 residents of multiple provider episodes; and (5) percentage of patients prescribed extended release opioids who were opioid naive. RESULTS A total of 33 027 461 opioid prescriptions were filled by SC state residents within the time period of Q1 2010 through Q4 2018. A 41% decrease in the quarterly prescribing rate of opioids occurred from Q1 2010 to Q4 2018. The decrease in overall opioid prescribing was mirrored by significant decreases in all 4 high-risk prescribing behaviors. CONCLUSION PDMPs may represent the most complete data regarding the dispensing of opioid prescriptions and as such be valuable tools to inform and monitor the supply of licit opioids. Our results indicate that public health policy, legislative action, and multiple clinical interventions aimed at reducing high rates of opioid prescribing across the health care ecosystem appear to be succeeding in the state of South Carolina.
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Affiliation(s)
- Sarah J. Ball
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kit Simpson
- Department of Health Administration and Policy, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Jingwen Zhang
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Justin Marsden
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - William P. Moran
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Patrick D. Mauldin
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jenna L. McCauley
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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14
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Larney S, Peacock A, Tran LT, Stockings E, Santomauro D, Santo T, Degenhardt L. All-Cause and Overdose Mortality Risk Among People Prescribed Opioids: A Systematic Review and Meta-analysis. PAIN MEDICINE 2021; 21:3700-3711. [PMID: 32951045 DOI: 10.1093/pm/pnaa214] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To estimate all-cause and overdose crude mortality rates and standardized mortality ratios among people prescribed opioids for chronic noncancer pain and risk of overdose death in this population relative to people with similar clinical profiles but not prescribed opioids. DESIGN Systematic review and meta-analysis. METHODS Medline, Embase, and PsycINFO were searched in February 2018 and October 2019 for articles published beginning 2009. Due to limitations in published studies, we revised our inclusion criteria to include cohort studies of people prescribed opioids, excluding those studies where people were explicitly prescribed opioids for the treatment of opioid use disorder or acute cancer or palliative pain. We estimated pooled all-cause and overdose crude mortality rates using random effects meta-analysis models. No studies reported standardized mortality ratios or relative risks. RESULTS We included 13 cohorts with 6,029,810 participants. The pooled all-cause crude mortality rate, based on 10 cohorts, was 28.8 per 1000 person-years (95% CI = 17.9-46.4), with substantial heterogeneity (I2 = 99.9%). The pooled overdose crude mortality rate, based on six cohorts, was 1.1 per 1000 person-years (95% CI = 0.4-3.4), with substantial heterogeneity (I2 = 99.5%), but indications for opioid prescribing and opioid exposure were poorly ascertained. We were unable to estimate mortality in this population relative to clinically similar populations not prescribed opioids. CONCLUSIONS Methodological limitations in the identified literature complicate efforts to determine the overdose mortality risk of people prescribed opioids. There is a need for large-scale clinical trials to assess adverse outcomes in opioid prescribing, especially for chronic noncancer pain.
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Affiliation(s)
- Sarah Larney
- Department of Family Medicine and Emergency Medicine, Université de Montréal and Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CR-CHUM), Montreal, Quebec, Canada.,National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia
| | - Lucy T Tran
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia
| | - Emily Stockings
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia
| | - Damian Santomauro
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia.,Queensland Centre for Mental Health Research, Brisbane, Queensland, Australia.,Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Thomas Santo
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia
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15
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Bhatraju E, Liebschutz JM, Lodi S, Forman LS, Lira MC, Kim TW, Colasanti J, Del Rio C, Samet JH, Tsui JI. Post-traumatic stress disorder and risky opioid use among persons living with HIV and chronic pain. AIDS Care 2021:1-8. [PMID: 33535800 PMCID: PMC8333265 DOI: 10.1080/09540121.2021.1876838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Persons with HIV (PWH) experience chronic pain and Post-Traumatic Stress Disorder (PTSD) at higher rates than the general population, and more often receive opioid medications to treat chronic pain. A known association exists between PTSD and substance use disorders, but less is known about the relationship between PTSD and risky opioid use among PWH taking prescribed opioid medications. In this observational study of PWH on long-term opioid medications for pain we examined associations between PTSD symptom severity based on the Post Traumatic Stress Disorder Checklist for DSM-5 (PCL-5, response range 0-80) and the following outcomes: 1) risk for opioid misuse (COMM score ≥13); 2) risky alcohol use (AUDIT score ≥8); 3) concurrent benzodiazepine prescription; and 4) morphine equivalent dose. Among 166 patients, 38 (23%) had a PCL-5 score over 38, indicating high PTSD symptom burden. Higher PCL-5 score (per 10 point difference) was associated with increased odds of opioid misuse (aOR 1.55; 95%CI: 1.31-1.83) and risky drinking (aOR: 1.28;1.07-1.52). No significant association was observed between PCL-5 score and benzodiazepine prescriptions or morphine equivalent dose. These findings suggest that when addressing alcohol and opioid use in PWH on long term opioid therapy, attention to PTSD symptoms is especially important given the higher risk for risky alcohol and opioid use among patients with this common comorbid condition.
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Affiliation(s)
- Elenore Bhatraju
- Division of General Internal Medicine, Department of Medicine, Harborview Medical Center and University of Washington School of Medicine, Seattle, WA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sara Lodi
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA, USA
| | - Theresa W Kim
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA, USA
| | - Jonathan Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA, USA.,Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Judith I Tsui
- Division of General Internal Medicine, Department of Medicine, Harborview Medical Center and University of Washington School of Medicine, Seattle, WA, USA
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Abstract
OBJECTIVE Opioid-related deaths are a leading cause of accidental deaths in the United States (U.S.). This study aims to examine the national trends in opioid exposures reported to U.S. poison centers (PCs). METHODS The National Poison Data System (NPDS) was queried for opioid exposures between 2011 and 2018. We descriptively assessed the demographic and clinical characteristics. Trends in opioid frequencies and rates were analyzed using Poisson regression. Independent predictors of serious adverse events in opioid exposures were studied. RESULTS There were a total of 604,183 opioid exposure calls made to the PCs during the study period. The frequency of opioid exposures decreased by 28.9% (95% CI: -29.6%, -28.1%; p < 0.001), and the rate of opioid exposures decreased by 21.2% (95% CI: -24.7%, -16.9%; p < 0.001). Multiple substance exposures accounted for 48.9% cases. The most frequent age group was 20-29 years (19.3%). Suspected suicides accounted for 34.9% cases. There were 7,246 deaths in our study sample, with 6.8% of cases demonstrating major effects. Hydrocodone was the most frequently observed opioid causing a toxic exposure and naloxone was used in 20.6% cases. Important predictors of a serious adverse event were age, gender, multi-substance exposures, and reasons for exposure. CONCLUSIONS Analysis of calls to PCs indicated a decreasing trend of opioid exposures. However, the proportion of SAEs due to such exposures increased. There was a high proportion of intentional exposures and occurred in older age groups. PCs are a vital component of real-time public health surveillance of overdoses in the current opioid crisis.
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Affiliation(s)
- Saumitra V Rege
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Moira Smith
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Heather A Borek
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Christopher P Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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Xu KY, Hartz SM, Borodovsky JT, Bierut LJ, Grucza RA. Association Between Benzodiazepine Use With or Without Opioid Use and All-Cause Mortality in the United States, 1999-2015. JAMA Netw Open 2020; 3:e2028557. [PMID: 33295972 PMCID: PMC7726637 DOI: 10.1001/jamanetworkopen.2020.28557] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Although overall rates of opioid use have been plateauing, coprescriptions of benzodiazepines and opioids have increased greatly in recent years. It is unknown whether this combination is an independent risk factor for all-cause mortality as opposed to being more frequently used by persons with a baseline elevated risk of death. OBJECTIVE To evaluate whether benzodiazepine use, with or without opioid use, is associated with increased all-cause mortality relative to the use of low-risk antidepressants. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used a large, nationally representative US data set (the National Health and Nutrition Examination Surveys [NHANES]) from 1999 to 2015. Eight cycles of NHANES data were used, spanning 37 610 person-years of follow-up time among 5212 individuals. Statistical analysis was performed from August 24, 2019, through May 23, 2020. EXPOSURES The primary exposure variable was benzodiazepine and opioid coprescriptions. Individuals taking selective serotonin reuptake inhibitors (SSRIs) served as an active comparator reference group. MAIN OUTCOMES AND MEASURES All-cause mortality was obtained via linkage of NHANES to the National Death Index. Propensity scores were calculated from covariates associated with sociodemographic factors, comorbidities, and medication use for more than 1000 prescription types. Propensity score-weighted mortality hazards were calculated from Cox proportional hazards regression models. RESULTS Of 5212 participants aged 20 years or older (1993 men [38.2%]; mean [SD] age, 54.8 [16.9] years) followed up for a median of 6.7 years (range, 0.2-16.8 years), 101 deaths (33.0 per 1000 person-years) occurred among those receiving cotreatment, 236 deaths (26.5 per 1000 person-years) occurred among those receiving only benzodiazepines, and 227 deaths (20.2 per 1000 person-years) occurred among SSRI recipients taking neither opioids nor benzodiazepines. After propensity score weighting, a significant increase in all-cause mortality was associated with benzodiazepine and opioid cotreatment (hazard ratio, 2.04 [95% CI, 1.65-2.52]) and benzodiazepines without opioids (hazard ratio, 1.60 [95% CI, 1.33-1.92]). Subgroup analyses revealed an increased risk of mortality for individuals receiving cotreatment who were 65 years or younger but not for those older than 65 years; similar findings were observed for those receiving benzodiazepines without opioids. CONCLUSIONS AND RELEVANCE This study found a significant increase in all-cause mortality associated with benzodiazepine use with or without opioid use in comparison with SSRI use. Benzodiazepine and opioid cotreatment, in particular, was associated with a 2-fold increase in all-cause mortality even after taking into account medical comorbidities and polypharmacy burden.
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Affiliation(s)
- Kevin Y. Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Sarah M. Hartz
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jacob T. Borodovsky
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Laura J. Bierut
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
- Alvin J. Siteman Cancer Center, Barnes Jewish Hospital, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Richard A. Grucza
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
- Center for Health Outcomes Research, St Louis University, St Louis, Missouri
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18
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Goldberg SB, Riordan KM, Sun S, Kearney DJ, Simpson TL. Efficacy and acceptability of mindfulness-based interventions for military veterans: A systematic review and meta-analysis. J Psychosom Res 2020; 138:110232. [PMID: 32906008 PMCID: PMC7554248 DOI: 10.1016/j.jpsychores.2020.110232] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/12/2020] [Accepted: 08/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Military veterans report high rates of psychiatric and physical health symptoms that may be amenable to mindfulness-based interventions (MBIs). Inconsistent prior findings and questions of fit between MBIs and military culture highlight the need for a systematic evaluation of this literature. OBJECTIVE To quantify the efficacy and acceptability of MBIs for military veterans. DATA SOURCES We searched five databases (MEDLINE/PubMed, CINAHL, Scopus, Web of Science, PsycINFO) from inception to October 16th, 2019. STUDY SELECTION Randomized controlled trials (RCTs) testing MBIs in military veterans. RESULTS Twenty studies (k = 16 unique comparisons, N = 898) were included. At post-treatment, MBIs were superior to non-specific controls (e.g., waitlist, attentional placebos) on measures of posttraumatic stress disorder (PTSD), depression, general psychological symptoms (i.e., aggregated across symptom domains), quality of life / functioning, and mindfulness (Hedges' gs = 0.32 to 0.80), but not physical health. At follow-up (mean length = 3.19 months), MBIs continued to outperform non-specific controls on general psychological symptoms, but not PTSD. MBIs were superior to specific active controls (i.e., other therapies) at post-treatment on measures of PTSD and general psychological symptoms (gs = 0.19 to 0.25). Participants randomized to MBIs showed higher rates of attrition than those randomized to control interventions (odds ratio = 1.98). Several models were not robust to tests of publication bias. Study quality and risk of bias assessment indicated several areas of concern. CONCLUSIONS MBIs may improve psychological symptoms and quality of life / functioning in veterans. Questionable acceptability and few high-quality studies support the need for rigorous RCTs, potentially adapted to veterans.
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19
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Vadiei N, Bhattacharjee S. Concurrent Opioid and Benzodiazepine Utilization Patterns and Predictors Among Community-Dwelling Adults in the United States. Psychiatr Serv 2020; 71:1011-1019. [PMID: 32517642 DOI: 10.1176/appi.ps.201900446] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Using benzodiazepines and opioids together substantially increases the risk of fatal overdose. Yet, concurrent benzodiazepine and opioid prescribing rates continue to increase amid the opioid overdose epidemic. Therefore, this study sought to identify patterns and predictors associated with self-reported concurrent benzodiazepine and opioid use among community-dwelling adults. METHODS This retrospective, cross-sectional study used Medical Expenditure Panel Survey data from 2011, 2013, and 2015. The study population included adults (age ≥18) who did not die during the calendar year. The dependent variable was concurrent benzodiazepine and opioid use, which was identified with Multum Lexicon therapeutic class codes. Multivariable logistic regression analysis was conducted to examine the association of various individual-level factors with concurrent benzodiazepine and opioid use. RESULTS The final study sample consisted of 44,808 individuals (unweighted), of which 680 (1.6%) (weighted frequency=7,806,636) reported concurrent benzodiazepine and opioid use. Several individual-level factors were significantly associated with reporting use of this combination. For example, individuals with anxiety were more likely to report using both benzodiazepines and opioids (odds ratio [OR]=9.61, 95% confidence interval [CI]=7.37-12.5), and those with extreme pain levels were more likely to report concurrent use (OR=5.11, 95% CI=2.98-8.78). Other predictors of reporting concurrent benzodiazepine and opioid use were depression, arthritis, region, race-ethnicity, insurance, activities disability, general and mental health status, and smoking status. CONCLUSIONS Several individual-level factors were associated with reporting concurrent benzodiazepine and opioid use. Therefore, enhanced educational interventions targeting both clinicians and community-dwelling adults are warranted to minimize use of this high-risk medication combination.
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Affiliation(s)
- Nina Vadiei
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson
| | - Sandipan Bhattacharjee
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson
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20
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Koffel E, DeRonne B, Hawkins EJ. Co-prescribing of Opioids with Benzodiazepines and Other Hypnotics for Chronic Pain and Insomnia: Trends and Health Outcomes. PAIN MEDICINE 2020; 21:2055-2059. [PMID: 32186734 DOI: 10.1093/pm/pnaa054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Erin Koffel
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- University of Minnesota Medical School, Minneapolis, Minnesota
| | - Beth DeRonne
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Eric J Hawkins
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, Washington
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
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Molnar AO, Bota S, Jeyakumar N, McArthur E, Battistella M, Garg AX, Sood MM, Brimble KS. Potentially inappropriate prescribing in older adults with advanced chronic kidney disease. PLoS One 2020; 15:e0237868. [PMID: 32818951 PMCID: PMC7444541 DOI: 10.1371/journal.pone.0237868] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022] Open
Abstract
Background Older adults with chronic kidney disease (CKD) are at heightened risk for polypharmacy. We examined potentially inappropriate prescribing in this population and whether introducing pharmacists into the ambulatory kidney care model was associated with improved prescribing practices. Methods Retrospective cohort study using linked administrative databases. We included patients with an eGFR ≤30 mL/min/1.73 m2 ≥66 years of age followed in multidisciplinary kidney clinics in Ontario, Canada (n = 25,016 from 28 centres). The primary outcome was the absence of a statin prescription or the receipt of a potentially inappropriate prescription defined by the American Geriatric Society Beers Criteria® and a modified Delphi panel that identified key drugs of concern in CKD. We calculated the crude cumulative incidence and incidence rate for the primary outcome and used change-point regression to determine if a change occurred following pharmacist introduction. Results There were 6,007 (24%) and 16,497 patients (66%) not prescribed a statin and with ≥1 potentially inappropriate prescription, respectively. The rate of potentially inappropriate prescribing was 125.6 per 100 person-years and was higher in more recent years. The change-point regression analysis included 2,275 patients from two centres. No immediate change was detected at pharmacist introduction, but potentially inappropriate prescribing was increasing pre-pharmacist introduction, and this rising trend was reversed post-pharmacist introduction. The incidence of potentially inappropriate prescribing still remained high post-pharmacist introduction. Conclusions Potentially inappropriate prescribing practices were common. Incorporating pharmacists into the kidney care model may improve prescribing practices. The role of pharmacists in the ambulatory kidney care team warrants further investigation in a randomized controlled trial.
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Affiliation(s)
- Amber O. Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- * E-mail:
| | | | | | | | - Marisa Battistella
- University Health Network/Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Amit X. Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Manish M. Sood
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada
- Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - K. Scott Brimble
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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