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Jeffery MM, Chaisson CE, Hane C, Rumanes L, Tucker J, Hang L, McCoy R, Chen CL, Bicket MC, Hooten WM, Larochelle M, Becker WC, Kornegay C, Racoosin JA, Sanghavi D. Assessment of Potentially Inappropriate Prescribing of Opioid Analgesics Requiring Prior Opioid Tolerance. JAMA Netw Open 2020; 3:e202875. [PMID: 32293684 PMCID: PMC7160686 DOI: 10.1001/jamanetworkopen.2020.2875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Opioid-tolerant only (OTO) medications, such as transmucosal immediate-release fentanyl products and certain extended-release opioid analgesics, require prior opioid tolerance for safe use, as patients without tolerance may be at increased risk of overdose. Studies using insurance claims have found that many patients initiating these medications do not appear to be opioid tolerant. OBJECTIVES To measure prevalence of opioid tolerance in patients initiating OTO medications and to determine whether linked electronic health record (EHR) data contribute evidence of opioid tolerance not found in insurance claims data. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used a national database of deidentified longitudinal health information, including medical and pharmacy claims, insurance enrollment, and EHR data, from January 1, 2007, to December 31, 2016. Data included 131 756 US residents with at least 183 days of continuous enrollment in commercial or Medicare Advantage insurance (including medical and pharmacy benefits) who had received an OTO medication and who had no inpatient stays in the 30 days prior to starting an OTO medication; of these, 20 044 individuals had linked EHR data within the prior 183 days. Data were analyzed from July 1, 2017, to August 31, 2018. EXPOSURES Initiating an OTO medication. MAIN OUTCOMES AND MEASURES Prior opioid tolerance demonstrated through pharmacy fills or EHR data on prescriptions written. RESULTS Among 153 385 OTO use episodes identified, 89 029 (58.0%) occurred among women, 62 900 (41.0%) occurred among patients with Medicare Advantage insurance, 39 394 (25.7%) occurred in the Midwest, 17 366 (11.3%) occurred in the Northeast, 73 316 (47.8%) occurred in the South, and 23 309 (15.2%) occurred in the West. Less than half of use episodes (73 117 episodes [47.7%]) involved patients with evidence in claims data of opioid tolerance prior to initiating therapy with an OTO medication, including 31 392 of 101 676 episodes (30.9%) involving transdermal fentanyl, 1561 of 2440 episodes (64.0%) involving transmucosal fentanyl, 36 596 of 43 559 episodes (84.0%) involving extended-release oxycodone, and 3568 of 5710 episodes (62.5%) involving extended-release hydromorphone. Among 20 044 OTO use episodes with linked EHR and claims data, less than 1% of OTO episodes identified in claims had evidence of opioid tolerance in structured EHR data that was not present in claims data (108 episodes [0.5%]). After limiting the sample to OTO episodes identified in claims with a matching OTO prescription within 14 days in the structured EHR data, only 40 of 939 episodes (4.0%) occurred among patients with evidence of tolerance that was not present in claims data. CONCLUSIONS AND RELEVANCE This cohort study found that most patients initiating OTO medications did not have evidence of prior opioid tolerance, suggesting they were at increased risk of opioid-related harms, including fatal overdose. Data from EHRs did not contribute substantial additional evidence of opioid tolerance beyond the data found in prescription claims. Future research is needed to understand the clinical rationale behind these observed prescribing patterns and to quantify the risk of harm to patients associated with potentially inappropriate prescribing.
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Affiliation(s)
| | | | | | | | | | | | - Rozalina McCoy
- Division of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Catherine L. Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco
| | - Mark C. Bicket
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Marc Larochelle
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - William C. Becker
- VA Connecticut Healthcare System, West Haven
- Yale School of Medicine, New Haven, Connecticut
| | - Cynthia Kornegay
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Judith A. Racoosin
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Darshak Sanghavi
- Previously with OptumLabs, Cambridge, Massachusetts
- UnitedHealthcare, Boston, Massachusetts
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Cocoros NM, Larochelle MR, Popovic J, Petrone AB, Kornegay C, Ju J, Racoosin JA. Assessment of prior opioid tolerance among new users of fentanyl transdermal system in FDA's Sentinel System. Pharmacoepidemiol Drug Saf 2018; 28:112-116. [PMID: 30379379 DOI: 10.1002/pds.4677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 08/15/2018] [Accepted: 09/15/2018] [Indexed: 11/10/2022]
Abstract
PURPOSE Fentanyl transdermal system (FTS) is intended only for patients with prior opioid tolerance. The purpose of this study is to identify the proportion of new FTS users who had evidence of prior opioid tolerance, by dosage strength, in FDA's Sentinel System. METHODS We identified new FTS episodes (183-day washout) from 2009 through 2013. Members were <65 years and enrolled in medical and pharmacy coverage for 183 days prior to initial FTS dispensing (index). We assessed the proportion of users with prior tolerance stratified by dosage strength of FTS using four definitions of opioid tolerance: ≥30-mg oxycodone equivalents/day in each of 7 consecutive days immediately prior to index; ≥30-mg oxycodone equivalents/day for any 7 days in the 30 days prior to index (secondary); any dose in each of 7 days in the 7 consecutive days immediately prior to index (tertiary); and any dose for any 7 days in the 30 days prior to index (quaternary). RESULTS Of 44 450 episodes of 25 mcg/hr FTS, 37% met the primary definition, and 77% met the quaternary definition. Of 3507 episodes of 100 mcg/hr FTS, 57% and 74% met the primary and quaternary definitions, respectively. Those aged 25 to 34 years had the highest proportion of episodes with prior tolerance; those aged 55 to 64 accounted for more of the episodes overall. CONCLUSIONS In Sentinel, many new users of FTS did not have evidence of prior opioid tolerance by the primary definition, ie, the product label definition, which is the minimum standard for the lowest FTS dose (12 mcg/hr), especially at the highest strength (100 mcg/hr). Validation of this metric is warranted, but our findings suggest the need for further prescriber education regarding appropriate prescribing of FTS.
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Affiliation(s)
- Noelle M Cocoros
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Marc R Larochelle
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Jennifer Popovic
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Andrew B Petrone
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Cynthia Kornegay
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Jing Ju
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Judith A Racoosin
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
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Larochelle MR, Cocoros NM, Popovic J, Dee EC, Kornegay C, Ju J, Racoosin JA. Opioid tolerance and urine drug testing among initiates of extended-release or long-acting opioids in Food and Drug Administration's Sentinel System. J Opioid Manag 2018; 13:315-327. [PMID: 29199397 DOI: 10.5055/jom.2017.0400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE A risk evaluation and mitigation strategy for extended-release and long-acting (ER/LA) opioid analgesics was approved by the Food and Drug Administration in 2012. Our objective was to assess frequency of opioid tolerance and urine drug testing for individuals initiating ER/LA opioid analgesics. DESIGN Retrospective cohort study. SETTING Sentinel, a distributed database with electronic healthcare data on >190 million predominantly commercially insured members. PATIENTS, PARTICIPANTS Members under age 65 initiating ER/LA opioid analgesics between January 2009 and December 2013. MAIN OUTCOME MEASURE(S) We examined the proportion of opioid-tolerant-only ER/LA opioid analgesic initiates meeting tolerance criteria: receipt of ≥30 mg oxycodone equivalents per day in 7 days prior to the first opioid-tolerant-only dispensing. We separately examined the proportion of new users of extended-release oxycodone (ERO) and other ER/LA opioid analgesics with a claim for a urine drug test in the 30 days prior to, and separately for the 183 days after, dispensing. RESULTS We identified 79,824 ERO, 7,343 extended-release hydromorphone, and 91,778 transdermal fentanyl opi-oid-tolerant-only episodes. Tolerance criteria were met in 64 percent of ERO, 64 percent of extended-release hydromorphone and 40 percent of transdermal fentanyl episodes. We identified 210,581 incident ERO and 311,660 other ER/LA opioid analgesic episodes. Use of urine drug testing for ERO compared with other ER/LA opioid analgesics was: 4 percent vs 14 percent respectively in the 30 days prior to initiation and 9 percent vs 23 percent respectively in the 183 days following initiation. CONCLUSIONS These results suggest potential areas for improving appropriate ER/LA opioid analgesic prescribing practices.
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Affiliation(s)
- Marc R Larochelle
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Section of General Internal Medicine, Boston, Massachusetts
| | - Noelle M Cocoros
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jennifer Popovic
- Program for Health Data and Standardized Methods, RTI International, Waltham, Massachusetts
| | - Elizabeth C Dee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Cynthia Kornegay
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Jing Ju
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Judith A Racoosin
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
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Coyle DT, Pratt CY, Ocran-Appiah J, Secora A, Kornegay C, Staffa J. Opioid analgesic dose and the risk of misuse, overdose, and death: A narrative review. Pharmacoepidemiol Drug Saf 2017; 27:464-472. [PMID: 29243305 DOI: 10.1002/pds.4366] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 10/06/2017] [Accepted: 11/03/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Despite the rise in serious adverse events paralleling increased prescription opioid analgesic use in the United States over the past 2 decades, the association between opioid analgesic dose and the risk of serious adverse health outcomes is incompletely characterized. We sought to synthesize the medical literature for observational studies examining the association between opioid analgesic dose and the risk of serious adverse health outcomes, with particular attention to the outcomes of misuse, abuse, addiction, overdose, and death. METHODS Searching MEDLINE using PubMed and bibliography review, we identified 22 observational studies published between 2000 and 2015 that assessed the association between opioid analgesic dose and the risk of serious adverse health outcomes. Some of these studies had significant methodological limitations. Twelve reviewed studies examined the outcomes of misuse, overdose, or death; no studies examining the risk of addiction or abuse met our criteria for inclusion. RESULTS The results of multiple studies clearly indicate an increasing risk of serious adverse health outcomes associated with increasing opioid analgesic dose. In particular, the risk of misuse, overdose, and death increases with increasing opioid analgesic dose. However, there is no opioid dose inflection point beyond which the risk of these adverse health outcomes increases. No opioid analgesic dose is without risk. CONCLUSIONS The reviewed studies show an increasing risk of serious adverse health outcomes-including misuse, overdose, and death-associated with increasing opioid analgesic dose. Further research is needed to characterize the relationship between opioid analgesic dose and the risk of addiction and abuse. This analysis could inform policy actions for regulators and clinical decision making for providers.
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Affiliation(s)
- David Tyler Coyle
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Chih-Ying Pratt
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Josephine Ocran-Appiah
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Alex Secora
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Cynthia Kornegay
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Judy Staffa
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
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Graham DJ, By K, McKean S, Mosholder A, Kornegay C, Racoosin JA, Young J, Levenson M, MaCurdy TE, Worrall C, Kelman JA. Cardiovascular and mortality risks in older Medicare patients treated with varenicline or bupropion for smoking cessation: an observational cohort study. Pharmacoepidemiol Drug Saf 2014; 23:1205-12. [DOI: 10.1002/pds.3678] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 06/09/2014] [Accepted: 06/09/2014] [Indexed: 11/06/2022]
Affiliation(s)
- David J. Graham
- Office of Surveillance and Epidemiology; Food and Drug Administration; Silver Spring MD USA
| | - Kunthel By
- Office of Biostatistics; Food and Drug Administration; Silver Spring MD USA
| | | | - Andrew Mosholder
- Office of Surveillance and Epidemiology; Food and Drug Administration; Silver Spring MD USA
| | - Cynthia Kornegay
- Office of Surveillance and Epidemiology; Food and Drug Administration; Silver Spring MD USA
| | | | | | - Mark Levenson
- Office of Biostatistics; Food and Drug Administration; Silver Spring MD USA
| | | | - Chris Worrall
- Centers for Medicare & Medicaid Services; Washington, DC USA
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Toh S, Baker MA, Brown JS, Kornegay C, Platt R. Rapid assessment of cardiovascular risk among users of smoking cessation drugs within the US Food and Drug Administration's Mini-Sentinel program. JAMA Intern Med 2013; 173:817-9. [PMID: 23529063 DOI: 10.1001/jamainternmed.2013.3004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Kim PW, Wu YT, Cooper C, Rochester G, Valappil T, Wang Y, Kornegay C, Nambiar S. Meta-analysis of a possible signal of increased mortality associated with cefepime use. Clin Infect Dis 2010; 51:381-9. [PMID: 20624065 DOI: 10.1086/655131] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND On the basis of meta-analyses, concern has been raised regarding a possible signal of increased mortality associated with the use of cefepime versus other beta-lactam antibiotics. To further investigate this possible signal, we accessed findings and data from published and unpublished cefepime clinical trials. METHODS We performed meta-analyses using trial- and patient-level data from comparative trials. Trial-level analyses were performed using summary data from all patients in the trials, and patient-level analyses were performed on trials for which patient-level data were available. Thirty-day, all-cause mortality was analyzed using the Mantel-Haenszel adjusted risk difference (ARD) method. RESULTS The trial-level meta-analysis was based on 88 trials (9467 cefepime patients and 8288 comparator patients). The 30-day, all-cause mortality rates were 6.21% (588/9467) for the cefepime patients and 6.00% (497/8288) for comparator patients (ARD per 1000 population, 5.38; 95% confidence interval [CI], -1.53 to 12.28). In the patient-level analysis (35 trials, 5058 cefepime patients, and 3976 comparator patients), 30-day, all-cause mortality rates were 5.63% (285/5058) for cefepime patients and 5.68% (226/3976) for comparator patients (ARD per 1000 population, 4.83; 95% CI, -4.72 to 14.38). A sensitivity analysis based solely on the 24 febrile neutropenia trials did not show a statistically significant increase in mortality with cefepime use (ARD per 1000 population, 9.67; 95% CI, -2.87 to 22.21). CONCLUSIONS In both trial-level and patient-level meta-analyses, we did not identify a statistically significant increase in mortality among cefepime-treated patients, compared with those treated with other antibacterials.
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Affiliation(s)
- Peter W Kim
- Office of Antimicrobial Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland 20993, USA.
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Brinker A, Kornegay C, Nourjah P. Trends in adherence to a revised risk management program designed to decrease or eliminate isotretinoin-exposed pregnancies: evaluation of the accutane SMART program. ACTA ACUST UNITED AC 2005; 141:563-9. [PMID: 15897377 DOI: 10.1001/archderm.141.5.563] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To review adherence to selected procedures outlined in the System to Manage Accutane-Related Teratogenicity (SMART) program during the first year of implementation vs the procedures in effect in the year prior to initiation of the SMART program. DESIGN Observational. SETTING A novel pharmacy compliance survey and an ongoing, voluntary survey. PATIENTS Female recipients of isotretinoin. INTERVENTION In April 2002, Hoffmann-La Roche Inc, Nutley, NJ, manufacturer of Accutane brand isotretinoin and at that time the sole source of isotretinoin, revised earlier guidelines and instituted the SMART risk management program, which included the use of qualification stickers to affix to all prescriptions for Accutane to indicate, among other things, a negative pregnancy test just before the prescription was written. The goal of the SMART program was to decrease or eliminate isotretinoin-exposed pregnancies. MAIN OUTCOME MEASURES Use and completion of prescription qualification stickers; changes in pretherapy pregnancy testing and birth control use. RESULTS The results of the pharmacy compliance survey indicated high (>90%) use of prescription qualification stickers. Results of the patient survey suggested that 9% of prescription qualification stickers within the observed user cohort were issued without a pregnancy test. Furthermore, the pregnancy rate for patients participating in the survey was similar to that reported for cohorts recruited before the SMART program. CONCLUSIONS The usefulness of the results derived from 2 surveys designed to evaluate the SMART program is limited by the lack of reliability and validity of the survey instruments and by questionable generalizability to all female recipients of isotretinoin. The presence of a qualification sticker may not have an impact on pregnancy testing or compliance with effective birth control behavior as outlined in the SMART program.
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Affiliation(s)
- Allen Brinker
- Food and Drug Administration, Center for Drug Evaluation and Research, Office of Drug Safety, Rockville, MD 20857, USA.
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Affiliation(s)
- Diane K Wysowski
- Office of Drug Safety, Food and Drug Administration, Rockville, MD 20857, USA.
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