Retrospective study investigating naloxone prescribing and cost in US Medicaid and Medicare patients

BACKGROUND

Opioid overdoses in the USA have increased to unprecedented levels. Administration of the opioid antagonist naloxone can prevent overdoses.

OBJECTIVE

This study was conducted to reveal the pharmacoepidemiologic patterns in naloxone prescribing to Medicaid patients from 2018 to 2021 as well as Medicare in 2019.

DESIGN

Observational pharmacoepidemiologic study SETTING: US Medicare and Medicaid naloxone claims INTERVENTION: The Medicaid State Drug Utilisation Data File was utilised to extract information on the number of prescriptions and the amount prescribed of naloxone at a national and state level. The Medicare Provider Utilisation and Payment was also utilised to analyse prescription data from 2019.

OUTCOME MEASURES

States with naloxone prescription rates that were outliers of quartile analysis were noted.

RESULTS

The number of generic naloxone prescriptions per 100 000 Medicaid enrollees decreased by 5.3%, whereas brand naloxone prescriptions increased by 245.1% from 2018 to 2021. There was a 33.1-fold difference in prescriptions between the highest (New Mexico=1809.5) and lowest (South Dakota=54.6) states in 2019. Medicare saw a 30.4-fold difference in prescriptions between the highest (New Mexico) and lowest states (also South Dakota) after correcting per 100 000 enrollees.

CONCLUSIONS

This pronounced increase in the number of naloxone prescriptions to Medicaid patients from 2018 to 2021 indicates a national response to this widespread public health emergency. Further research into the origins of the pronounced state-level disparities is warranted.

Rising cases of drug-induced pulmonary fibrosis: Analysis of the Food and Drug Administration Adverse Event Reporting System (FAERS) database, 2000-2022

PURPOSE

Pulmonary fibrosis (PF) is a severe, progressive disease, which may be caused by exposure to certain medications.

METHODS

We queried the U.S. FDA Adverse Event Reporting System (FAERS) from 2000 to 2022, using the search terms "pulmonary fibrosis" and "idiopathic pulmonary fibrosis" and excluded reports with patients under the age of 18 years, and patients with unknown sex or age. Reports were sorted by generic drug names, counted, and plotted over time using a best-fit trendline based on an exponential function.

RESULTS

From 2000 to 2022, there were 24 095 935 adverse drug events reported in FAERS, of which 17 520 (0.07%) were reported as PF. After excluding reports containing patients with unknown age (5255, 30%), sex (122, 0.7%), and age below 18 years old (155, 0.9%), our study included 11 988 reports. The mean age of the study sample was 66.5 ± 13.1 years, and 6248 patients (52.1%) were male. Plotting the 11 988 reports by year revealed an exponential best fit line (R2 = 0.88) with a positive slope over time. The top five drug classes associated with PF were disease modifying antirheumatic drugs (DMARDs, 39.4%), antineoplastic agents (26.4%), cardiovascular agents (12.6%), corticosteroids (4.6%), and immunosuppressive agents (4.0%).

CONCLUSION

A 23-year analysis of the FAERS database revealed exponentially increasing adverse event reports of PF. Significant annual increases in reporting of PF suspected with DMARDs and antineoplastic agents were identified. Our study highlights important trends, which should be used to guide PF research related to drugs of potential importance.

First generation antipsychotic-associated serious adverse events in women: a retrospective analysis of a pharmacovigilance database

BACKGROUND

Women have been under-represented in trials of antipsychotic medications.

AIM

Our primary objective was to evaluate five adverse events (AE) associated with first-generation antipsychotics (FGAs) among women relative to men through an analysis of the FDA Adverse Event Reporting System (FAERS).

METHOD

We queried 24.6 million AE reports from 2000 to 2023 involving FGAs. The study cohort consisted of chlorpromazine (n = 3317), fluphenazine (n = 1124), haloperidol (n = 16,709), loxapine (n = 3151), perphenazine (n = 816), thioridazine (n = 665), thiothixene (n = 244), and trifluoperazine (n = 360). Cases of neuroleptic malignant syndrome (NMS), tardive dyskinesia (TD), Torsades de Pointes (TdP), agranulocytosis (AG), and cerebrovascular adverse events (CVAE) were identified. Reporting odds ratios (ROR) and associated 95% confidence intervals (CI) were calculated with logistic regression for each AE among women relative to men.

RESULTS

A total of 2,857 serious AEs were evaluated in the study cohort (NMS = 1810, TD = 434, TdP = 260, AG = 149, CVAE = 204). The ROR for women compared to men was 0.79 (95% CI, 0.71-0.87) for NMS, 0.83 (0.68-1.01) for TD, 1.21 (0.94-1.53) for TdP, 0.71 (0.51-0.98) for AG, and 0.91 (0.68-1.19) for CVAE. A secondary analysis revealed a higher odds in women compared to men of hospitalization associated with reports of TD (ROR = 1.95, 1.29-2.94) and death associated with reports of AG (ROR = 2.46, 1.15-5.24). A subgroup analysis of haloperidol revealed an ROR = 1.67 (1.26-2.21) for women relative to men for TdP.

CONCLUSION

The subgroup analysis of haloperidol AEs revealed a significantly higher reporting odds ratio for TdP. Additionally, the secondary study findings suggest that women were more vulnerable to worse outcomes associated with certain AEs of FGAs.

State-level variation in distribution of oxycodone and opioid-related deaths from 2000 to 2021: an ecological study of ARCOS and CDC WONDER data in the USA

OBJECTIVES

This study aims to characterise oxycodone's distribution and opioid-related overdoses in the USA by state from 2000 to 2021.

DESIGN

This is an observational study.

SETTING

More than 80 000 Americans died of an opioid overdose in 2021 as the USA continues to struggle with an opioid crisis. Prescription opioids play a substantial role, introducing patients to opioids and providing a supply of drugs that can be redirected to those seeking to misuse them.

METHODS

The Drug Enforcement Administration annual summary reports from the Automation of Reports and Consolidated Orders System provided weights of oxycodone distributed per state by business type (pharmacies, hospitals and practitioners). Weights were converted to morphine milligram equivalents (MME) per capita and normalised for population. The Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research provided mortality data for heroin, other opioids, methadone, other synthetic narcotics and other/unspecified narcotics.

RESULTS

There was a sharp 280.13% increase in total MME/person of oxycodone from 2000 to 2010, followed by a slower 54.34% decrease from 2010 to 2021. Florida (2007-2011), Delaware (2003-2020) and Tennessee (2012-2021) displayed consistent and substantial elevations in combined MME/person compared with other states. In the peak year (2010), there was a 15-fold difference between the highest and lowest states. MME/person from only pharmacies, which constituted >94% of the total, showed similar results. Hospitals in Alaska (2000-2001, 2008, 2010-2021), Colorado (2008-2021) and DC (2000-2011) distributed substantially more MME/person over many years compared with other states. Florida stood out in practitioner-distributed oxycodone, with an elevation of almost 15-fold the average state from 2006 to 2010. Opioid-related deaths increased +806% from 2000 to 2021, largely driven by heroin, other opioids and other synthetic narcotics.

CONCLUSIONS

Oxycodone distribution across the USA showed marked differences between states and business types over time. Investigation of opioid policies in states of interest may provide insight for future actions to mitigate opioid misuse.

Declining but Pronounced State-Level Disparities in Prescription Opioid Distribution in the United States

The United States (US) opioid epidemic is a persistent and pervasive public health emergency that claims the lives of over 80,000 Americans per year as of 2021. There have been sustained efforts to reverse this crisis over the past decade, including a number of measures designed to decrease the use of prescription opioids for the treatment of pain. This study analyzed the changes in federal production quotas for prescription opioids and the distribution of prescription opioids for pain and identified state-level differences between 2010 and 2019. Data (in grams) on opioid production quotas and distribution (from manufacturer to hospitals, retail pharmacies, practitioners, and teaching institutions) of 10 prescription opioids (codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, and tapentadol) for 2010 to 2019 were obtained from the US Drug Enforcement Administration. Amounts of each opioid were converted from grams to morphine milligram equivalent (MME), and the per capita distribution by state was calculated using population estimates. Total opioid production quotas increased substantially from 2010 to 2013 before decreasing by 41.5% from 2013 (87.6 MME metric tons) to 2019 (51.3). The peak year for distribution of all 10 prescription opioids was between 2010 and 2013, except for codeine (2015). The largest quantities of opioid distribution were observed in Tennessee (520.70 MME per person) and Delaware (251.45) in 2011 and 2019. There was a 52.0% overall decrease in opioid distribution per capita from 2010 to 2019, with the largest decrease in Florida (-61.6%) and the smallest in Texas (-18.6%). Southern states had the highest per capita distribution for eight of the ten opioids in 2019. The highest to lowest state ratio of total opioid distribution, corrected for population, decreased from 5.25 in 2011 to 2.78 in 2019. The mean 95th/5th ratio was relatively consistent in 2011 (4.78 ± 0.70) relative to 2019 (5.64 ± 0.98). This study found a sustained decline in the distribution of ten prescription opioids during the last five years. Distribution was non-homogeneous at the state level. Analysis of state-level differences revealed a fivefold difference in the 95th:5th percentile ratio between states, which has remained unchanged over the past decade. Production quotas did not correspond with the distribution, particularly in the 2010-2016 period. Future research, focused on identifying factors contributing to the observed regional variability in opioid distribution, could prove valuable to understanding and potentially remediating the pronounced disparities in prescription opioid-related harms in the US.

Pronounced State-Level Disparities in Medicaid Prescribing of Buprenorphine for Opioid Use Disorder (2019-2020)

OBJECTIVE

The purpose of this study was to analyze buprenorphine prescribing across states in Medicaid patients during 2019-2020.

METHOD

Buprenorphine prescriptions per Medicaid enrollee per state were calculated for 2019 and 2020. Data analysis was conducted with buprenorphine formulations that are approved by the U.S. Food & Drug Administration for opioid use disorder (OUD; including generic and brand name formulations of buprenorphine mono product and buprenorphine/naloxone combination products) using Microsoft Excel. The totals of mono product buprenorphine were divided over the total of combination buprenorphine/naloxone in 2019 and 2020 to obtain the ratio of mono/combo. Formulations of buprenorphine indicated for pain were excluded. States outside 95% confidence intervals (1.96 standard deviations above and below the mean) were considered statistically significant.

RESULTS

The overall change in buprenorphine prescribing between 2019 and 2020 was modest (+3.6%) but highly variable, with more than a 10% increase in 17 states (Iowa = +100.5%, p < .05) but more than a 10% decrease in 9 states (Alabama = -68.5%, p < .05). Total amount reimbursed in 2019 increased (+9.9%) to $1.42 billion in 2020. Branded formulations accounted for two fifths (39.5%) of prescribing but more than two thirds (66.8%) of spending in 2020.

CONCLUSIONS

The COVID-19 pandemic exacerbated state-level disparities in buprenorphine prescribing for OUD among Medicaid patients. Legislation expanding buprenorphine-waivered providers and Medicaid expansion may have contributed to the statistically significant changes in state buprenorphine prescriptions.

Dynamic changes in methadone utilisation for opioid use disorder treatment: a retrospective observational study during the COVID-19 pandemic

OBJECTIVES

Opioid use disorder (OUD) is a major public health concern in the USA, resulting in high rates of overdose and other negative outcomes. Methadone, an OUD treatment, has been shown to be effective in reducing the risk of overdose and improving overall health and quality of life. This study analysed the distribution of methadone for the treatment of OUD across the USA over the past decade and through the COVID-19 pandemic.

DESIGN

Retrospective observational study using secondary data analysis of the Drug Enforcement Administration and Medicaid Databases.

SETTING

USA.

PARTICIPANTS

Patients who were dispensed methadone at US opioid treatment programmes (OTPs).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were the overall pattern in methadone distribution and the number of OTPs in the USA per year. The secondary outcome was Medicaid prescriptions for methadone.

RESULTS

Methadone distribution for OUD has expanded significantly over the past decade, with an average state increase of +96.96% from 2010 to 2020. There was a significant increase in overall distribution of methadone to OTP from 2010 to 2020 (+61.00%, p<0.001) and from 2015 to 2020 (+26.22%, p<0.001). However, the distribution to OTPs did not significantly change from 2019 to 2021 (-5.15%, p=0.491). There was considerable state-level variation in methadone prescribing to Medicaid patients with four states having no prescriptions.

CONCLUSIONS

There have been dynamic changes in methadone distribution for OUD. Furthermore, pronounced variation in methadone distribution among states was observed, with some states having no OTPs or Medicaid coverage. New policies are urgently needed to increase access to methadone treatment, address the opioid epidemic in the USA and reduce overdose deaths.

High Prescribing and State-Level Variation in Z-Drug Use Among Medicare Patients

BACKGROUND

Z-drugs are nonbenzodiazepine hypnotics used for sleep initiation and maintenance; these drugs increase the risk of fall-related injuries in older adults. The American Geriatrics Society's Beers criteria classifies Z-drugs as high-risk and strongly recommends avoiding prescribing Z-drugs to older adults due to adverse effects. The study objectives were to determine the prevalence of Z-drug prescribing among Medicare Part D patients and identify state or specialty-dependent prescribing differences. This study also aimed to determine prescribing patterns of Z-drugs to Medicare patients.

METHODS

Z-drug prescription data was extracted from the Centers for Medicare and Medicaid Services State Drug Utilization Data for 2018. For all 50 states, the number of prescriptions per 100 Medicare enrollees and days-supply per prescription was determined. The percentage of total prescriptions prescribed by each specialty and the average number of prescriptions per provider within each specialty was also determined.

RESULTS

Zolpidem was the most prescribed Z-drug (95.0%). Prescriptions per 100 enrollees were significantly high in Utah (28.2) and Arkansas (26.7) and significantly low in Hawaii (9.3) relative to the national average (17.5). Family medicine (32.1%), internal medicine (31.4%), and psychiatry (11.7%) made up the largest percentages of total prescriptions. The number of prescriptions per provider was significantly high among psychiatrists.

DISCUSSION

Contrary to the Beers criteria, Z-drugs are prescribed to older adults at high rates.

Newer Antiseizure Medications and Suicidality: Analysis of the Food and Drug Administration Adverse Event Reporting System (FAERS) Database

BACKGROUND

The association between antiseizure medications (ASMs) and suicidality remains controversial. Analyses of additional datasets are needed to further elucidate the complex relationship between antiseizure medications and suicidality.

OBJECTIVE

The aim of this study was to compare the safety profile of newer ASMs with older ASMs through an analysis of the US Food and Drug Administration Adverse Event Reporting System (FAERS) database, with a focus on suicidality.

METHODS

We queried over 17 million reports in the FAERS database from 2012 to 2021 and identified cases involving ASMs. After removing incomplete and duplicate reports, the study cohort consisted of lacosamide (n = 7593), perampanel (n = 1813), clobazam (n = 3827), brivaracetam (n = 1166), and vigabatrin (n = 5293) compared with a control group of older ASMs (topiramate, lamotrigine, valproic acid, carbamazepine, levetiracetam; n = 71,535). Cases of suicidality (completed suicide, suicidal ideation, attempted suicide, suicidal behavior, suicidal depression) were identified in each group. Adjusted (age and sex) odds ratios (aOR) and associated 95% confidence intervals (CI) were calculated using logistic regression analysis for each new drug when compared with the control group of older ASM drugs.

RESULTS

A total of 6309 cases of suicidality were identified among reports with ASMs. Most reports were sourced from healthcare professionals (5516, 87.4%). The proportion of reports involving suicidality were 210/7593 (2.8%) for lacosamide, 185/1813 (10.2%) for perampanel, 108/3827 (2.8%) for clobazam, 57/1166 (4.9%) for brivaracetam, 14/5293 (0.3%) for vigabatrin, and 5735/71,535 (8.0%) for older ASMs. Compared with older ASMs, the aOR for suicidality was 0.33 (95% CI 0.28-0.38) for lacosamide, 1.34 (95% CI 1.15-1.56) for perampanel, 0.35 (95% CI 0.29-0.43) for clobazam, 0.60 (95% CI 0.45-0.77) for brivaracetam, and 0.03 (95% CI 0.02-0.05) for vigabatrin.

CONCLUSION

When compared with older ASMs, four newer ASMs (lacosamide, clobazam, brivaracetam, and vigabatrin) were found to have significantly lower odds of suicidality, while perampanel was found to significantly increase the odds of suicidality. Pronounced variability (greater than 30 fold) in the proportion of FAERS reports associated with suicidality among the drugs studied was identified. The results of this case control study of FDA adverse event reports spanning 10 years and 6309 cases of suicidality expand our understanding of the safety profile of newer ASMs.

An Analysis of Oxycodone and Hydrocodone Distribution Trends in Delaware, Maryland, and Virginia Between 2006 and 2014

Objective Opioid medications are widely recognized for their use in analgesia and their addictive properties that have led to the opioid epidemic. Areas with historically high prescribing patterns have been shown to suffer more from the crisis. There is also regional variability in these trends. This study is a county level analysis of oxycodone and hydrocodone use in Delaware, Maryland, and Virginia between 2006 and 2014. Materials and methods A retrospective analysis of oxycodone and hydrocodone distributed as collected by the Drug Enforcement Administration's (DEA) Washington Post Automation of Reports and Consolidated Orders System (ARCOS) in Delaware, Maryland, and Virginia. Raw drug weights in each county were adjusted to "daily average dose" (grams/county population/365) using publicly available population estimates for all state counties. Purchasing data collected from ARCOS was used to compare distribution trends during this period. This study was limited in that ARCOS report quantity of drug distribution rather than average dose of script written.  Results There was a 57.59% increase in the weight of oxycodone and hydrocodone prescribed between 2006 and 2014. Oxycodone prescriptions increased by 75.50% and hydrocodone by 11.05%. Oxycodone increased across all three states between 2006 and 2010 and declined until 2014. Hydrocodone also increased but to a lesser extent than oxycodone. There was substantial variability in daily average dose of both opioids at the county level in all states. Pharmacies accounted for largest portion of oxycodone (69.17%) and hydrocodone (75.27%) purchased in the region. Hospitals accounted for 26.67% of oxycodone and 22.76% of hydrocodone purchased. Practitioners and mid-level providers, including Nurse Practitioners and Physician Assistants, did not significantly contribute to this increase. Conclusion In the states of Maryland, Delaware, and Virginia, the distribution of the prescription opioids oxycodone and hydrocodone increased by 57.59%. Daily average dose increased between 2006 and 2010 in all three states, followed by a decline until 2014. Variability in daily average dose by county highlights the relationship between geography and likelihood of receiving high-dose opioids. Increased monitoring at regional health centers and improving substance abuse treatment infrastructure at the county level may be a more efficient strategy in combating the opioid epidemic. Future research is needed to understand the socioeconomic trends that may influence prescribing trends of opioid medications.

Reductions and pronounced regional differences in morphine distribution in the United States

OBJECTIVES

The purpose of this longitudinal study was to describe the temporal pattern of morphine distribution nationally and between states.

METHODS

Drug weight was obtained from Report 5 of the US Drug Enforcement Administration's Automation of Reports and Consolidated Orders System (ARCOS) to characterize patterns in the distribution of morphine from 2012 to 2021. Morphine distribution amounts were separated by state and business type and corrected for population. States outside a 95% confidence interval relative to the national average were considered statistically significant.

KEY FINDINGS

In 2012, there was a 4.6-fold difference in morphine distribution between the highest-prescribing state, Tennessee (180.2 mg/person), and the lowest-prescribing state, Texas (39.4 mg/person). By the end of 2021, national distribution of morphine had decreased by 59.9% when compared to the peak year 2012. In 2021, Tennessee (51.1 mg/person) remained the highest-prescribing state with a 3.0-fold difference relative to Texas (17.2 mg/person). The average hospital decrease (-73.9%) from 2012 to 2021 was larger than that of pharmacies (-58.2%).

CONCLUSIONS

The national 59.9% decline in morphine in the last decade may be attributable to prioritization of the US opioid crisis as a public concern. Further research is necessary to understand the persistent regional difference between states.

Examination of methadone involved overdoses during the COVID-19 pandemic

BACKGROUND

The US opioid overdose epidemic continues to escalate. The restrictions on methadone availability including take-home dosing were loosened during the COVID-19 pandemic although there have been concerns about the high street value of diverted methadone. This report examined how fatal overdoses involving methadone have changed over the past two-decades including during the pandemic.

METHODS

The CDC's Wide-ranging Online Data for Epidemiologic Research (WONDER) was used to find the unintentional methadone related overdose death rate from 1999 to 2020. Unintentional methadone deaths were defined using the ICD X40-44 codes with only data for methadone (T40.3). Data from the DEA's Automation of Reports and Consolidated Orders System (ARCOS) on methadone overall use, opioid treatment programs use, and pain management use was gathered for all states for 2020 and corrected for population.

RESULTS

There have been dynamic changes over the past two-decades in methadone overdoses. Overdoses increased from 1999 (0.9/million) to 2007 (15.9) and declined until 2019 (6.5). Overdoses in 2020 (9.6) were 48.1% higher than in 2019 (t(50) = 3.05, p < .005). The state level correlations between overall methadone use (r(49) = +0.75, p < .001), and opioid treatment program use (r(49) = +0.77, p < .001) with overdoses were positive, strong, and statistically significant. However, methadone use for pain treatment was not associated with methadone overdoses (r(49) = -0.08).

CONCLUSIONS

Overdoses involving methadone significantly increased by 48.1% in 2020 relative to 2019. Policy changes that were implemented following the COVID-19 pandemic involving methadone take-homes may warrant further study before they are made permanent.

Death and Disability Reported with Cases of Vaccine Anaphylaxis Stratified by Administration Setting: An Analysis of the Vaccine Adverse Event Reporting System from 2017 to 2022

The serious nature of post-vaccination anaphylaxis requires healthcare professionals to be adequately trained to respond to these hypersensitivity emergencies. The aim of this study was to compare outcomes reported with cases of vaccine anaphylaxis stratified by administration setting. We queried reports in the Vaccine Adverse Event Reporting System (VAERS) database from 2017 to 2022 and identified cases involving anaphylaxis with an onset within one day of vaccine administration. The primary outcome was the combined prevalence of death or disability for each setting while the secondary outcome was the prevalence of hospitalization. Adjusted (age, sex, prior history of allergy, vaccine type) odds ratios (aOR) and associated 95% confidence intervals (CI) were calculated using logistic regression analysis. A total of 2041 cases of anaphylaxis comprised the primary study cohort with representation in the sample from all 50 US states and the District of Columbia. The mean age was 43.3 ± 17.5 years, and most cases involved women (79.9%). Cases of anaphylaxis were reported after receiving a coronavirus vaccine (85.2%), influenza vaccine (5.9%), tetanus vaccine (2.2%), zoster vaccine (1.6%), measles vaccine (0.7%), and other vaccine (4.5%). Outcomes associated with reports of vaccine anaphylaxis included 35 cases of death and disability and 219 hospitalizations. Compared with all other settings, the aOR of death and disability when anaphylaxis occurred was 1.92 (95% CI, 0.86-4.54) in a medical provider's office, 0.85 (95% CI, 0.26-2.43) in a pharmacy and 1.01 (95% CI, 0.15-3.94) in a public health clinic. Compared with all other settings, the aOR of hospitalization when anaphylaxis occurred was 1.02 (95% CI, 0.71-1.47) in a medical provider's office, 1.06 (95% CI, 0.72-1.54) in a pharmacy, and 1.12 (95% CI, 0.61-1.93) in a public health clinic. An analysis of a national database across six years revealed no significant differences in the odds of death/disability and odds of hospitalization associated with post-vaccination anaphylaxis in the medical office, pharmacy, and public health clinic compared with all other settings. This study expands our understanding of the safety of immunization services and reinforces that all settings must be prepared to respond to such an emergency.

Occurrence of Z-drugs, benzodiazepines, and ketamine in wastewater in the United States and Mexico during the Covid-19 pandemic

Z-drugs, benzodiazepines and ketamine are classes of psychotropic drugs prescribed for treating anxiety, sleep disorders and depression with known side effects including an elevated risk of addiction and substance misuse. These drugs have a strong potential for misuse, which has escalated over the years and was hypothesized here to have been exacerbated during the COVID-19 pandemic. Wastewater-based epidemiology (WBE) constitutes a fast, easy, and relatively inexpensive approach to epidemiological surveys for understanding the incidence and frequency of uses of these drugs. In this study, we analyzed wastewater (n = 376) from 50 cities across the United States and Mexico from July to October 2020 to estimate drug use rates during a pandemic event. Both time and flow proportional composite and grab samples of untreated municipal wastewater were analyzed using solid-phase extraction followed by liquid chromatography-tandem mass spectrometry to determine loadings of alprazolam, clonazepam, diazepam, ketamine, lorazepam, nordiazepam, temazepam, zolpidem, and zaleplon in raw wastewater. Simultaneously, prescription data of the aforementioned drugs were extracted from the Medicaid database from 2019 to 2021. Results showed high detection frequencies of ketamine (90 %), lorazepam (87 %), clonazepam (76 %) and temazepam (73 %) across both Mexico and United States and comparatively lower detection frequencies for zaleplon (22 %), zolpidem (9 %), nordiazepam (<1 %), diazepam (<1 %), and alprazolam (<1 %) during the pandemic. Average mass consumption rates, estimated using WBE and reported in units of mg/day/1000 persons, ranged between 62 (temazepam) and 1100 (clonazepam) in the United States. Results obtained from the Medicaid database also showed a significant change (p < 0.05) in the prescription volume between the first quarter of 2019 (before the pandemic) and the first quarter of 2021 (pandemic event) for alprazolam, clonazepam and lorazepam. Study results include the first detections of zaleplon and zolpidem in wastewater from North America.

Pronounced State-Level Disparities in Prescription of Cannabinoids to Medicaid Patients

Introduction

Dronabinol is approved in the USA for chemotherapy-induced nausea as well as vomiting and HIV-induced anorexia, while cannabidiol is primarily approved for childhood epileptic disorders Lennox-Gastaut and Dravet syndrome. The use pattern for these prescription cannabinoids in the USA is unknown. This study examined Medicaid claims for two FDA-approved prescription cannabinoids, dronabinol and cannabidiol, approved in 1985 and 2018, respectively, from 2016-2020 to better understand the pharmacoepidemiologic trends and distribution of these drugs in US Medicaid amidst the increasing use of non-pharmaceutical formulations of cannabis.

Methods

The longitudinal study analyzed Medicaid prescription claims that were calculated by extracting the prescriptions on a state level from 2016 to 2020 for two cannabinoids, dronabinol and cannabidiol, where outcomes over each year were calculated. Outcomes were (1) the number of prescriptions for each state corrected for the number of Medicaid enrollees and (2) dronabinol and cannabidiol spending. Spending refers to the amount reimbursed by the state Medicaid program.

Results

Dronabinol prescriptions per state decreased by 25.3% from 2016 to 2020, while cannabidiol prescriptions increased by 16,272.99% from 2018 to 2020. The spending on these drugs parallels that of their prescription trend with a 66.3% decrease in reimbursement for dronabinol ($5.7 million in 2020), whereas cannabidiol increased by +26,582.0% ($233.3 million in 2020). Dronabinol prescriptions, when corrected for the number of enrollees, in Connecticut were 136.4 times larger than in New Mexico, and seventeen states had zero prescriptions. Idaho's prescriptions of cannabidiol (27.8/10,000 enrollees) were significantly elevated relative to the national average and were 15.4-fold higher than Washington, DC (1.8/10K enrollees).

Conclusions

The prescriptions of pharmaceutical-grade tetrahydrocannabinol decreased while those of cannabidiol increased. This study also identified pronounced state-level variation in cannabinoid prescribing to Medicaid patients. State formularies and prescription drug list variation may contribute to the drug reimbursements in Medicaid, though further research is needed to identify the health policy or pharmacoeconomic origins of these disparities.

Variation in adverse drug events of opioids in the United States

Background: The United States (US) ranks high, nationally, in opioid consumption. The ongoing increase in the misuse and mortality amid the opioid epidemic has been contributing to its rising cost. The worsening health and economic impact of opioid use disorder in the US warrants further attention. We, therefore, assessed commonly prescribed opioids to determine the opioids that were over-represented versus under-represented for adverse drug events (ADEs) to better understand their distribution patterns using the Food and Drug Administration's Adverse Event Reporting System (FAERS) while correcting for distribution using the Drug Enforcement Administration's Automation of Reports and Consolidated Orders System (ARCOS). Comparing the ratio of the percentage of adverse drug events as reported by the FAERS relative to the percentage of distribution as reported by the ARCOS database is a novel approach to evaluate post-marketing safety surveillance and may inform healthcare policies and providers to better regulate the use of these opioids. Methods: We analyzed the adverse events for 11 prescription opioids, when correcting for distribution, and their ratios for three periods, 2006-2010, 2011-2016, and 2017-2021, in the US. The opioids include buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, and tapentadol. Oral morphine milligram equivalents (MMEs) were calculated by conversions relative to morphine. The relative ADEs of the selected opioids, opioid distributions, and ADEs relative to distribution ratios were analyzed for the 11 opioids. Results: Oxycodone, fentanyl, and morphine accounted for over half of the total number of ADEs (n = 667,969), while meperidine accounted for less than 1%. Opioid distributions were relatively constant over time, with methadone repeatedly accounting for the largest proportions. Many ADE-to-opioid distribution ratios increased over time, with meperidine (60.6), oxymorphone (11.1), tapentadol (10.3), and hydromorphone (7.9) being the most over-represented for ADEs in the most recent period. Methadone was under-represented (<0.20) in all the three periods. Conclusion: The use of the FAERS with the ARCOS provides insights into dynamic changes in ADEs of the selected opioids in the US. There is further need to monitor and address the ADEs of these drugs.

Declines and regional variation in opioid distribution by U.S. hospitals

ABSTRACT

The United States is enduring a preventable opioid crisis, particularly involving a population being treated in a hospital setting, a subset of whom may escalate to illicit opioids. This project analyzed trends in distribution of opioids by hospitals in the United States. Opioids monitored included buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, powdered opium, remifentanil, and tapentadol. The Automation of Reports and Consolidated Orders System (ARCOS) reports on substances controlled by the Drug Enforcement Administration. National data from ARCOS reports 5 and 7 from 2000 to 2019 were used for an observational study on hospital opioid distribution. Morphine milligram equivalents (MMEs) were calculated using oral conversion factors. The MME per person per state was calculated to compare data from the peak year, 2012, with data from 2019. Opioid use peaked in 2012, with a -46.6% decline from 2012 to 2019. Half (25) of the states have seen a decrease of -50% or greater. Of the opioid compounds observed, buprenorphine has seen increased (+122.5%) hospital use from 2012 to 2019. All other opioids have been experiencing a decline (≥50%), particularly hydromorphone (-49.9%), oxymorphone (-57.7%), methadone (-58.7%), morphine (-66.9%), codeine (-67.5%), and meperidine (-77.6%). There was a 6-fold difference in population-corrected use of opioids in 2019 between the lowest (6.8 MME/person in New Jersey) and highest (Alaska = 39.6) states. This study demonstrates the considerable progress made thus far by hospitals in curbing the U.S. opioid crisis.

Examination of multiple drug arrests reported to the Maine Diversion Alert Program

PURPOSE

Much of the responsibility for the increasing drug overdoses in the US has been attributed to opioids but most opioid overdoses also involve another drug. The objective of this study was to identify the drugs involved in polysubstance arrests. The substances that were more likely to be found in conjunction with other substances, using the drug arrests reported to Maine's Diversion Alert Program (DAP) were examined.

METHODS

Single and multiple drug arrests were quantified (N = 9,216). Multiple drug arrest percentages were compared to single drug arrest percentages to create a Multiple-to-Single Ratio (MSR) specific to each drug family and each drug to identify over (MSR > 1) and under-representation (MSR < 1).

RESULTS

Over three-fifths (63.8%) of all arrests involved a single drug. Opioids accounted for over-half (53.5%) of single arrests, followed by stimulants (27.7%) and hallucinogens (7.7%). Similarly, nearly two-fifths (39.6%) of multiple arrests were for opioids, followed by stimulants (30.8%) and miscellaneous (13.0%). Miscellaneous psychoactive prescription substances (e.g. clonidine, gabapentin, cyclobenzaprine, hydroxyzine) had the highest (1.51) MSR of any drug family. Conversely, stimulants (0.63), opioids (0.42), and hallucinogens (0.35) were significantly underrepresented in polysubstance arrests. Carisoprodol (8.80), amitriptyline (6.34), and quetiapine (4.69) had the highest MSR. Bath-salts (0.34), methamphetamine (0.44), and oxycodone (0.54) had the lowest MSR.

CONCLUSION

The misuse of opioids, both alone and in conjunction with another drug, deserves continued surveillance. In addition, common prescription drugs with less appreciated misuse potential, especially carisoprodol, amitriptyline, and quetiapine, require greater attention for their ability to enhance the effects of other drugs.

Rise, and pronounced regional variation, in methylphenidate, amphetamine, and lisdexamfetamine distribution in the United States

Background

The prescription stimulants methylphenidate, amphetamine, and lisdexamfetamine are sympathomimetic drugs with therapeutic use. They are designated in the United States as Schedule II substances, defined by the 1970 Controlled Substances Act as having a “high potential for abuse”. Changing criteria for the diagnosis of Attention Deficit Hyperactivity Disorder in 2013 and the approval of lisdexamfetamine for binge eating disorder in 2015 may have impacted usage patterns. This report compared the pharmacoepidemiology of these stimulants in the United States from 2010–2017.

Methods

Distribution of amphetamine, methylphenidate, lisdexamfetamine were examined via weights extracted from the Drug Enforcement Administration’s (DEA) Automated Reports and Consolidated Ordering System (ARCOS). Median stimulant Daily Dosage per patient was determined for a regional analysis. The percent of cost and prescriptions attributable to each stimulant and atomoxetine in Medicaid from the “Drug Utilization 2018 - National Total” from the Centers for Medicare and Medicaid was determined.

Results

There was a rise in amphetamine (+67.5%) and lisdexamfetamine (+76.7%) from 2010–2017. The change in methylphenidate (−3.0%) was modest. Persons/day stimulant usage was lower in the West than in other US regions from 2014-2017. There was a negative correlation (r(48) = −0.43 to −0.65, p < .05) between the percent Hispanic population per state and the Daily Dosage/population per stimulant. Methylphenidate formulations accounted for over half (51.7%) of the $3.8 billion reimbursed by Medicaid and the plurality (45.4%) of the 22.0 million prescriptions. Amphetamine was responsible for less than one-fifth (18.4%) of cost but one-third of prescriptions (33.6%). Lisdexamfetamine’s cost (26.0%) exceeded prescriptions (16.3%).

Conclusion

The rising amphetamine and lisdexamfetamine distribution may correspond with a rise in adult ADHD diagnoses. Regional analysis indicates that stimulant distribution in the West may be distinct from that in other regions. The lower stimulant distribution in areas with greater Hispanic populations may warrant further study.

Decline and Pronounced Regional Disparities in Medical Cocaine Usage in the United States

Background: Cocaine is a stimulant and Schedule II drug used as a local anesthetic and vasoconstrictor. Objective: This descriptive study characterized medical cocaine use in the United States. Methods: Retail drug distribution data from 2002 to 2017 were extracted for each state from the Drug Enforcement Administration, which reports on medical, research, and analytical chemistry use. The percentage of buyers (pharmacies, hospitals, and providers) was obtained. Use per state, corrected for population, was determined. Available cross-sectional data on cocaine use as reported by the Medicare and Medicaid programs for 2013-2017 and electronic medical records were examined. Results: Medical cocaine use decreased by -62.5% from 2002 to 2017. Hospitals accounted for 84.9% and practitioners for 9.9% of cocaine distribution in 2017. The number of pharmacies carrying cocaine dropped by -69.4%. The percentages of hospitals, practitioners, and pharmacies that carried cocaine in 2017 were 38.4%, 2.3%, and 0.3%, respectively. There was a 7-fold difference in 2002 (South Dakota, 76.1 mg/100 persons; Delaware, 10.1 mg/100 persons). Relative to the average state in 2017, those reporting the highest values (Montana, 20.1; North Dakota, 24.1 mg/100 persons) were significantly elevated. Cocaine use within the Medicare and Medicaid programs was negligible. Cocaine use within the Geisinger system was rare from 2002 to 2007 (<4 orders/100 000 patients per year) but increased to 48.7 in 2018. Conclusion and Relevance: If these pharmacoepidemiological patterns continue, licit cocaine may soon become a historical relic. The pharmacology and pharmacotherapeutics education of health care providers may need to be adjusted accordingly.

Pronounced declines in dispensed licit fentanyl, but not fentanyl derivatives

BACKGROUND

Fentanyl and its derivatives are highly utilized opioid-based analgesics provided to patients in various formulations, but this agent has also been implicated in many overdoses when misused. The evolving opioid crisis has increased pressure on the healthcare industry to monitor opioid prescriptions. Different policies and procedures implemented to contain the crisis have impacted the utilization of some opioids.

OBJECTIVE

A prior report identified three-fold differences between states in fentanyl use. This study explored fentanyl distribution patterns from 2010 to 2019.

METHODS

The amount of fentanyl base distributed from 2010 to 2019 was obtained from the Drug Enforcement Administration. Sufentanil, alfentanil, and remifentanil were also analyzed from 2010 to 2017, the most recent year reported. Prescriptions, units, and reimbursement for 2010 and 2019 were obtained from Medicaid and fentanyl prescriber specialty from Medicare Part D.

RESULTS

There was a 65.5% decrease in the overall milligrams of fentanyl per person distributed corrected for population. Ohio had the greatest decrease (-79.3%), while Mississippi saw the smallest (-44.5%). There was a 6.8-fold regional difference in the quantity of fentanyl distributed per person in 2010 from hospitals (South Dakota = 775.2, Alabama = 113.2 μg/person). The regional difference was also sizeable for pharmacies (6.2-fold, Mississippi = 1,025.3, Washington DC = 165.6). Medicaid reimbursement in 2019 was $165 million for over eight hundred-thousand prescriptions with the majority for generic (99.7%) and injectable (77.6%) formulations. Interventional pain management and anesthesia were over-represented, and hematology/oncology significantly under-represented for fentanyl prescriptions in Medicare.

CONCLUSION

The distribution of fentanyl-based substances decreased, although not uniformly, in the US over the last decade. Additionally, the most prescribed formulations of fentanyl have transitioned away from transdermal, potentially in an effort to regulate its availability. The considerable state-level disparities observed for fentanyl distribution from pharmacies and hospitals warrant further attention as there may be regional practices which are incongruent with evidence-based medicine.

Declines and pronounced regional disparities in meperidine use in the United States

There have been increasing concerns about adverse effects and drug interactions with meperidine. The goal of this study was to characterize meperidine use in the United States. Meperidine distribution data were obtained from the Drug Enforcement Administration's Automated of Reports and Consolidated Orders System. The Medicare Part D Prescriber Public Use File was utilized to capture overall trends in national prescriptions in this observational report. Nationally, meperidine distribution decreased by 94.6% from 2001 to 2019. In 2019, Arkansas, Alabama, Oklahoma, and Mississippi saw significantly greater distribution when compared with the US state average of 9.27 mg per 10 persons (SD = 6.82). Meperidine distribution showed an 18-fold difference between the highest state (Arkansas = 36.8 mg) and lowest state (Minnesota = 2.1 mg). Five of the six states with the lowest distribution were in the Northeast. Meperidine distribution per state was correlated with the prevalence of adult obesity (r(48) = +0.48, p < .001). Family medicine and internal medicine physicians accounted for 28.9% and 20.5%, respectively, of meperidine total daily supply (TDS) in 2017. Interventional pain management (5.66) and pain management (3.48) physicians accounted for the longest TDS per provider. The use of meperidine declined over the last two decades. Meperidine varied by geographic region with south-central states, and those with more obesity, showing greater distribution. Primary care doctors continue to account for the majority of meperidine daily supply. Increasing knowledge of meperidine's undesirable adverse effects like seizures and serious drug-drug interactions is likely responsible for these pronounced reductions.

Pronounced Regional Disparities in United States Methadone Distribution

BACKGROUND

Methadone is an evidence-based treatment for opioid use disorder (OUD) and pain management. Methadone for OUD may be difficult for some patients to access, particularly those in rural areas.

OBJECTIVE

The purpose of this study was to characterize methadone distribution patterns between 2017 and 2019 across the United States.

METHODS

The US Drug Enforcement Administration's Automated Reports and Consolidated Ordering System was used to acquire the number of opioid treatment programs (OTPs) per state and methadone distribution weight in grams. Methadone distributions by weight, corrected for state population and number of OTPs, were compared from 2017 to 2019 between states, within regions, and nationally.

RESULTS

The national distribution of methadone increased +12.3% for OTPs but decreased -34.6% for pain. Whereas all states saw a decrease in pain distribution, the Northeast showed a significantly smaller decrease than all other regions. Additionally, the majority of states experienced an increase in distribution for OTPs, and most states demonstrated a relatively stable or increasing number of OTPs, with an +11.5% increase nationally. The number of OTPs per 100K state population ranged from 2.1 in Rhode Island to 0.0 in Wyoming.

CONCLUSION AND RELEVANCE

Although methadone distribution for OUD was increasing in the United States, the pronounced regional disparities identified warrant further consideration to improve patient access to this evidence-based pharmacotherapy, particularly in the Midwest and West regions. Greater implementation of telehealth and involvement of primary care into opioid treatment practice offer possible solutions to eliminating geographical treatment barriers.

Opioid Mortality Following Implementation of Medical Cannabis Programs in the United States

INTRODUCTION

The United States is in the midst of an opioid overdose epidemic. Emerging evidence suggests that medical cannabis (MC) may reduce use of opioids for pain in some individuals, with potential impacts on opioid-related overdose. However, there may be other important differences between states that did, and did not, adopt MC.

METHODS

This study evaluated differences following legal MC sales on US opioid-related overdose deaths, corrected for population, from 1999 to 2017 using an interrupted time series. Comparisons by MC status were also made for Medicaid expansion and the Centers for Disease Control death certificate reporting quality (0: <good, 1: good, 2: excellent).

RESULTS

Overdose deaths were significantly higher in MC states from 2012-2017. Overdose death slopes over time increased in states with (pre=1.46±0.46, post=2.90±0.58, p<0.05) and without (pre =0.20±.10, post=1.04±0.22, p<0.005) MC. Post-legalization slopes were significantly higher in MC states (p<0.01). Two states without (11.1%) as compared to 11 states with (91.7%) MC expanded Medicaid by 2014 (χ²[1]=19.03, p<0.0005). MC states (1.50±0.23) had higher death certificate reporting quality relative to states without MC (0.78±0.22, p<0.05).

DISCUSSION

MC states had higher rates of opioid overdoses. Although there was no decrease in association with MC introduction, these results were confounded by states without MC having lower overdose reporting quality. Medicaid expansion was also more common in states with MC. Finally, the potency of fentanyl analogues may have obscured any protective effects of MC against illicit opioid harms.

Assessment of Controlled Substance Distribution to U.S. Veterinary Teaching Institutions From 2006 to 2019

Objective: To evaluate the changing pattern of distribution of Schedule II and III opioids, barbiturates, and stimulants to veterinary educational institutions in the United States.

Design: Longitudinal study.

Sample: Veterinary teaching institutions that use Schedule II and III drugs.

Procedures: Distribution of controlled substances to veterinary teaching institutions was obtained from the Drug Enforcement Administration's Automated Reports and Consolidated Orders System (ARCOS) for opioids (e.g., methadone, fentanyl, codeine), barbiturates (pentobarbital, butalbital), and stimulants (amphetamine, methylphenidate, lisdexamfetamine) from 2006–2019. Opioids were converted to their morphine milligram equivalents (MME) for evaluation over time.

Results: Controlled substance distribution to veterinary schools exhibited dynamic, and agent specific, changes. The total MME for 11 opioids peaked in 2013 and decreased by 17.3% in 2019. Methadone accounted for two-fifths (42.3%) and fentanyl over one-third (35.4%) of the total MME in 2019. Pentobarbital distribution was greatest by weight of all substances studied and peaked in 2011 at 69.4 kg. Stimulants underwent a pronounced decline and were very modest by 2014.

Conclusions and Clinical Relevance: Opioids by total MME in veterinary teaching practice have undergone more modest changes than opioids used with humans. Hydrocodone, codeine and recently fentanyl use have declined while methadone increased. Stimulant distribution decreased to become negligible. Together, this pattern of findings warrant continued monitoring.

Rise and regional disparities in buprenorphine utilization in the United States

PURPOSE

Buprenorphine is an opioid partial agonist used to treat opioid use disorder. While several policy changes have attempted to increase buprenorphine availability, access remains well below optimal levels. This study characterized how buprenorphine utilization in the United States has changed over time and whether there are regional disparities in distribution of the medication.

METHODS

The amount of buprenorphine distributed from 2007 to 2017 was obtained from the Drug Enforcement Administration's Automated Reports and Consolidated Ordering System. Data were expressed as the percent change and milligrams per person in each state. The formulations and cost for prescriptions covered by Medicaid (2008 to 2018) were also examined.

RESULTS

Buprenorphine distributed to pharmacies increased about 7-fold (476.8 to 3179.9 kg) while the quantities distributed to hospitals grew 5-fold (18.6 to 97.6 kg) nationally from 2007 to 2017. Buprenorphine distribution per person was almost 20-fold higher in Vermont (40.4 mg/person) relative to South Dakota (2.1 mg/person). There was a strong association between the number of physicians authorized to prescribe buprenorphine and distribution per state (r[49] = +0.94, P < .0005). The buprenorphine/naloxone sublingual film (Suboxone) was the predominant formulation (92.6% of 0.31 million Medicaid prescriptions) in 2008 but accounted for less than three-fifth (57.3% of 6.56 million prescriptions) in 2018.

CONCLUSIONS

Although buprenorphine availability has substantially increased over the last decade, distribution was very nonhomogeneous across the United States.

Dynamic changes in prescription opioids from 2006 to 2017 in Texas

BACKGROUND

The US is experiencing an epidemic of opioid overdoses which may be at least partially due to an over-reliance on opioid analgesics in the treatment of chronic non-cancer pain and subsequent escalation to heroin or illicit fentanyl. As Texas was reported to be among the lowest in the US for opioid use and misuse, further examination of this state is warranted.

MATERIALS AND METHODS

This study was conducted to quantify prescription opioid use in Texas. Data was obtained from the publicly available US Drug Enforcement Administration's Automation of Reports and Consolidated Orders System (ARCOS) which monitors controlled substances transactions from manufacture to commercial distribution. Data for 2006-2017 from Texas for ten prescription opioids including eight primarily used to relieve pain (codeine, fentanyl, hydrocodone, hydromorphone, meperidine, morphine, oxycodone, oxymorphone) and two (buprenorphine and methadone) for the treatment of an Opioid Use Disorder (OUD) were examined.

RESULTS

The change in morphine mg equivalent (MME) of all opioids (+23.3%) was only slightly greater than the state's population gains (21.1%). Opioids used to treat an OUD showed pronounced gains (+90.8%) which were four-fold faster than population growth. Analysis of individual agents revealed pronounced elevations in codeine (+387.5%), hydromorphone (+106.7%), and oxycodone (+43.6%) and a reduction in meperidine (-80.3%) in 2017 relative to 2006. Methadone in 2017 accounted for a greater portion (39.5%) of the total MME than hydrocodone, oxycodone, morphine, hydromorphone, oxymorphone, and meperidine, combined. There were differences between urban and rural areas in the changes in hydrocodone and buprenorphine.

CONCLUSIONS

Collectively, these findings indicate that continued vigilance is needed in Texas to appropriately treat pain and an OUD while minimizing the potential for prescription opioid diversion and misuse. Texas may lead the US in a return to pre-opioid epidemic prescription levels.

Trends in the medical supply of fentanyl and fentanyl analogues: United States, 2006 to 2017

Fentanyl is an important opioid for pain management, but also has exceptional potential for misuse. Seven states have implemented opioid prescribing laws. The objectives of this study were to: 1) characterize the temporal pattern of fentanyl, fentanyl analogue, and other opioid use over the past decade, and 2) determine whether opioid prescribing laws impacted fentanyl use in the US. Drug weights were obtained from the US Automated Reports of Consolidated Orders System (June 2018), a comprehensive publically available resource, from 2006 to 2017 for fentanyl, sufentanil, remifentanil, alfentanil, other prescription opioids, and analyzed by presence of a state opioid prescribing law. Fentanyl, corrected for population, was reduced from 2016 to 2017 (-17.9%) and these decreases significantly exceeded the changes in hydrocodone (-12.3%), oxycodone (-10.1%), morphine (-13.3%), or codeine (-8.8%). Fentanyl showed a particularly large decline in Maine, a state with a strong opioid prescribing law. There was a 3.5 fold difference in fentanyl (μg per capita) in Alaska (488.2) relative to Oregon (1718.4). Hospital use of remifentanil and sufentanil tripled from 2006 to 2017. Although all states experienced a 2016 to 2017 decline in fentanyl, and this reduction was larger than many other prescription opioids, the rate of decline varied over three-fold between states. Strong state laws may account for a portion of the variance in fentanyl and other opioid reductions. The population health risks of fentanyl and fentanyl analogues warrants ongoing vigilance.

Descriptive, observational study of pharmaceutical and non-pharmaceutical arrests, use, and overdoses in Maine

OBJECTIVES

The Maine Diversion Alert Program grants healthcare providers access to law enforcement data on drug charges. The objectives of this report were to analyse variations in drug charges by demographics and examine recent trends in arrests, prescriptions of controlled substances and overdoses.

DESIGN

Observational.

SETTING

Arrests, controlled prescription medication distribution and overdoses in Maine.

PARTICIPANTS

Drug arrestees (n=1272) and decedents (n=2432).

PRIMARY OUTCOME MEASURES

Arrestees were analysed by sex and age. Substances involved in arrests were reported by schedule (I-V or non-controlled prescription) and into opioids, stimulants or other classes. Controlled substances reported to the Drug Enforcement Administration (2007-2017) were evaluated. Drug-induced deaths (2007-2017) reported to the medical examiner were examined by the substance(s) identified.

RESULTS

Males were more commonly arrested for stimulants and schedule II substances. More than two-thirds of arrests involved individuals under the age of 40. Individuals age >60 were elevated for oxycodone arrests. Over three-fifths (63.38%) of arrests involved schedule II-IV substances. Opioids accounted for almost half (44.6%) of arrests followed by stimulants (32.5%) and sedatives (9.1%). Arrests involving buprenorphine exceeded those for oxycodone, hydrocodone, methadone, tramadol and morphine, combined. Prescriptions for hydrocodone (-56.0%) and oxycodone (-46.9%) declined while buprenorphine increased (+58.1%) between 2012 and 2017. Deaths from 2007 to 2017 tripled. Acetylfentanyl and furanylfentanyl were the most common fentanyl analogues identified.

CONCLUSIONS

Although the overall profile of those arrested for drug crimes in 2017 involve males, age <40 and heroin, exceptions (oxycodone for older adults) were observed. Most prescription opioids are decreasing while deaths involving opioids continue to increase in Maine.

Opioid distribution trends (2006-2017) in the US Territories

Background

The US mainland is experiencing an epidemic of opioid overdoses. Unfortunately, the US Territories (Guam, Puerto Rico, and the Virgin Islands) have often been overlooked in opioid pharmacoepidemiology research. This study examined common prescription opioids over the last decade.

Methods

The United States Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS) was used to report on ten medical opioids: buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, and oxymorphone, by weight from 2006 to 2017. Florida and Hawaii were selected as comparison areas.

Results

Puerto Rico had the greatest Territorial oral morphine mg equivalent (MME) per capita (421.5) which was significantly higher (p < .005) than the Virgin Islands (139.2) and Guam (118.9) but significantly lower than that of Hawaii (794.6) or Florida (1,509.8). Methadone was the largest opioid by MMEs in 2017 in most municipalities, accounting for 41.1% of the total in the Virgin Islands, 37.9% in Florida, 36.6% in Hawaii but 80.8% in Puerto Rico. Puerto Rico and Florida showed pronounced differences in the distribution patterns by pharmacies, hospitals, and narcotic treatment programs for opioids.

Conclusions

Continued monitoring of the US Territories is needed to provide a balance between appropriate access to these important agents for cancer related and acute pain while also minimizing diversion and avoiding the opioid epidemic which has adversely impacted the US mainland.

Trends in use of prescription stimulants in the United States and Territories, 2006 to 2016

BACKGROUND

Stimulants are considered the first-line treatment for Attention Deficit Hyperactivity Disorder (ADHD) in the US and they are used in other indications. Stimulants are also diverted for non-medical purposes. Ethnic and regional differences in ADHD diagnosis and in stimulant use have been identified in earlier research. The objectives of this report were to examine the pharmacoepidemiological pattern of these controlled substances over the past decade and to conduct a regional analysis.

METHODS

Data (drug weights) reported to the US Drug Enforcement Administration's Automation of Reports and Consolidated Orders System for four stimulants (amphetamine, methylphenidate, lisdexamfetamine, and methamphetamine) were obtained from 2006 to 2016 for Unites States/Territories. Correlations between state level use (mg/person) and Hispanic population were completed.

RESULTS

Amphetamine use increased 2.5 fold from 2006 to 2016 (7.9 to 20.0 tons). Methylphenidate use, at 16.5 tons in 2006, peaked in 2012 (19.4 tons) and subsequently showed a modest decline (18.6 tons in 2016). The consumption per municipality significantly increased 7.6% for amphetamine and 5.5% for lisdexamfetamine but decreased 2.7% for methylphenidate (all p < .0005) from 2015 to 2016. Pronounced regional differences were also observed. Lisdexamfetamine use in 2016 was over thirty-fold higher in the Southern US (43.8 mg/person) versus the Territories (1.4 mg/person). Amphetamine use was about one-third lower in the West (48.1 mg/person) relative to the Northeastern (75.4 mg/person, p < .05) or the Midwestern (69.9 mg/person, p ≤ .005) states. States with larger Hispanic populations had significantly lower methylphenidate (r(49) = -0.63), lisdexamfetamine (B, r(49) = -0.49), and amphetamine (r(49) = -0.43) use.

CONCLUSIONS

Total stimulant usage doubled in the last decade. There were dynamic changes but also regional disparities in the use of stimulant medications. Future research is needed to better understand the reasons for the sizable regional and ethnic variations in use of these controlled substances.

Trends in Medical Use of Opioids in the U.S., 2006-2016

INTRODUCTION

The U.S. is experiencing an opioid epidemic which is at least partially iatrogenic and fueled by both prescription and illicit misuse. This study provides a nationwide examination of opioid distribution patterns during the last decade.

METHODS

Data were obtained from the U.S. Drug Enforcement Administration's Automation of Reports and Consolidated Orders System for 2006-2016. Analyses include quantities of ten opioids legally dispensed nationwide by weight and converted to Morphine Milligram Equivalents. Geospatial and state-level analyses were also completed in 2017.

RESULTS

The total for ten opioids peaked in 2011 (389.5 metric tons Morphine Milligram Equivalents) relative to both 2006 (286.1) and 2016 (364.6). Changes in the volume of opioids by weight over the decade were agent specific. Since 2011, there were decreases in hydrocodone (-28.4%); oxymorphone (-28.0%); fentanyl (-21.4%); morphine (-18.9%); oxycodone (-13.8%); and meperidine (-58.0%) and an increase in buprenorphine (75.2%) in 2016. There were substantial inter-state variations in rates with a fivefold difference between the highest Morphine Milligram Equivalents in 2016 (Rhode Island=2,623.7 mg/person) relative to the lowest (North Dakota=484.7 mg/person). An association was identified between state median age and per capita Morphine Milligram Equivalents (r =0.49, p<0.0005).

CONCLUSIONS

With the exception of buprenorphine, used to treat an opioid use disorder, prescription opioid use has been decreasing over the past 5 years in the U.S. Further efforts are needed to continue to optimize the balance between appropriate opioid access for acute pain while minimizing diversion and treating opioid addiction.

Illicit and prescription drug misuse as reported to the Maine Diversion Alert Program

BACKGROUND

The opioid epidemic is rapidly evolving and new tools are needed to combat drug abuse. The Maine Diversion Alert Program (DAP) is an informational resource that facilitates communication about drug arrests between the criminal justice and healthcare fields. The objectives of this report were to: (1) describe the illegal and prescription pharmaceuticals reported to the DAP; (2) determine if the drugs implicated in arrests changed from the first to latter half of 2016; (3) identify the demographic and other characteristics of arrestees; and (4) outline the strengths and limitations of the DAP for other areas considering implementing similar programs.

METHODS

The arrests (N=2,368, 31.4% female, mean age=33.7, SD=9.9, Min=18, Max=71.5) reported to the DAP were examined. Drugs were classified by Drug Enforcement Administration Schedule (I-V, non-controlled prescription) and into families (opioids, stimulants, sedatives, hallucinogens, and other). A comparison between the first and second half of 2016 and arrest by county was completed.

RESULTS

Arrests involved 2,957 substances (drugs and paraphernalia). Most arrests (80.6%) involved a single drug. One-third (33.2%) of arrests involved illicit drugs (i.e. Schedule I) and three-fifths (59.8%) were for controlled prescription medical drugs (i.e. Schedule II-V), and a minority (6.8%) involved non-controlled prescription drugs (e.g. gabapentin, bupropion). Opioids (e.g. heroin, buprenorphine, and oxycodone) accounted for over-half (51.3%) of arrests followed by stimulants (29.0%, e.g. cocaine), and sedatives (7.6%). Arrests for oxycodone significantly decreased (51.9%) and alprazolam increased (89.3%) during 2016. Arrestees for non-controlled prescription drugs were older than arrestees for illegal drugs. Arrests, correcting for population, were most common in more urban (e.g. Androscoggin and Cumberland) counties.

CONCLUSIONS

Opioids (illicit and prescription) account for over half of all arrests. However, arrests for oxycodone decreased while arrests for benzodiazepines, and especially alprazolam, increased in 2016. The DAP is a novel source of information for healthcare decisions and can empirically inform law enforcement about drug misuse and addiction.

Using Controlled Substance Receipt Patterns to Predict Prescription Overdose Death

BACKGROUND

This study evaluates complete state data from controlled substance prescribing trends in the prescription monitoring program (PMP) database and their association with the risk of prescription drug overdose death.

SUMMARY

Maine PMP records of individuals who died of prescription overdose deaths between 2006 and 2010 were selected (n = 690). For each subject, an age, gender, and residence matched cohort of PMP users in a 50: 1 ratio was identified (n = 34,500). Key Messages: Prescription opioids contributed to 480 of 690 prescription deaths, many co-ingestions were noted, and OR for overdose death increased with milligram of morphine equivalent (MME)/day >100. The majority who were prescribed MME >100 per day received a prescription within 90 days of overdose matching the toxicology cause of death.

CONCLUSIONS

Medication profiles available through state PMP can identify dosing of prescriptions associated with drug overdose death.

A New Tool to Tackle the Opioid Epidemic: Description, Utility, and Results from the Maine Diversion Alert Program

STUDY OBJECTIVE

The opioid epidemic continues to impact the United States, and new strategies are needed to combat this epidemic. The objective of this study was to analyze 2015 drug arrest data from Maine's Diversion Alert (DA) program (diversionalert.org), compare arrest data between the first quarters of 2015 and 2016, and provide an analysis of the sex differences in the arrests as well as information about DA use.

STUDY DESIGN

This was a population-based descriptive study using data from the Maine DA program. The study population consisted of persons arrested for prescription, nonprescription, or illicit drugs.

DATA SOURCE

DA database.

MEASUREMENTS AND MAIN RESULTS

The DA program addresses Maine's prescription drug abuse epidemic with innovative resources that provide access to drug arrest data for health care providers to identify and respond to patients at risk for overdose, those engaged in illegal prescription drug distribution, and those who need treatment. Drug arrest data from 2015 (2723 arrests) and the first quarter of 2016 (788 arrests) were compared and analyzed. The drugs implicated in the arrests were organized by Drug Enforcement Agency (DEA) schedule category and whether they were pharmaceuticals (synthesized and distributed by a pharmaceutical company) or nonpharmaceuticals (grown or synthesized in clandestine laboratories). Most arrests were for possession (64.5%) followed by trafficking (23.8%). Heroin was listed in more than three-quarters (76.4%) of the Schedule I arrests, followed by marijuana (11.7%) and "bath salts" (6.3%). Cocaine and crack cocaine were implicated in almost half (46.7%) of the Schedule II arrests, followed by oxycodone (21.0%) and methamphetamine/amphetamine (15.8%). Buprenorphine was responsible for almost all (96.7%) of the Schedule III arrests. The benzodiazepines alprazolam (34.3%), clonazepam (33.8%), diazepam (11.9%), and lorazepam (8.5%) were listed in the preponderance of the Schedule IV arrests. Arrests increased in 2016 by 49.2% for heroin (p<0.01) and 170.0% for methamphetamine (p≤0.0005) relative to 2015. Arrests for trafficking increased by 42.9% (p<0.05). Males outnumbered females 2:1 in DA. Schedule IV agents accounted for only 6.8% of arrests for males versus 11.5% for females (p≤0.0001). Conversely, Schedule I agents were implicated in 33.0% of arrests for males versus only 27.3% for females (p<0.005).

CONCLUSION

DA is an important tool for providing timely information for health care providers regarding individuals with a history of past misuse of psychotherapeutic agents, particularly opioids and stimulants.

Ximelagatran: A New Era in Oral Anticoagulation

Objective:

To review the pharmacology, pharmacokinetics, and clinical trials of the oral direct thrombin inhibitor ximelagatran.

Data Sources:

All primary articles involving ximelagatran or its active form, melagatran, and indexed on MEDLINE or International Pharmaceutical Abstracts databases (1966–December 2002) were evaluated. Recent ximelagatran and melagatran abstracts were also obtained online from the American Society of Hematology at www.hematology.org/meeting/abstracts.cfm (2001 and 2002).

Data Synthesis:

Ximelagatran is an orally bioavailable prodrug of melagatran that directly blocks unbound thrombin and fibrin-bound thrombin. Ximelagatran displays predictable pharmacodynamic and pharmacokinetic properties with a linear dose–response relationship and low interpatient variability. These parameters allow fixed dosing of ximelagatran without routine coagulation monitoring. Ximelagatran has yet to be approved by the FDA; however, several major clinical trials have been completed. These clinical trials have revealed that an easier-to-manage ximelagatran regimen is at least as effective and has a similar safety profile as conventional therapy for prevention of venous thromboembolism (VTE). The results of studies with ximelagatran for treatment of VTE and prevention of thrombosis associated with atrial fibrillation are promising, but need further investigation.

Conclusions:

Ximelagatran possesses several advantages over warfarin including fixed dosing and the lack of coagulation monitoring, the absence of known diet or drug interactions, and a faster onset of action. Ximelagatran appears to be at least as effective as warfarin for prevention of VTE. Further research is needed with ximelagatran in the treatment of VTE and atrial fibrillation.

Use and Misuse of Opioids in Maine: Results From Pharmacists, the Prescription Monitoring, and the Diversion Alert Programs

OBJECTIVE

Although opioids have substantial efficacy for acute pain management, escalation to opioid misuse and abuse is a persistent concern. This report assesses the current status of the opioid epidemic in Maine using three complementary data sets.

METHOD

A representative sample of pharmacists (N = 275) completed an online survey regarding the extent that opioids affected their practice. A county-level analysis of opioid prescriptions (N = 1.22 million) reported to the Maine Prescription Monitoring Program (M-PMP) in 2014 and the agents implicated in arrests as reported to the Maine Diversion Alert Program (DAP, N = 2,700) in 2014/15 also was completed.

RESULTS

A significantly greater number of pharmacists agreed that opioid misuse (85.9%), rather than diversion (76.8%) or access (54.2%), was a concern. Only half (56.2%) reported use of the M-PMP. Opioids were dispensed to 22.4% of residents (37.7% of women in their 80s). This was enough to supply everyone in Maine with a 16.1-day supply. Buprenorphine accounted for almost half of opioid prescriptions to young adults (46.3% women, 49.3% men). Arrests increased by 13.3% from 2014 to 2015, and the proportion of arrests that involved prescription opioids decreased while those involving stimulants and heroin were elevated.

CONCLUSIONS

Pharmacists are very aware of the potential for opioid misuse, but many do not consistently use the M-PMP. There continues to be substantial legitimate use, as well as criminal activity, involving oxycodone and other prescription opioids. Continued vigilance and use of tools like the PMP and DAP are necessary to minimize nonmedical use of opioids in Maine.

A Novel Education and Training Program to Enhance Student Advocacy

Objective. To develop and implement a unique student advocacy program to train student pharmacists to be effective advocates for the profession of pharmacy and the patients it serves. Design. The Academy is a 2-day program hosted annually in Washington, DC, that combines didactic presentations on the legislative process, communication with policymakers, current legislation, and active-learning exercises such as mock congressional visits. The Academy culminates with visits to Capitol Hill where students meet with legislators and their staff to discuss pending legislation. Assessment. Nearly 350 students from 43 schools and colleges of pharmacy completed the program in its 4 years. Students are assessed following the active-learning exercises and meetings with legislators. Conclusion. Advocacy has been listed as a competency that requires more attention in pharmacy education. The Academy provides a model that schools may replicate to enhance their advocacy offerings.

Pharmacy students provide care comparable to pharmacists in an outpatient anticoagulation setting

OBJECTIVE

To evaluate whether student participation in ambulatory clinics influenced the percentage of therapeutic international normalized ratio (INR) results among patients on chronic warfarin therapy.

METHODS

Medical records in outpatient anticoagulation clinics managed by pharmacists under physician protocol were reviewed retrospectively in 2 university-affiliated clinics in Amarillo and Lubbock, TX. Pharmacy student activities included patient interviews, vital sign measurements, fingersticks, counseling, and documentation. Patient visits were conducted by a precepted pharmacy student or a pharmacist without a student, and the INR was measured at the subsequent patient visit.

RESULTS

Records of 1,958 anticoagulation patient visits were reviewed; 865 patients were treated by pharmacists, and 1093 were treated by precepted students. The follow-up INR was therapeutic for 48.5% of third-year (P3) students' patients, 45.6% of fourth-year (P4) students' patients, 51.2% of residents' patients, and 44.7% of pharmacists's patients (p = 0.23). Eight variables were associated with the follow-up INR (baseline INR, warfarin noncompliance, held warfarin doses, a warfarin dosage adjustment, diet change, alcohol use, tobacco use, and any medication changes).

CONCLUSION

Student participation in the patient-care process did not compromise patient care and no significant difference in patient outcomes was found between patients in an anticoagulation clinic cared for by precepted students and those cared for by pharmacists.

Achieving equivalent academic performance between campuses using a distributed education model

OBJECTIVES

To demonstrate that students in competency-based anatomy and pharmaceutical calculations courses performed similarly whether enrolled in the classes through distance education or face-to-face lectures.

METHODS

Student outcomes data including module examination scores, final course grades, and student demographics data were collected, merged, and analyzed.

RESULTS

Mean module examination final scores and final course grades did not significantly differ between students at the lecture site and students at the remote site.

CONCLUSIONS

The competency-based anatomy and pharmaceutical calculations courses, whether remote or at the lecture site, provided equitable learning opportunities and roughly equivalent learning outcomes for students.

Assessment of manual blood pressure and heart rate measurement skills of pharmacy students: a follow-up investigation

OBJECTIVES

To evaluate the impact of a laboratory course on the manual blood pressure (BP) and heart rate (HR) measurement skills of pharmacy students.

METHODS

After 1 lecture and 1 laboratory session on vital sign technique, pharmacy students enrolled in a patient assessment laboratory course were randomly paired with a classmate and manually measured the classmate's BP and HR. Within 2 minutes, the BP and HR were measured by an Omron 711-AC automatic monitor. The same assessment procedures with manual and automatic measurements were repeated near the end of the laboratory course. Student skills were also evaluated through direct observation by faculty members.

RESULTS

Student and machine measurements of systolic blood pressure (SBP), diastolic blood pressure (DBP), and HR significantly correlated at the final assessment (r = 0.92, 0.83, and 0.91 respectively; p < 0.001 for each. The proportion of student and device values agreeing to within 5 units (mmHg and beats-per-minute) at baseline versus at the final assessment significantly improved from 38% to 67% for SBP, 51% to 77% for DBP, and 52% to 79% for HR (p < 0.001 for each). The percentage of students correctly performing all 13 AHA endorsed steps for BP measurement improved significantly from 4.6% to 75.6% (p < 0.001).

CONCLUSIONS

Significant improvement and the attainment of competency in manual vital signs measurement were demonstrated by pharmacy students after 11 weeks of skill rehearsal in a laboratory course.

Parenterals laboratory course to reduce microbial contamination rates in media fill tests performed by pharmacy students

OBJECTIVES

To evaluate microbial contamination rates of low- and medium-risk level media fill tests performed by pharmacy students near the beginning and end of a parenterals laboratory course in the second- professional year of a doctor of pharmacy (PharmD) program.

METHODS

Students enrolled in a required parenterals laboratory class (N = 84) participated in this study. The aseptic technique procedures performed at the beginning of the course were identical to the procedures performed at the end of the course and included 3 low-risk level media-fill tests and a medium-risk level media-fill test. Single-strength trypticase-soy broth (TSB) was substituted for the drug and was used to detect microbial contamination for all manipulations.

RESULTS

The baseline and end-of-course contamination rate was 21 of 504 syringes and 0 of 498 syringes, respectively (p < 0.001). Eighteen of 84 students at baseline and 0 of 83 students near the end of the course produced one or more contaminated syringes (p < 0.001). Of the 21 contaminated syringes at baseline, low-risk manipulations accounted for 14 and medium-risk manipulations accounted for 7. Of the low-risk procedures, the ampule produced the highest contamination rate (11 syringes), followed by the vial (2 syringes) and the reconstitution (1 syringe).

CONCLUSIONS

This study demonstrated a decreased rate of microbial contamination during the manipulation of parenteral products and a corresponding improvement in aseptic technique skills among pharmacy students enrolled in a parenterals laboratory course. The most sensitive tests for poor aseptic technique and bacterial contamination were medium-risk manipulations and low-risk manipulations involving an ampule.

Preadmission predictors of PharmD graduates' performance on the NAPLEX

OBJECTIVES

To identify prepharmacy variables that predicted graduate performance on the North American Pharmacist Licensure Examination (NAPLEX) test.

METHODS

Undergraduate and pharmacy school transcripts for 424 students admitted to the Texas Tech University Health Sciences Center (TTUHSC) Doctor of Pharmacy program from the fall of 1996 to the fall of 2001 were reviewed. NAPLEX scores were provided by the Texas State Board of Pharmacy (TSBP). Statistical analyses were performed using SPSS, 11.5.

RESULTS

Grade point average, composite Pharmacy College Admission Test (PCAT) score, and California Critical Thinking Skills Test (CCTST) score were each positively correlated with NAPLEX score (p < 0.001 for each). Type of school where organic chemistry was completed; age; advanced courses taken in chemistry, biology, and math; and attainment of a BS, BA, or MS degree were not significantly correlated with NAPLEX score (p > 0.05). When comparing students who successfully graduated and passed the NAPLEX with students who were academically suspended or who failed the NAPLEX, there were significant differences in mean PCAT scores, CCTST score, and age (p < 0.05 for all). Stepwise regression analysis applying all admission variables except PCAT subscores revealed a correlation between predictors (composite PCAT, prepharmacy GPA, and age) and NAPLEX score (p < 0.001).

CONCLUSION

Composite PCAT score was the strongest predictor of success and failure on the NAPLEX. However, the combined predictive ability of PCAT and CCTST scores, prepharmacy GPA, and age was relatively low. Thus, a full review of each candidate's application is justified.

Evaluation of pharmacy students' blood pressure and heart rate measurement skills after completion of a patient assessment course

OBJECTIVES

To evaluate pharmacy students' skills at measuring brachial artery blood pressure and radial heart rate at the completion of a patient assessment course in the second-professional year of a doctor of pharmacy (PharmD) program.

METHODS

Students enrolled in a required patient assessment laboratory course (n = 83) participated in this study. Each student was randomly matched with a classmate and manually measured the classmate's blood pressure by auscultation of the brachial artery and heart rate by palpation of the radial pulse.

RESULTS

The student-device absolute disagreement was 6.5 +/- 4.8 mmHg for systolic blood pressure (SBP), 6.2 +/- 4.5 mmHg for diastolic blood pressure (DBP), and 5.3 +/- 4.0 beats per minute (BPM) for heart rate. Student and machine measurements of SBP, DBP, and HR significantly correlated.

CONCLUSIONS

Pharmacy students in the second-professional year of a PharmD program demonstrated competence in but not mastery of manual blood pressure and heart rate measurement. These skills need further refinement during third- and fourth-professional year APPEs.

Effect of angiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor blockers on the rate of new-onset diabetes mellitus: a review and pooled analysis

The rising prevalence and health burden of diabetes mellitus require that new approaches for prevention among high-risk populations be evaluated. Emerging evidence from the prospective evaluations of secondary and tertiary outcomes and from retrospective evaluations in randomized controlled trials suggests that angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type 1 receptor blockers (ARBs) may reduce the occurrence of new-onset diabetes. Therefore, we each independently searched MEDLINE for randomized controlled trials from January 1966-October 2005 that used an ACE inhibitor or ARB as a primary intervention versus a control group not receiving an ACE inhibitor or ARB and that reported the occurrence of diabetes. Thirteen trials were identified. In each of the 13 studies, the frequency of diabetes in the ACE inhibitor or ARB groups was lower than that in the control groups. In addition, it was consistent in that no study significantly excluded any benefit from ACE inhibitors or ARBs on the rate of new-onset diabetes. The combined occurrence of new-onset diabetes in all 13 studies was 2249 cases among 31,283 patients (7.2%) in the ACE inhibitor or ARB group versus 3230 cases among 35,988 patients (9.0%) in the control group. The combined relative risk of diabetes was 0.80, with a 95% confidence interval of 0.76-0.84, based on a two-sided alpha of 0.05, in favor of ACE inhibitors and ARBs. This observation needs to be confirmed by randomized controlled trials with the frequency of diabetes as the primary prospective end point.

Predictors of academic success in a doctor of pharmacy program

OBJECTIVES

To evaluate the correlation between specific prepharmacy college variables and academic success in the Texas Tech doctor of pharmacy degree program.

METHODS

Undergraduate and pharmacy school transcripts for 424 students admitted to the Texas Tech doctor of pharmacy degree program between May 1996 and May 2001 were reviewed in August of 2005. Statistical analyses were performed using SPSS Release 11.5. The undergraduate college variables included prepharmacy grade point-average (GPA), organic chemistry school type (2- or 4-year institution), chemistry, biology, and math courses beyond required prerequisites, and attainment of a bachelor of science (BS), bachelor of arts (BA), or master of science (MS) degree. Measurements of academic success in pharmacy school included cumulative first-professional year (P1) GPA, cumulative GPA (grade point average of all coursework finished to date), and graduation without academic delay or suspension.

RESULTS

Completing advanced biology courses and obtaining a BS degree prior to pharmacy school were each significantly correlated with a higher mean P1 GPA. Furthermore, the mean cumulative GPA of students with a BS degree was 86.4 versus cumulative GPAs of those without a BS degree which were 84.9, respectively (p = 0.039). Matriculates with advanced prerequisite biology coursework or a BS degree prior to pharmacy school were significantly more likely to graduate from the doctor of pharmacy program without academic delay or suspension (p = 0.021 and p = 0.027, respectively). Furthermore, advanced biology coursework was significantly and independently associated with graduating on time (p = 0.044).

CONCLUSIONS

Advanced biology coursework and a science baccalaureate degree were significantly associated with academic success in pharmacy school. On multivariate analysis, only advanced biology coursework remained a significant predictor of success.

Retrospective evaluation of a possible interaction between warfarin and levofloxacin

STUDY OBJECTIVES

In order to clarify the clinical significance of a suspected drug interaction, we sought to determine if the international normalized ratio (INR) is affected when levofloxacin is administered in patients receiving long-term warfarin therapy.

DESIGN

Retrospective cohort study using pharmacy and medical records.

SETTING

Outpatient clinic.

PATIENTS

Forty-three patients receiving long-term warfarin therapy who subsequently were prescribed either levofloxacin (22 patients) or felodipine (21 controls); felodipine was chosen as it has been shown not to interact with warfarin. Patients in both groups were required to have a documented INR before the start of levofloxacin or felodipine (pre-INR) and either during levofloxacin or felodipine therapy or within 15 days after the drug had been started (post-INR).

MEASUREMENTS AND MAIN RESULTS

Patient demographics were similar between the two treatment groups. The mean +/- SD age of the patients in the levofloxacin and control groups was 59.5 +/- 8.7 and 65.3 +/- 11.5 years, respectively (p=0.07). The mean change between the pre- and post-INR (primary outcome measure) was 0.31 +/- 0.82 (pre-INR 2.46, post-INR 2.76) and 0.21 +/- 0.54 (pre-INR 2.46, post-INR 2.67) in the levofloxacin and felodipine groups, respectively (p=0.65). A post hoc power analysis, based on a sample-derived, weighted standard deviation of 0.68, revealed that the study had 66% power to detect a change of 0.5 in the INR value. The percentage of patients who required a warfarin dosage adjustment based on the post-INR (secondary outcome measure) was 41% (9 of 22 patients) in the levofloxacin group and 33% (7 of 21 patients) in the felodipine group.

CONCLUSION

Although our primary analysis did not detect a warfarin-levofloxacin interaction, the potential for such an interaction, especially in idiosyncratic cases, cannot be ruled out. Clinicians should closely monitor INR values when levofloxacin is administered jointly with warfarin.

Determination of the lack of a drug interaction between azithromycin and warfarin

STUDY OBJECTIVE

To determine the effect on the international normalized ratio (INR) of adding azithromycin to patients receiving stable dosages of warfarin.

DESIGN

Retrospective chart review.

SETTING

Outpatient clinic.

PATIENTS

Ambulatory patients receiving warfarin and azithromycin concurrently who had a documented therapeutic INR value before the start of azithromycin therapy (pre-INR) and a documented INR value within 30 days after the start of azithromycin therapy (post-INR).

MEASUREMENTS AND MAIN RESULTS

Patients given felodipine during long-term warfarin therapy formed a comparative control group. Patient demographics were similar in both treatment groups. Mean age of the azithromycin group (17 patients) was 59 +/- 13 years and of the control group (20 patients) 65 +/- 12 years. All 17 patients in the azithromycin group and 16 of the controls were women. Mean change from pre-INR to post-INR in the azithromycin and control groups, respectively, was 0.14 +/- 0.64 (pre-INR 2.46, post-INR 2.61) and 0.19 +/- 0.54 (pre-INR 2.46, post-INR 2.66) (p = 0.74). A post hoc power analysis based on a pooled standard deviation of 0.60 revealed that the study had 68% power to detect a 0.5 change in the INR value.

CONCLUSION

No interaction between azithromycin and warfarin was observed in ambulatory patients with therapeutic baseline INR values.