Seeking drugs or seeking help? Escalating "doctor shopping" by young heroin users before fatal overdose

Alprazolam misuse: Analysis of French Addictovigilance Network data from 2011 to 2020

OBJECTIVES

Alprazolam, a high-potency and short-acting anxiolytic benzodiazepine, is one of the most misused benzodiazepines in France. In the context of various reports on alprazolam misuse during the COVID-19 pandemic, the objective of this study was to assess alprazolam abuse potential by analyzing French addictovigilance and international data.

METHODS

Data collected from 2011 to 2020 using the following epidemiological tools of the French Addictovigilance Network were analyzed: spontaneous reports (SRs), OPPIDUM (addiction care center data), OSIAP (falsified prescriptions), DRAMES (substance-related deaths), and chemical submission surveys. Moreover, the VigiBase™ database was analyzed to evaluate alprazolam abuse liability worldwide.

RESULTS

During the study period, 675 SRs concerning alprazolam misuse were recorded (sex ratio: ̴1; median age: 39 years). The desired effects were intensification of the therapeutic anxiolytic effect, euphoric effect, and management of substance withdrawal. Alprazolam was the third and first benzodiazepine listed in OPPIDUM and OSIAP surveys. Analysis of the SR and OPPIDUM data showed a recent increase in the alprazolam-opioid combination. In DRAMES data, alprazolam was directly linked to 11 deaths (associated with opioids in 10/11). VigiBase™ data analysis highlighted that France was the third country with the most cases of alprazolam misuse. The disproportionality analysis showed that in France, alprazolam was associated with higher risk of misuse and dependence compared with other benzodiazepines: reporting odds ratio=1.43, (95% CI: 1.04-1.95) and=1.97 (95% CI:1.50-2.59), respectively.

CONCLUSIONS

This study highlighted an increase in various signals of alprazolam abuse in France, and an increased use of the alprazolam-opioid combination that was also linked to most of the recorded alprazolam-linked deaths. These signals have been reported also in the international literature, and should be thoroughly investigated.

Syndemic factors associated with non-fatal overdose among young opioid users in New York City

Introduction

Rates of illicit opioid use are particularly high among young adults, yet research on overdose experience and factors associated with overdose in this population remains limited. This study examines the experiences and correlates of non-fatal overdose among young adults using illicit opioids in New York City (NYC).

Methods

539 participants were recruited via Respondent-Driven Sampling in 2014-2016. Eligibility criteria included: aged 18-29 years old; current residence in NYC; and nonmedical prescription opioid (PO) use and/or heroin use in the past 30 days. Participants completed structured interviews to assess their socio-demographics, drug use trajectories, current substance use and lifetime and most recent overdose experiences, and were tested on-site for hepatitis C virus (HCV) antibodies.

Results

43.9% of participants reported lifetime overdose experience; of these, 58.8% had experienced two or more overdose events. The majority of participants' most recent overdoses (63.5%) were due to polysubstance use. In bivariable analyses, after RDS adjustment, having ever overdosed was correlated with: household income of >$100,00 growing up (vs. $51,000-100,000); lifetime homelessness; HCV antibody-positive status; lifetime engagement in regular nonmedical benzodiazepine use, regular heroin injection and regular PO injection; and using a non-sterile syringe in the past 12 months. Multivariable logistic regression identified childhood household income >$100,00 (AOR=1.88), HCV-positive status (AOR=2.64), benzodiazepine use (AOR=2.15), PO injection (AOR=1.96) and non-sterile syringe use (AOR=1.70) as significant independent correlates of lifetime overdose. A multivariable model with multiple overdoses (vs. one) found only lifetime regular heroin use and PO injection to be strong correlates.

Discussion

Results indicate a high prevalence of lifetime and repeated overdose among opioid-using young adults in NYC, highlighting a need for intensified overdose prevention efforts for this population. The strong associations of HCV and indices of polydrug use with overdose suggest that prevention efforts should address the complex risk environment in which overdose occurs, attending to the overlapping nature of disease-related risk behavior and overdose risk behavior among young people who inject opioids. Overdose prevention efforts tailored for this group may find it useful to adopt a syndemic conception of overdose that understands such events as resulting from multiple, and often interrelated, risk factors.

Comparing measures of centrality in bipartite patient-prescriber networks: A study of drug seeking for opioid analgesics

Visiting multiple prescribers is a common method for obtaining prescription opioids for nonmedical use and has played an important role in fueling the United States opioid epidemic, leading to increased drug use disorder and overdose. Recent studies show that centrality of the bipartite network formed by prescription ties between patients and prescribers of opioids is a promising indicator for drug seeking. However, node prominence in bipartite networks is typically estimated with methods that do not fully account for the two-mode topology of the underlying network. Although several algorithms have been proposed recently to address this challenge, it is unclear how these algorithms perform on real-world networks. Here, we compare their performance in the context of identifying opioid drug seeking behaviors by applying them to massive bipartite networks of patients and providers extracted from insurance claims data. We find that two variants of bipartite centrality are significantly better predictors of subsequent opioid overdose than traditional centrality estimates. Moreover, we show that incorporating non-network attributes such as the potency of the opioid prescriptions into the measures can further improve their performance. These findings can be reproduced on different datasets. Our results demonstrate the potential of bipartiteness-aware indices for identifying patterns of high-risk behavior.

Network-based Analysis of Prescription Opioids Dispensing Using Exponential Random Graph Models (ERGMs)

The United States has been experiencing an unprecedented level of opioid overdose-related mortality due in part to excessive use of prescription opioids. Peer-driven network interventions may be beneficial. A key assumption of social network interventions is that of some members of the network act as key players and can influence the behavior of others in the network. We used opioid prescription records to create a social network of patients who use prescription opioid in the state of Rhode Island. The study population was restricted to patients on stable opioid regimens who used one source of payment and received the same opioid medication from ≥ 3 prescribers and pharmacies. An exponential random graph model (ERGM) was employed to examine the relationship between patient attributes and the likelihood of tie formation and modularity was used to assess for homophily (the tendency of individuals to associate with similar people). We used multivariable logistic regression to assess predictors of high betweenness centrality, a measure of influence within the network. 372 patients were included in the analysis; average age was 51 years; 53% were female; 57% were prescribed oxycodone, 34% were prescribed hydrocodone and 9% were prescribed buprenorphine/naloxone. After controlling for the main effects in the ERGM model, homophily was associated with age group, method of payment, number and type of opioid prescriptions filled, mean daily dose, and number of providers seen. Type of opioid and number of prescribers were identified as significant predictors of high betweenness centrality. We conclude that patients who use multiple prescribers or have a diagnosis of opioid use disorder may help promote positive health behaviors or disrupt harmful behaviors in an opioid prescription network.

Fertility Practitioners’ Coping Strategies When Faced with Intra-Role Conflict from Screening Aspiring Single Mothers by Choice

Women without a partner can become single mothers by choice through the use of fertility treatments. In Belgium, the decision to accept a candidate single mother by choice rests with the fertility clinic’s multidisciplinary team of fertility practitioners. As a result, the fertility practitioners fulfil a gatekeeping role. However, this can cause an intra-role conflict as the responsibility to select the best fitting candidates is at odds with the responsibility to help patients. In this explorative study, we examine how fertility practitioners cope with the strain resulting from intra-role conflict in the decision-making process regarding single motherhood by choice in Belgium. The findings showed that practitioners appear to mainly resort to problem-focused coping, by constructing a grassroots criteria list and by shifting their role from screening agent to counsellor. These results are based on ten open in-depth interviews with fertility practitioners employed in the multidisciplinary teams of fertility centers, using a reflexive interview lead.

Evolution of doctor shopping for oxycodone in the 67 million inhabitants in France as a proxy for potential misuse or abuse

ABSTRACT

This nationwide study aimed to compare use of oxycodone and doctor shopping for oxycodone in 2010 and 2016, and to quantify doctor shopping for oxycodone by sex, age, formulation, and dosage in 2010 and 2016. This study is a cross-sectional comparative analysis of doctor shopping based on all dispensings of oxycodone in France, in 2010 and 2016. Dispensings of oxycodone were extracted from the Système national des données de santé, which covers the 67 million inhabitants in France. Quantification of doctor shopping relies on an algorithm accounting for overlapping prescriptions, which is a proxy for potential misuse or abuse. The number of subjects who received oxycodone increased by 214% from 67,838 subjects in 2010 to 212,753 subjects in 2016, and the number of subjects with doctor-shopping behavior increased by 197%, from 1066 subjects in 2010 to 3163 subjects in 2016. For 30- to 44-year-old men, the total quantity of oxycodone obtained by doctor shopping increased by 391%, from 4582 defined daily doses in 2010 to 22,517 defined daily doses in 2016. By formulation and dosage, the total quantity of oxycodone obtained by doctor shopping increased with the dosage for both immediate-release and extended-release tablets in 2010 and 2016. The widespread extent of doctor shopping and its 3-fold increase in line with population exposure is a strong signal in the French context. These results are another argument to avoid trivializing oxycodone to prevent misuse, potential abuse, and potential oxycodone-related deaths, but it requires caution to prevent compromising effective treatment of pain.

Early Detection of Prescription Drug Abuse Using Doctor Shopping Monitoring From Claims Databases: Illustration From the Experience of the French Addictovigilance Network

Opioid analgesics and maintenance treatments, benzodiazepines and z-drugs, and other sedatives and stimulants are increasingly being abused to induce psychoactive effects or alter the effects of other drugs, eventually leading to dependence. Awareness of prescription drug abuse has been increasing in the last two decades, and organizations such as the International Narcotics Control Board has predicted that, worldwide, prescription drug abuse may exceed the use of illicit drugs. Assessment of prescription drug abuse tackles an issue that is hidden by nature, which therefore requires a specific monitoring. The current best practice is to use multiple detection systems to assess prescription drug abuse by various populations in a timely, sensitive, and specific manner. In the early 2000's, we designed a method to detect and quantify doctor shopping for prescription drugs from the French National Health Data System, which is one of the world's largest claims database, and a first-class data source for pharmacoepidemiological studies. Doctor shopping is a well-known behavior that involves overlapping prescriptions from multiple prescribers for the same drug, to obtain higher doses than those prescribed by each prescriber on an individual basis. In addition, doctor shopping may play an important role in supplying the black market. The paper aims to review how doctor shopping monitoring can improve the early detection of prescription drug abuse within a multidimensional monitoring. The paper provides an in-depth overview of two decades of development and validation of the method as a complementary component of the multidimensional monitoring conducted by the French Addictovigilance Network. The process accounted for the relevant determinants of prescription drug abuse, such as pharmacological data (e.g., formulations and doses), chronological and geographical data (e.g., impact of measures and comparison between regions), and epidemiological and outcome data (e.g., profiles of patients and trajectories of care) for several pharmacological classes (e.g., opioids, benzodiazepines, antidepressants, and methylphenidate).

Patterns of Cannabis Consumption, Social Networks, and Foraging

This study considered contextual factors (i.e., times, places, peers) associated with cannabis use. A total of 153 participants answered an anonymous online survey, completed the Cannabis Use Disorders Identification Test – Revised (CUDIT-R), and indicated their numbers of regular smoking partners, and times and places cannabis was normally purchased. Recent cannabis smokers had higher CUDIT-R scores and purchased cannabis from more places more often. Multiple regression considered subscales of the CUDIT-R. Greater cannabis consumption was associated with more smoking partners and purchases of cannabis at more times and places. Cannabis dependence was associated with cannabis purchases from more places and times and reports that there were more people prepared to do them favors. Harmful use was associated with more purchases at more locations. Patterns of cannabis foraging were compared with foraging behaviors previously observed for caffeine, nicotine, and alcohol. The data could inform the development and use of social media and location-aware services seeking to target risky substance use.

Co-prescription network reveals social dynamics of opioid doctor shopping

This paper examines network prominence in a co-prescription network as an indicator of opioid doctor shopping (i.e., fraudulent solicitation of opioids from multiple prescribers). Using longitudinal data from a large commercially insured population, we construct a network where a tie between patients is weighted by the number of shared opioid prescribers. Given prior research suggesting that doctor shopping may be a social process, we hypothesize that active doctor shoppers will occupy central structural positions in this network. We show that network prominence, operationalized using PageRank, is associated with more opioid prescriptions, higher predicted risk for dangerous morphine dosage, opioid overdose, and opioid use disorder, controlling for number of prescribers and other variables. Moreover, as a patient's prominence increases over time, so does their risk for these outcomes, compared to their own average level of risk. Results highlight the importance of co-prescription networks in characterizing high-risk social dynamics.

Characteristics of doctor-shoppers: a systematic literature review

Objective: Doctor-shopping has significant consequences for patients and payers and can indicate misuse of drugs, polypharmacy, less continuity of care, and increased medical expenses. This study reviewed the literature describing doctor-shoppers in the adult population. Methods: A systematic literature review was performed in PubMed and supplemented by a Google search of grey literature. Overall, 2885 records were identified; 43 papers served as a source of definition of a doctor-shopper, disease, treatment, patient characteristics, patient special needs, country. Results: Definitions of doctor-shopping were heterogeneous. Overall, 40% of studies examined the use of opioids, antidepressants, or psychoactive drugs, while the others focused on chronic or frequent diseases. Most studies were conducted in countries with easy access to healthcare resources (USA, France, Taiwan, Hong Kong). The prevalence of doctor-shopping ranged from 0.5% among opioid users in the USA to 25% of patients registered at general practices in Japan. Comorbidities, active substance abuse, greater distance from healthcare facility, younger age, longer disease and poor patient satisfaction increased doctor-shopping. Conclusions: Knowing the characteristics of doctor-shoppers may help identify such patients and reduce the associated waste of medical resources, but concerns about the misuse of drugs or healthcare resources should not prevent proper disease management.

Combating escalating harms associated with pharmaceutical opioid use in Australia: the POPPY II study protocol

INTRODUCTION

Opioid prescribing has increased 15-fold in Australia in the past two decades, alongside increases in a range of opioid-related harms such as opioid dependence and overdose. However, despite concerns about increasing opioid use, extramedical use and harms, there is a lack of population-level evidence about the drivers of long-term prescribed opioid use, dependence, overdose and other harms.

METHODS AND ANALYSIS

We will form a cohort of all adult residents in New South Wales (NSW), Australia, who initiated prescribed opioids from 2002 using Pharmaceutical Benefits Scheme dispensing records. This cohort will be linked to a wide range of other datasets containing information on sociodemographic and clinical characteristics, health service use and adverse outcomes (eg, opioid dependence and non-fatal and fatal overdose). Analyses will initially examine patterns and predictors of prescribed opioid use and then apply regression and survival analysis to quantify the risks and risk factors of adverse outcomes associated with prescribed opioid use.

ETHICS AND DISSEMINATION

This study has received full ethical approval from the Australian Institute of Health and Welfare Ethics Committee, the NSW Population and Health Services Research Committee and the ACT Health Human Research Ethics Committee. This will be the largest postmarketing surveillance study of prescribed opioids undertaken in Australia, linking exposure and outcomes and examining risk factors for adverse outcomes of prescribed opioids. As such, this work has important translational promise, with direct relevance to regulatory authorities and agencies worldwide. Project findings will be disseminated at scientific conferences and in peer-reviewed journals. We will also conduct targeted dissemination with policy makers, professional bodies and peak bodies in the pain, medicine and addiction fields through stakeholder workshops and advisory groups. Results will be reported in accordance with the REporting of studies Conducted using Observational Routinely collected Data (RECORD) Statement.

Doctor shopping of opioid analgesics relative to benzodiazepines: A pharmacoepidemiological study among 11.7 million inhabitants in the French countries

BACKGROUND

The abuse of prescription opioids and its subsequent consequences is an important public concern particularly in the USA. The literature on opioid analgesic abuse is scarce.

OBJECTIVE

We assess the extent and risk of opioid analgesics abuse relative to benzodiazepines (BZD) using the doctor shopping method, taken into account the pharmacological characteristics (dosage, route of administration, extended or immediate release).

METHODS

We used SNIIRAM database covering 11.7 million inhabitants. All individuals with at least one reimbursement for non-injectable opioid analgesic or BZD in 2013 were included. Opioids for mild to moderate pain and for moderately severe to severe pain were studied. The Doctor Shopping Quantity (DSQ) is the quantity obtained by overlapping prescriptions from several prescribers. The Doctor Shopping Indicator (DSI) is the DSQ divided by the total dispensed quantity.

RESULTS

The strong opioid analgesics have the highest DSI (2.79%) versus 2.06% for BZD hypnotics. Flunitrazepam ranked first according to its DSI (13.2%), followed by morphine (4%), and zolpidem (2.2%). The three-strong opioids having the highest DSI were morphine, oxycodone and fentanyl (respectively 4%, 1.7% and 1.5%). The highest DSI was observed for the highest dosages of morphine (DSI = 8.4% for 200 mg) and oxycodone (DSI = 2.8% for 80 mg). The highest DSI for fentanyl was described with nasal and transmucosal forms (4.1% and 3.3% respectively). The highest DSI for morphine was described for extended-release (4.1%).

CONCLUSION

There is a need to reinforce surveillance systems to track opioid misuse and to increase awareness of healthcare professionals.

Seeking prescription opioids from physicians for nonmedical use among people who inject drugs in a Canadian setting

BACKGROUND AND OBJECTIVES

Despite the high prevalence of prescription opioid (PO) misuse, little is known about the phenomenon of seeking POs for nonmedical use among high-risk populations, such as people who inject drugs (PWID). We therefore sought to examine the prevalence and correlates of seeking POs from a physician for nonmedical use among PWID in Vancouver, Canada.

METHODS

Cross-sectional data from two open prospective cohort studies of PWID in Vancouver were collected between June 2013 and May 2014 (n = 1252). Multivariable logistic regression was used to identify factors associated with seeking POs from physicians for nonmedical use.

RESULTS

Of 1252 participants, 458 individuals (36.6%) reported ever trying to get a PO prescription from a physician for nonmedical use and, of these, 343 (74.9%, comprising 27.4% of the total sample) reported ever being successful. Variables independently and positively associated with PO-seeking behavior included older age (adjusted odds ratio [AOR] = 1.02), Caucasian ethnicity (AOR = 1.38), having ever overdosed (AOR = 1.32), having ever participated in methadone maintenance therapy (AOR = 1.90), having ever dealt drugs (AOR = 1.65), and having ever been refused a prescription for pain medication (AOR = 2.02) (all p < .05).

DISCUSSION AND CONCLUSIONS

We observed that PO-seeking behavior was common among this sample of PWID and associated with several markers of higher intensity drug use.

SCIENTIFIC SIGNIFICANCE

Our findings highlight the need to identify evidence-based public health and clinical strategies to mitigate PO misuse among PWID without compromising care for PWID with legitimate medical concerns. (Am J Addict 2016;25:275-282).

Prevalence, prescribed quantities, and trajectory of multiple prescriber episodes for benzodiazepines: A 2-year cohort study

BACKGROUND

Little is known about the use of multiple prescribers for benzodiazepines, which might reflect fragmented patient care and increases the risk of hospital admission for drug dependence or poisoning. Therefore, we aimed to identify the prevalence, prescribed quantities, and trajectory of multiple prescriber episodes for benzodiazepines.

METHODS

We conducted a 2-year cohort study of 1178,361 recipients aged 0-74 years using a large health insurance claims database in Japan. We quantified multiple prescriber episodes for benzodiazepines occurring in ambulatory care settings in a baseline and subsequent year by (1) counting the number of unique providers within a 12-month period, (2) calculating the maximum number of unique providers within a single month, and (3) identifying consecutive overlapping prescriptions of over 30 days duration.

RESULTS

Among 58,314 patients with a benzodiazepine prescription during the baseline year, 282 (0.5%) filled prescriptions from four or more providers within a 12-month period, 439 (0.8%) filled prescriptions from three or more providers within a single month, and 757 (1.3%) filled consecutive overlapping prescriptions. The odds for multiple prescriber episodes were significantly higher among patients with multiple chronic conditions. Consecutive overlapping prescriptions had the best accuracy to detect patients with potentially questionable prescribed quantities as well as to predict those with multiple prescriber episodes in the subsequent year.

CONCLUSIONS

These results highlight the need for pharmacists to increase their involvement in prescription oversight and for health insurance agencies to implement a prescription monitoring program to screen for patients with multiple prescriber episodes for benzodiazepines.

Discrepancies in addressing overdose prevention through prescription monitoring programs

BACKGROUND

State prescription monitoring programs (PMPs) purport to address the prescription opioid epidemic, but have evidenced limited effect on reducing opioid-related mortality.

METHODS

We systematically reviewed publicly available, PMP web-based materials from December, 2012 to October, 2013, to assess the degree to which overdose prevention was articulated in state PMP goals, mission statement, and accessible educational materials. The sites and available resources of 47 state PMPs with a web presence were reviewed by two independent coders for use of "overdose" and related terms. Website materials were further coded to capture five general thematic orientations: supply reduction-therapeutic, supply reduction-punitive, demand reduction, public health/research, and harm reduction oriented in content.

RESULTS

Twenty-nine of 47 (62%) PMPs did not address overdose or related terms in available online materials; six (12.8%) contained overdose-oriented messaging; and two included specific overdose prevention tools for providers. There were a median of three thematic orientations represented on the 18 state PMP websites mentioning only the term overdose, compared with a median of 4.5 thematic domains on the six PMP websites with overdose-oriented content.

CONCLUSIONS

A more comprehensive, public health orientation for PMPs that explicitly and publicly articulates their application and role in overdose prevention may increase PMP effectiveness and use.

Emergency department utilization and subsequent prescription drug overdose death

PURPOSE

Prescription drug overdose (PDO) deaths are a critical public health problem in the United States. This study aims to assess the association between emergency department (ED) utilization patterns in a cohort of ED patients and the risk of subsequent unintentional PDO mortality.

METHODS

Using data from the New York Statewide Planning and Research Cooperative System for 2006-2010, a nested case-control design was used to examine the relationship between ED utilization patterns in New York State residents of age 18-64 years and subsequent PDO death.

RESULTS

The study sample consisted of 2732 case patients who died of PDO and 2732 control ED patients who were selected through incidence density sampling. With adjustment for demographic characteristics, and diagnoses of pain, substance abuse, and psychiatric disorders, the estimated odds ratios of PDO death relative to one ED visit or less in the previous year were 4.90 (95% confidence interval [CI]: 4.50-5.34) for those with two ED visits, 16.61 (95% CI: 14.72-18.75) for those with three ED visits, and 48.24 (95% CI: 43.23-53.83) for those with four ED visits or more.

CONCLUSIONS

Frequency of ED visits is strongly associated with the risk of subsequent PDO death. Intervention programs targeting frequent ED users are warranted to reduce PDO mortality.

The POPPY Research Programme protocol: investigating opioid utilisation, costs and patterns of extramedical use in Australia

INTRODUCTION

Opioid prescribing is increasing in many countries. In Australia, there is limited research on patterns of prescribing and access, or the outcomes associated with this use. The aim of this research programme is to use national dispensing data to estimate opioid use and costs, including problematic or extramedical use in the Australian population.

METHODS AND ANALYSIS

In a cohort of persons dispensed at least one opioid in 2013, we will estimate monthly utilisation and costs of prescribed opioids, overall and according to individual opioid formulations and strengths. In a cohort of new opioid users, commencing therapy between 1 July 2009 and 31 December 2013, we will examine patterns of opioid use including initiation of therapy, duration of treatment and concomitant use of opioids and other prescribed medicines. We will also examine patterns of extramedical opioid use based on indicators including excess dosing, use of more than one opioid concomitantly, doctor/pharmacy shopping and accelerated time to prescription refill.

ETHICS AND DISSEMINATION

This protocol was approved by the NSW Population and Health Services Ethics Committee (March 2014) and data access approved by the Department of Human Services External Review Evaluation Committee (June 2014). This will be one of the first comprehensive Australian studies with the capability to investigate individual patterns of use and track extramedical use. In the first instance our analysis will be based on 5 years of dispensing data but will be expanded with ongoing annual data updates. This research has the capability to contribute significantly to pharmaceutical policy within Australia and globally. In particular, the trajectory of extramedical prescription-opioid use has been the subject of limited research to date. The results of this research will be published widely in general medical, pharmacoepidemiology, addiction and psychiatry journals.

The non-medical use of tramadol in the UK: findings from a large community sample

BACKGROUND

Prescription drug misuse has become a public health problem in several developed countries. In the UK, there has been no increase in people seeking treatment for prescription drug dependence, but there has been a progressive rise in fatal overdoses involving tramadol.

OBJECTIVES

To explore the source, motivations for use and patterns of use of tramadol in the UK.

METHODS

We conducted anonymous online survey of drug use and related behaviours as part of an ongoing drug trend monitoring initiative. We included questions assessing the patterns of use, source and function of tramadol.

RESULTS

UK Survey respondents (n = 7360) were predominantly young (mean age 29), and 90% reported being employed or studying. Less than 1% reported past-year use of heroin or methadone, but about 1/3 reported past-year use of cocaine. 326 (5% of respondents) reported having used tramadol in the preceding year, usually obtained by prescription but in 1/3 of cases from a friend; rarely from a dealer or from the internet. Most used the drug for pain relief, but 163 respondents (44%) reported using tramadol for reasons other than pain relief - particularly, using it to relax, to sleep, to get high or to relieve boredom. Nineteen per cent took doses higher than prescribed, and 10% reported difficulty discontinuing. Twenty-eight per cent combined tramadol with alcohol or other drugs to enhance its effect.

CONCLUSION

Misuse and sharing of tramadol, supplied by prescription, was common.

Personally prescribed psychoactive drugs in overdose deaths among drug abusers: a retrospective register study

INTRODUCTION AND AIMS

Psychoactive prescription drug (PPD) abuse-related overdose deaths have increased in many countries in recent decades. We aimed to investigate the role of personally prescribed psychoactive drugs in abuse-related overdose mortality and explore any associations with level of social disadvantage.

DESIGN AND METHODS

This register linkage study included all 243 people who had died of abuse-related drug-induced poisoning in Finland in 2000 and 2008. Data on registered purchases of psychoactive drugs within one and three years of death were linked to data on the psychoactive drug/s contributing to death in each case. Social disadvantage was measured by receipt of income support, long-term unemployment and disability pension.

RESULTS

Thirty-six percent of those abusers who had died of a drug overdose had purchased a similarly acting drug within three years of death. In all overdoses, the proportion increased from 20% in 2000 to 49% in 2008 (P < 0.001). A similar increase was seen in purchases within one year of death; from one-tenth in 2000 to one-third of all cases in 2008 (P < 0.001). The majority (83%) of the deceased had received income support, while only 13-14% were long-term unemployed or on disability pension. Disability pension recipients had significantly more prescribed psychoactive drug purchases than non-recipients (P < 0.001 for three and one years within death).

DISCUSSION AND CONCLUSIONS

Personally prescribed PPDs pose a potential threat to people who abuse drugs. Health-care services should invest greater effort in identifying people who abuse drugs and in monitoring their drug prescriptions.

High levels of opioid analgesic co-prescription among methadone maintenance treatment clients in British Columbia, Canada: results from a population-level retrospective cohort study

BACKGROUND AND OBJECTIVES

The non-medical use of prescription opioids (PO) has increased dramatically in North America. Special consideration for PO prescription is required for individuals in methadone maintenance treatment (MMT). Our objective is to describe the prevalence and correlates of PO use among British Columbia (BC) MMT clients from 1996 to 2007.

METHODS

This study was based on a linked, population-level medication dispensation database. All individuals receiving 30 days of continuous MMT for opioid dependence were included in the study. Key measurements included the proportion of clients receiving >7 days of a PO other than methadone during MMT from 1996 to 2007. Factors independently associated with PO co-prescription during MMT were assessed using generalized linear mixed effects regression.

RESULTS

16,248 individuals with 27,919 MMT episodes at least 30 days in duration were identified for the study period. Among them, 5,552 individuals (34.2%) received a total of 290,543 PO co-prescriptions during MMT. The majority (74.3%) of all PO dispensations >7 days originated from non-MMT physicians. The number of PO prescriptions per person-year nearly doubled between 1996 and 2006, driven by increases in morphine, hydromorphone and oxycodone dispensations. PO co-prescription was positively associated with female gender, older age, higher levels of medical co-morbidity as well as higher MMT dosage, adherence, and retention.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

A large proportion of MMT clients in BC received co-occurring PO prescriptions, often from physicians and pharmacies not delivering MMT. Experimental evidence for the treatment of pain in MMT clients is required to guide clinical practice.

Increasing trends in Schedule II opioid use and doctor shopping during 1999-2007 in California

PURPOSE

To examine the age and gender-specific trends of Schedule II opioid use among California residents, with special reference to multiple provider users (doctor shoppers).

METHODS

Utilizing data from the California Prescription Drug Monitoring Program, we examined age and gender-specific trends of Schedule II opioid use during calendar years 1999-2007. Specifically, we analyzed the following: (1) the prevalence of Schedule II opioid users among California's population and (2) the proportion of these opioid users who were doctor shoppers (defined as an individual who used more than five different prescribers for all Schedule II opioids he or she obtained in a calendar year).

RESULTS

Among all age and gender groups, the prevalence of Schedule II opioid users in California increased by 150%-280% and the prevalence of doctor shoppers among users increased by 111%-213% over 9 years. The prevalence of opioid users was lowest among 18-44 year old men (1.25%) and highest among 65-year and older women (5.31%) by 2007. The prevalence of doctor shoppers was approximately 1.4% among those up to age 64 years and 0.5% among those 65 years and older. The gender difference in doctor shoppers among all age groups was negligible. On average, the cumulative morphine-equivalent amount of Schedule II opioid per individual obtained per year was threefold to sixfold higher for doctor shoppers than for the general population across different age and gender groups.

CONCLUSIONS

Age and gender differences in opioid use were relatively small, whereas the trends for use of opioids and multiple providers grew at a disquieting rate.

National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999-2009

BACKGROUND

Pharmaceutical opioid related deaths have increased. This study aimed to place pharmaceutical opioid overdose deaths within the context of heroin, cocaine, psychostimulants, and pharmaceutical sedative hypnotics examine demographic trends, and describe common combinations of substances involved in opioid related deaths.

METHODS

We reviewed deaths among 15-64 year olds in the US from 1999-2009 using death certificate data available through the CDC Wide-Ranging Online Data for Epidemiologic Research (WONDER) Database. We identified International Classification of Disease-10 codes describing accidental overdose deaths, including poisonings related to stimulants, pharmaceutical drugs, and heroin. We used crude and age adjusted death rates (deaths/100,000 person years [p-y] and 95% confidence interval [CI] and multivariable Poisson regression models, yielding incident rate ratios; IRRs), for analysis.

RESULTS

The age adjusted death rate related to pharmaceutical opioids increased almost 4-fold from 1999 to 2009 (1.54/100,000 p-y [95% CI 1.49-1.60] to 6.05/100,000 p-y [95% CI 5.95-6.16; p<0.001). From 1999 to 2009, pharmaceutical opioids were responsible for the highest relative increase in overdose death rates (IRR 4.22, 95% CI 3.03-5.87) followed by sedative hypnotics (IRR 3.53, 95% CI 2.11-5.90). Heroin related overdose death rates increased from 2007 to 2009 (1.05/100,000 persons [95% CI 1.00-1.09] to 1.43/100,000 persons [95% CI 1.38-1.48; p<0.001). From 2005-2009 the combination of pharmaceutical opioids and benzodiazepines was the most common cause of polysubstance overdose deaths (1.27/100,000 p-y (95% CI 1.25-1.30).

CONCLUSION

Strategies, such as wider implementation of naloxone, expanded access to treatment, and development of new interventions are needed to curb the pharmaceutical opioid overdose epidemic.

Reducing the health consequences of opioid addiction in primary care

Addiction to prescription opioids is prevalent in primary care settings. Increasing prescription opioid use is largely responsible for a parallel increase in overdose nationally. Many patients most at risk for addiction and overdose come into regular contact with primary care providers. Lack of routine addiction screening results in missed treatment opportunities in this setting. We reviewed the literature on screening and brief interventions for addictive disorders in primary care settings, focusing on opioid addiction. Screening and brief interventions can improve health outcomes for chronic illnesses including diabetes, hypertension, and asthma. Similarly, through the use of screening and brief interventions, patients with addiction can achieve improved health outcome. A spectrum of low-threshold care options can reduce the negative health consequences among individuals with opioid addiction. Screening in primary care coupled with short interventions, including motivational interviewing, syringe distribution, naloxone prescription for overdose prevention, and buprenorphine treatment are effective ways to manage addiction and its associated risks and improve health outcomes for individuals with opioid addiction.

The use of prescription monitoring programs to reduce opioid diversion and improve patient safety

An increase in the prescribing of opioids in an effort to improve management of chronic pain has led to enhanced availability of controlled substances for diversion and abuse. Evidence suggests that the use of prescription monitoring programs (PMPs) may help curtail this growing public health issue. The current use of PMPs varies widely from state to state but there have been important changes improving interconnectivity of PMPs across states. This paper describes current data on the effect of prescription monitoring programs on reducing abuse and diversion of controlled substances. It also offers suggestions on how PMPs may be incorporated into practice and clinical decision-making to ensure appropriate pain management and patient safety.

A model to identify patients at risk for prescription opioid abuse, dependence, and misuse

OBJECTIVE

The objective of this study was to use administrative claims data to identify and analyze patient characteristics and behavior associated with diagnosed opioid abuse.

DESIGN

Patients, aged 12-64 years, with at least one prescription opioid claim during 2007-2009 (n = 821,916) were selected from a de-identified administrative claims database of privately insured members (n = 8,316,665). Patients were divided into two mutually exclusive groups: those diagnosed with opioid abuse during 1999-2009 (n = 6,380) and those without a diagnosis for opioid abuse (n = 815,536). A logistic regression model was developed to estimate the association between an opioid abuse diagnosis and patient characteristics, including patient demographics, prescription drug use and filling behavior, comorbidities, medical resource use, and family member characteristics. Sensitivity analyses were conducted on the model's predictive power.

RESULTS

In addition to demographic factors associated with abuse (e.g., male gender), the following were identified as "key characteristics" (i.e., odds ratio [OR] > 2): prior opioid prescriptions (OR = 2.23 for 1-5 prior Rxs; OR = 6.85 for 6+ prior Rxs); at least one prior prescription of buprenorphine (OR = 51.75) or methadone (OR = 2.97); at least one diagnosis of non-opioid drug abuse (OR = 9.89), mental illness (OR = 2.45), or hepatitis (OR = 2.36); and having a family member diagnosed with opioid abuse (OR = 3.01).

CONCLUSIONS

Using medical as well as drug claims data, it is feasible to develop models that could assist payers in identifying patients who exhibit characteristics associated with increased risk for opioid abuse. These models incorporate medical information beyond that available to prescription drug monitoring programs that are reliant on drug claims data and can be an important tool to identify potentially inappropriate opioid use.

Morbidity associated with heroin overdose presentations to an emergency department: a 10-year record linkage study

INTRODUCTION

To examine hospitalizations in a cohort of 224 patients who presented with non-fatal heroin overdose to an ED.

METHODS

A record linkage study, using the morbidity, mental health and mortality databases in the Data Linkage Unit of the Department of Health, Western Australia. The main outcome measures were hospital separations 5 years before and after entry into the cohort.

RESULTS

Before entry into the cohort, 199 (89%) patients had an admission to mental health services. These 199 had a combined total of 1367 separations, most commonly for a mental health condition, injury or poisoning. Women had more than twice the relative risk (RR) of men for all separations (RR 2.35, 95% confidence interval [CI] 1.96-2.82, P < 0.001) and for injury and poisoning separations (RR 2.04, 95% CI 1.56-2.66, P < 0.001). The highest concentrations of separations occurred within 1 year before and 1 year after entry into the cohort. There were 12 (5.4%, 95% CI 2.9-9.4%) deaths, most commonly from overdose.

CONCLUSION

Non-fatal heroin overdose ED presentations are associated with a cluster of hospitalizations around that episode, likely to be related to heroin availability. Presentation to hospital by heroin users represents an opportunity to counsel less risky behaviour.

[Post-marketing surveillance systems for psychoactive prescription drug abuse]

Drugs affecting the central nervous system form a unique group of products for surveillance because they could be misused, abused or diverted. Considering the characteristics of this behaviour that is often concealed, specific post-marketing surveillance systems have been developed to monitor abuse of prescription drugs in some countries. The purpose of this review is to list and to describe post-marketing surveillance systems, according their methodology, in France and in foreign countries. These programs are based on adverse effect notifications, medical or legal consequences of abuse, general or specific population-based survey, professional networks or medication databases. Some programs use simultaneously several information sources. In conclusion, the multifaceted nature, the diversity and the inventiveness of post-marketing surveillance systems reflects the complexity of the abuse issue.

Illicit opioid intoxication: diagnosis and treatment

Opioid intoxications and overdose are associated with high rates of morbidity and mortality. Opioid overdose may occur in the setting of intravenous or intranasal heroin use, illicit use of diverted opioid medications, intentional or accidental misuse of prescription pain medications, or iatrogenic overdose. In this review, we focused on the epidemiology of illict opioid use in the United States and on the mechanism of action of opioid drugs. We also described the signs and symptoms, and diagnoses of intoxication and overdose. Lastly, we updated the reader about the most recent recommendations for treatment and prevention of opioid intoxications and overdose.

Which indicators can public health authorities use to monitor prescription drug abuse and evaluate the impact of regulatory measures? Controlling High Dosage Buprenorphine abuse

BACKGROUND

Two methods have been recently developed from a drug reimbursement database to provide useful indicators for public health authorities concerning the abuse potential of psychotropic drugs. The doctor-shopping indicator (DSI) measures the proportion of the drug obtained by doctor shopping among the overall quantity of the drug reimbursed and the clustering method reveals subgroups of deviant patients.

OBJECTIVE

The objective of the study was to analyze and compare indicators resulting from these two methods, applied to High Dosage Buprenorphine (HDB) (a product well-known to be diverted in France), in order to determine which public health authorities needs they answer.

DATA ANALYSIS

The patients with reimbursed HDB were grouped using the clustering method in terms of drug dispensations characteristics over a nine month period. The characteristics of the resulting subgroups, including their DSI, were then compared.

RESULTS

4787 Patients (73.4%) had no measurable doctor-shopping behaviour. But the comparison of the two methods demonstrated that the more a patient's profile was characterized by deviant behavior, the higher was the DSI: from 0.4% in a subgroup with a median profile to 72% in a subgroup with a deviant profile.

CONCLUSION

These two methods are useful surveillance tools for public health authorities: the clustering method may help devise pertinent intervention strategies to reduce prescription drug abuse while the DSI method provides quantitative information demonstrating whether these strategies are useful. We discuss the advantages and disadvantages of using these two methods as useful indicators for public health authorities.

The global diversion of pharmaceutical drugs non-medical use and diversion of psychotropic prescription drugs in North America: a review of sourcing routes and control measures

AIMS

North America features some of the world's highest consumption levels for controlled psychoactive prescription drugs (PPDs; e.g. prescription opioids, benzodiazepines, stimulants), with non-medical use and related harms (e.g. morbidity, mortality) rising in key populations in recent years. While the determinants, characteristics and impacts of these 'use' problems are increasingly well documented, little is known about the 'supply' side of non-medical PPD use, much of which is facilitated by 'diversion' as a key sourcing route. This paper provides a select review of the phenomenon of PPD diversion in North America, also considering interventions and policy implications.

METHODS

A conceptual and empirical review of select-peer- and non-peer-reviewed research literature from 1991 to 2010 focusing upon PPD diversion in North America was conducted.

RESULT

The phenomenon of PPD diversion is heterogeneous. Especially among general populations, a large proportion of PPDs for non-medical use are obtained from friends or family members. Other PPD diversion routes involve 'double doctoring' or 'prescription shopping'; street drug markets; drug thefts, prescription forgeries or fraud; as well as PPD purchases from the internet.

CONCLUSIONS

The distinct nature and heterogeneity make PPD diversion a complex and difficult target for interventions. Prescription monitoring programs (PMPs) appear to reduce overall PPD use, yet their impact on reducing diversion or non-medical use is not clear. Law enforcement is unlikely to reach PPD diversion effectively. Effective reduction will probably require reductions in overall PPD consumption volumes, although such will need to be accomplished without compromising standards of good medical (e.g. pain) care.

Prescription drug misuse in New Zealand: challenges for primary health care professionals

BACKGROUND

Prescription drug misuse (PDM) is an international phenomenon. Prescription drugs sought for this purpose are often obtained through the primary health care network.

OBJECTIVES

This study aimed to explore the challenges faced by community pharmacists (CPs) and general practitioners (GPs) when faced with the issue of "drug-seeking" and PDM. This forms part of a larger study of PDM issues for primary health care practitioners.

METHODS

Qualitative interviews were carried out in New Zealand with 17 GPs and 16 CPs, purposively sampled to provide information from a variety of demographic and work environments. Interviews were tape-recorded, transcribed verbatim, and a thematic analysis conducted. Data collection took place between June 2007 and January 2008, and interviewees were offered an NZ$30 voucher in recognition of their contribution to the research.

RESULTS

GPs and CPs faced a series of challenges in managing PDM, including identification of PDM, dealing with requests for inappropriate requests for psychoactive prescription drugs, verifying the legitimacy of requests and managing threatening behaviors. Specific issues were faced by rural practitioners, female practitioners and by locums and part-time staff. In particular, some participants reported feeling emotionally stressed after unpleasant drug-seeking incidents and some acknowledged that they may have missed identifying some drug-seeking because of lack of knowledge, "drug-seekers'" sophisticated strategies, or patients falling outside of their image of the archetypal "drug-seeker."

CONCLUSION

This study demonstrated that PDM can be an issue for primary health care practitioners, and it can cause disruption to their work. Training in how to better manage threatening and escalating incidents may be useful as would increasing the level of awareness of PDM issues among health professional students.

Competition in general practice: prescriptions to the elderly in a list patient system

Income motivation among general practitioners (GPs) is frequently discussed in the health economics literature. The question addressed in the present study on reimbursement drugs and addictive drugs is whether increased competition among GPs, which is part of a declared health policy to improve efficiency, contributes to more prescriptions for the elderly. The dataset comprises registered data of all prescribed drugs dispensed at pharmacies from the Norwegian Prescription Database merged with data on GPs. In choosing a method, particular attention is given to the fact that patients tend to be attracted to GPs who fit their preferences. Hence, we treat the composition of the patient list as endogenous. The results indicate that the stronger competition a GP faces, the more drugs are prescribed, which implies that GPs' prescription style may conflict with their role as gatekeepers, and even worse, it may be a hazard to patients' health.