Search Engines and Generative Artificial Intelligence Integration: Public Health Risks and Recommendations to Safeguard Consumers Online

BACKGROUND

The online pharmacy market is growing, with legitimate online pharmacies offering advantages such as convenience and accessibility. However, this increased demand has attracted malicious actors into this space, leading to the proliferation of illegal vendors that use deceptive techniques to rank higher in search results and pose serious public health risks by dispensing substandard or falsified medicines. Search engine providers have started integrating generative artificial intelligence (AI) into search engine interfaces, which could revolutionize search by delivering more personalized results through a user-friendly experience. However, improper integration of these new technologies carries potential risks and could further exacerbate the risks posed by illicit online pharmacies by inadvertently directing users to illegal vendors.

OBJECTIVE

The role of generative AI integration in reshaping search engine results, particularly related to online pharmacies, has not yet been studied. Our objective was to identify, determine the prevalence of, and characterize illegal online pharmacy recommendations within the AI-generated search results and recommendations.

METHODS

We conducted a comparative assessment of AI-generated recommendations from Google's Search Generative Experience (SGE) and Microsoft Bing's Chat, focusing on popular and well-known medicines representing multiple therapeutic categories including controlled substances. Websites were individually examined to determine legitimacy, and known illegal vendors were identified by cross-referencing with the National Association of Boards of Pharmacy and LegitScript databases.

RESULTS

Of the 262 websites recommended in the AI-generated search results, 47.33% (124/262) belonged to active online pharmacies, with 31.29% (82/262) leading to legitimate ones. However, 19.04% (24/126) of Bing Chat's and 13.23% (18/136) of Google SGE's recommendations directed users to illegal vendors, including for controlled substances. The proportion of illegal pharmacies varied by drug and search engine. A significant difference was observed in the distribution of illegal websites between search engines. The prevalence of links leading to illegal online pharmacies selling prescription medications was significantly higher (P=.001) in Bing Chat (21/86, 24%) compared to Google SGE (6/92, 6%). Regarding the suggestions for controlled substances, suggestions generated by Google led to a significantly higher number of rogue sellers (12/44, 27%; P=.02) compared to Bing (3/40, 7%).

CONCLUSIONS

While the integration of generative AI into search engines offers promising potential, it also poses significant risks. This is the first study to shed light on the vulnerabilities within these platforms while highlighting the potential public health implications associated with their inadvertent promotion of illegal pharmacies. We found a concerning proportion of AI-generated recommendations that led to illegal online pharmacies, which could not only potentially increase their traffic but also further exacerbate existing public health risks. Rigorous oversight and proper safeguards are urgently needed in generative search to mitigate consumer risks, making sure to actively guide users to verified pharmacies and prioritize legitimate sources while excluding illegal vendors from recommendations.

Comprehensive Approach to Opioid Management in a Primary Care Network

In response to the opioid epidemic, the Centers for Disease Control and Prevention released best practice recommendations for prescribing, yet adoption of these guidelines has been fragmented and frequently met with uncertainty by both patients and providers. This study aims to describe the development and implementation of a comprehensive approach to improving opioid stewardship in a large network of primary care providers. The authors developed a 3-tier approach to opioid management: (1) establishment and implementation of best practices for prescribing opioids, (2) development of a weaning process to decrease opioid doses when the risk outweighs benefits, and (3) support for patients when opioid use disorders were identified. Across 44 primary care practices caring for >223,000 patients, the total number of patients prescribed a chronic opioid decreased from 4848 patients in 2018 to 3106 patients in 2021, a decrease of 36% (P < 0.001). The percent of patients with a controlled substance agreement increased from 13% to 83% (P < 0.001) and the percent of patients completing an annual urine drug screen increased from 17% to 53% (P < 0.001). The number of patients coprescribed benzodiazepines decreased from 1261 patients at baseline to 834 at completion. A total of 6.5% of patients were referred for additional support from a certified alcohol and substance abuse counselor embedded within the program. Overall, the comprehensive opioid management program provided the necessary structure to support opioid prescribing and resulted in improved adherence to best practices, facilitated weaning of opioids when medically appropriate, and enhanced support for patients with opioid use disorders.

Comparison of record linkage software for deduplicating patient identities in California's Prescription Drug Monitoring Program

BACKGROUND

To help prevent overdose deaths involving prescription drugs, accurate linkage of prescription drug monitoring program (PDMP) records for individual patients is essential.

OBJECTIVES

To compare the accuracy of the linkage program used by California's PDMP against various record linkage programs with respect to accuracy in deduplicating patient identities in the PDMP, with implications for identifying high-risk opioid use and outlier behaviors.

RESEARCH DESIGN

We evaluated California's program, Link Plus, LinkSolv, and The Link King on 557 861 PDMP identity records with addresses in two 3-digit zip code areas for patients who filled a controlled substance prescription in 2013. Manual review was performed on a stratified sample of 720 paired records identified as matches by at least one program.

MEASURES

We estimated sensitivity and positive predictive value, and computed PDMP patient alerts for the patient entities identified by each program.

RESULTS

Sensitivity was 95% for LinkSolv and The Link King, 84% for Link Plus, and 73% for California's program; positive predictive value was ≥93% for all programs. The number of patient entities prompting a PDMP alert was similar among the programs for all alerts except multiple provider episodes (obtaining prescriptions from ≥6 prescribers or ≥6 pharmacies in the last 6 months), which were 10.9%, 26.6%, and 16.9% greater using The Link King, Link Plus, and LinkSolv, respectively, compared to California's program.

CONCLUSIONS

PDMPs should assess the accuracy of record linkage algorithms and the impacts of these algorithms on patient safety alerts and develop national best practices for PDMP record linkage.

Preventing controlled substance diversion in perioperative settings: a narrative review

PURPOSE

Diversion of controlled substances in the perioperative setting is an ongoing challenge, with consequences for patients, anesthesiologists, perioperative staff, and health care facilities alike. Perioperative environments are at high risk for diversion, since controlled substances are frequently handled in these settings, with varying levels of oversight. In this narrative review, we summarize strategies for preventing diversion of controlled substances in perioperative settings (i.e., operating rooms, endoscopy suites, and postanesthesia recovery units).

SOURCE

We performed a targeted literature search in PubMed MEDLINE, Embase, Scopus, Web of Science, the Cochrane Register of Controlled trials, and the Cochrane Database of Systematic Reviews, as well as a manual search for additional references. We used terminology related to drug diversion, drug abuse, anesthesiologists, pharmacists, physicians, operating room personnel, and controlled substances.

PRINCIPAL FINDINGS

Many strategies have been described for preventing diversion in perioperative settings, and these are broadly categorized into: education, distribution, auditing, or provider screening. Some of these approaches may be time- and resource-intensive. There is limited evidence to inform anesthesia departments' choice of which strategies to adopt.

CONCLUSION

Although awareness of perioperative controlled substance diversion has been improving, there are too few data to suggest an optimal approach. Anesthesia departments will need to work collaboratively with hospital pharmacies and actively select strategies that are reasonable given local resources.

Evaluation of Interprofessional Quality Improvement Interventions Led by an Ambulatory Care Pharmacist on Adherence to a Controlled Substance Agreement Policy

Background: A controlled substance agreement (CSA) is a risk mitigation strategy for patients managed on controlled substance medications such as opioids and benzodiazepines. Limited literature exists to describe the role of the clinic pharmacy team to promote adherence to CSA monitoring parameters. Objective: The objective of this study is to evaluate the impact of interprofessional educational and clinical interventions led by an ambulatory care pharmacist on adherence to monitoring parameters within a CSA policy. Methods: This retrospective observational study included patients on long-term controlled substances who had a clinic visit every 3 months during the study period. The primary outcomes were the proportion of patients with a signed CSA in the electronic medical record (EMR), urine drug screen (UDS) completion, and documentation of review of the statewide prescription drug monitoring program (PDMP) in the EMR 8 months prior to as compared to 8 months after implementation of pharmacist interventions. Results: Among 79 patients (mean age 55.7 years, 65.8% female, 54.4% African American), 8.9% pre- vs 88.6% post-interventions had a signed CSA (p<0.001), 35.4% pre- vs 65.8% post-interventions had a UDS completed (p<0.001), and 32.9% pre- vs 57% post-interventions had documentation of PDMP review (p=0.002). Conclusion: Adherence to monitoring parameters within a CSA policy significantly improved after educational and clinical interventions led by an ambulatory care pharmacist.

Provider perspectives and experiences following the integration of the prescription drug monitoring program into the electronic health record

Prescription drug monitoring programs (PDMPs) are a public health tool for prescribers and pharmacists to monitor controlled substance use at the patient level. The objectives of this study were to (1) assess attitudes about the PDMP and perceived changes in experience and decision-making following integration into the electronic health record (EHR), and (2) identify barriers to optimal PDMP use and user recommendations for improvement. This descriptive study used an electronic survey to obtain feedback from prescribers and pharmacists at a single academic medical center. Descriptive statistics were calculated, and textual data were analyzed. Of 1480 PDMP users 208 responded (14.1%). Responses demonstrated the integration of the PDMP into the EHR simplified log-in and access to PDMP information resulting in more frequent access and perceived improvement of care quality. Barriers included technical issues accessing the PDMP within the EHR and the lack of integration of other state PDMPs. Overall, the benefit of integrating the PDMP into the EHR was positive but largely limited to streamlining log-in and patient selection. Recommendations for improvement include addressing technological issues and education on PDMP interpretation and integrating new features that may modify prescribing, referral, and co-prescribing behaviors.

Controlled Substance Prescription History among Individuals Who Died of an Accidental Opioid-Involved Drug Overdose in Rhode Island

Background: Accidental opioid-involved overdose deaths are increasing nationally in the wake of the COVID-19 pandemic, but it is unclear if this reflects a change in populations most at risk. Objective: To determine whether the demographic characteristics and controlled substance prescription history of accidental opioid-involved drug overdose decedents in 2020 differed from prior years. Methods: We identified accidental opioid-involved overdose decedents using Rhode Island (RI) State Medical Examiner's Office data. Decedents were linked to the RI Prescription Drug Monitoring Program database. We compared demographic characteristics and prescription history by year of death. Results: From 2018 to 2020, 763 RI residents died from accidental opioid-involved overdose in RI. From 2018 to 2019, deaths decreased by 7%, but then increased by 31% from 2019 to 2020. Demographic characteristics were similar by year of death (all p > 0.05). The percentage of decedents with a prior opioid prescription and a prior benzodiazepine prescription declined from 2018 to 2020 (p < 0.01 and p = 0.03). Conclusions: We found that opioid-involved overdose deaths in RI are increasing overall, but without significant changes in demographics. While prior exposure to some controlled substances did decline over time, it is not clear if these changes reflect more responsible prescribing practices, or a more concerning pattern such as patient abandonment or decreased healthcare access. More studies are needed to better describe the current trend of increasing opioid-involved deaths while also pursuing current evidence-based interventions.

Changes in Single-Specialty Postoperative Opioid Prescribing Patterns in Response to Legislation: Single-Institution Analysis Over Time

OBJECTIVES

To determine changes in the prescriptions of postoperative opioids in response to Florida state legislation restricting the number of days for which these medications could be prescribed to 3 days in most circumstances or 7 days at provider discretion.

STUDY DESIGN

A retrospective review was performed for all patients undergoing 7 common outpatient otolaryngology surgical procedures.

SETTING

Single-institution academic center in Florida.

METHODS

Query of the state's online prescription drug monitoring program was used to compare prescription habits 3 months before and after the law and then again 1 year later.

RESULTS

A total of 561 patients were identified meeting criteria. The number of days that opioids were prescribed decreased significantly, from 6.42 to 4.48 to 3.03 days. There was a significant decrease in the proportion of patients receiving any postoperative opioid prescription, from 0.80 to 0.52 to 0.32. The total morphine milligram equivalents prescribed decreased from 28.4 before the law to 18.4 at 1 year after.

CONCLUSIONS

Legislative restrictions on the length of opioid prescriptions were associated with significant decreases in the proportion of patients receiving any opioids, the number of days that opioids were prescribed, and the total morphine milligram equivalents 3 months after the law went into effect, with even more dramatic changes at the 1-year time point. We opine that these changes are due to providers learning that many procedures do not require postoperative opioids and therefore increasingly considering and utilizing nonopioid alternatives in this setting.

Comparison of 3 Surveillance Methods to Detect Potential Controlled Substance Diversion in an Academic Medical Center

Objectives: To compare 3 methods of detecting potential diversion of controlled substances (CS) by health care personnel from inpatient units in a large, academic medical center. Methods: Three different reports were retrospectively analyzed and evaluated to determine which employees are "high-risk" for diversion over a 30-day period using defined criteria. Reports were derived from automated dispensing machines (ADMs), purchased third-party software (TPS), and the electronic health record (EHR). The primary outcome was the percentage of employees in each report who were deemed to be high-risk for CS diversion (positive predictive value [PPV]). Secondary outcomes included the number of false positives and description of high-risk users on each report. Descriptive statistics were used to analyze differences between methods. Results: The PPV was highly variable between reports. The PPVs among the ADM, TPS, and EHR reports were 3.28%, 6.82%, and 23.88%, respectively. False positives were high among all reports (96.72%, 93.18%, and 76.12% for the ADM, TPS, and EHR reports, respectively). Conclusions: A report from the EHR has the highest PPV to detect high-risk employees who may be diverting CS. However, false positives were high for all reports, indicating that significant improvements are needed in the development of accurate and reliable software to detect potential and actual CS diversion.

Concurrent Utilization of Prescription Opioids and Non-opioid Controlled Substances: Rhode Island Prescription Drug Monitoring Program, 2018

OBJECTIVE

To estimate the prevalence of concurrent prescription opioid and non-opioid controlled substance use in Rhode Island (RI).

METHODS

We conducted a cross sectional observational study using data from the RI Prescription Drug Monitoring Program on controlled substance prescriptions dispensed in 2018. We estimated the prevalence of concurrent use of other prescribed controlled substances among adults who received at least one opioid prescription.

RESULTS

In 2018, 142,692 RI adult residents received at least one opioid prescription, of whom 25.1% (99% confidence interval [CI]: 24.8-25.4) were concurrently prescribed at least one other controlled substance, including benzodiazepines (17.0%, 99% CI: 16.8-17.3), medications for insomnia (4.0%, 99% CI: 3.9-4.2), and stimulants (3.8%, 99% CI: 3.6-3.9).

CONCLUSION

The concurrent use of prescription opioids and other prescribed controlled substances is common. Our findings suggest an urgent need to implement focused initiatives to address controlled substance polypharmacy to reduce the risk of overdose.

The legalization of cannabinoid products and standardizing cannabis-drug development in the United States: a brief report

This brief report covers recent advances in cannabis and cannabinoid regulation and drug approval. The popularity of cannabis and cannabinoid products continues to rise, and these products are available for the majority of the population in the United States to purchase as easily as alcohol. Although many states have approved programs and research licenses, these activities and products all remain federally illegal. The solution may be for the United States to offer multiple pathways for product approval that adapt to the diversity of the products and the needs of the consumer. Multiple pathways for market approval would protect public health, whether the public is using cannabis and cannabinoids as a medicine, a wellness product, or as a recreational substance.
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idPAD: Paper Analytical Device for Presumptive Identification of Illicit Drugs

As drug overdose deaths across the United States continue to rise, there is increasing interest in field testing of illicit substances. This work discusses a paper-based analytical device (idPAD) that can run a library of 12 colorimetric tests at the same time, each detecting different chemical functional groups and materials found in illicit drugs, distractor substances, and cutting agents. The idPAD requires no electricity, costs less than $2 USD, and requires minimal training to operate. The results of the 12 tests form a color barcode which is "read" by comparison to standard images. The accuracy of the idPAD was assessed using samples of heroin, cocaine HCl, crack, and methamphetamine at concentrations of 25%-100% in a lactose matrix, as well as pure lactose. Based on 840 "reads" by three different users, the idPAD showed 95% sensitivity and 100% specificity for detecting these drugs; the most common error was mistaking cocaine HCl for crack or crack for cocaine HCl. In a second step, samples of heroin, cocaine, and methamphetamine (n = 30) and distractor substances (pharmaceuticals, cutting agents, and other illicit drugs, n = 64) were tested by two readers, yielding a sensitivity of 100% and specificity of 97%. Targeted substances were detected reliably at 55-180 μg/lane, and the idPAD was found to be stable for at least 3 months when stored at room temperature. The library approach used in the idPAD may provide the accuracy and robustness necessary for a presumptive field drug test.

Good Samaritan harm reduction policy and drug overdose deaths

OBJECTIVE

To examine the effects of a harm reduction policy, specifically Good Samaritan (GS) policy, on overdose deaths.

DATA SOURCES/STUDY SETTING

Secondary data from multiple cause of death, mortality records paired with state harm reduction and substance use prevention policy.

STUDY DESIGN

We estimate fixed effects Poisson count models to model the effect of GS policy on overdose deaths for all, prescription, and illicit drugs, controlled substances, and opioids, while controlling for other harm reduction and substance use prevention policies.

DATA COLLECTION/EXTRACTION METHODS

We merge secondary data sources by state and year between 1999 and 2016.

PRINCIPAL FINDINGS

We fail to identify a statistically significant effect of GS policy in reducing overdose deaths broadly.

CONCLUSIONS

While we are unable to identify an effect of GS policy on overdose deaths, GS policy may have important effects on first-stage outcomes not investigated in this paper. Given recent state policy changes and rapid increase in many categories of overdose deaths, additional research should continue to examine the implementation and effects of harm reduction policy specifically and substance use prevention policy broadly.

Use of nalbuphine as a substitute for butorphanol in combination with dexmedetomidine and tiletamine/zolazepam: a randomized non-inferiority trial

OBJECTIVES

The goal of this study was to determine whether a drug combination using nalbuphine with dexmedetomidine and tiletamine/zolazepam is non-inferior to one that uses butorphanol.

METHODS

All healthy cats presenting solely for gonadectomy to two trap-neuter-return mobile clinic days were randomly assigned to induction with a combination of tiletamine/zolazepam 3 mg/kg, dexmedetomidine 7.5 µg/kg and either butorphanol or nalbuphine at 0.15 mg/kg. All participants were blinded to the identity of the combinations. The primary endpoint was clinician satisfaction, comprised of the mean of four satisfaction ratings on a 7-point Likert scale (highly dissatisfied through to highly satisfied) recorded for induction, maintenance of anesthesia, surgery and recovery. Exploratory endpoints included each individual score, number of injections, duration of induction, duration of recovery and need for reversal agent. To assess non-inferiority for the primary endpoint and individual scores, the difference and 95% confidence intervals (CIs) of the difference between the mean clinical scores for the nalbuphine and butorphanol-based combinations were calculated and compared with a prespecified non-inferiority margin of 20% (1.4 points).

RESULTS

Seventy-two cats were enrolled, 36 in each group. The mean ± SD composite score for the combination with nalbuphine was 6.06 ± 0.59 (95% CI 5.86-6.25) points, while the combination with butorphanol was 6.22 ± 0.62 (95% CI 6.01-6.43). The difference between mean scores was 0.17 (-0.12 to 0.45), which did not exceed the prespecified boundary of 1.4, establishing the non-inferiority of nalbuphine. No individual clinical score for nalbuphine was inferior to butorphanol, and there were no significant differences for any secondary endpoints.

CONCLUSIONS AND RELEVANCE

The clinical experience of the nalbuphine-based combination was non-inferior to the butorphanol-based combination. Nalbuphine is an effective substitute for butorphanol, providing another option if butorphanol is unavailable due to shortage, controlled status or cost, without requiring a change in anesthetic workflow.

Trajectories of dispensed prescription opioids among beneficiaries enrolled in a Medicaid controlled substance "lock-in" program

PURPOSE

"Lock-in" programs (LIPs) are used by health insurers to address potential substance (eg, opioid) misuse among beneficiaries. We sought to (1) examine heterogeneity in trajectories of dispensed opioids (in average daily morphine milligram equivalents (MMEs)) over time: prior to, during, and following release from a LIP, and (2) assess associations between trajectory patterns and beneficiary characteristics.

METHODS

Medicaid claims were linked to Prescription Drug Monitoring Program records for a cohort of beneficiaries enrolled in the North Carolina Medicaid LIP (n = 2701). Using latent class growth analyses, we estimated trajectories of average daily MMEs of opioids dispensed to beneficiaries across specific time periods of interest.

RESULTS

Five trajectory patterns appeared to sufficiently describe underlying heterogeneity. Starting values and slopes varied across the 5 trajectory groups, which followed these overall patterns: (1) start at a high level of MMEs, end at a high level of MMEs (13.1% of cohort); (2) start medium, end medium (13.2%); (3) start medium, end low (21.5%); (4) start low, end medium (22.6%); and (5) start low, end low (29.6%). We observed strong associations between patterns and beneficiaries' demographics, substance use-related characteristics, comorbid conditions, and healthcare utilization.

CONCLUSIONS

In its current form, the Medicaid LIP appeared to have limited impact on beneficiaries' opioid trajectories. However, strong associations between trajectory patterns and beneficiary characteristics provide insight into potential LIP design modifications that might improve program impact (eg, LIP integration of substance use disorder assessment and referral to treatment, assessment and support for alternate pain therapies).

Tramadol: a valuable treatment for pain in Southeast Asian countries

Background

The supply of controlled drugs is limited in the Far East, despite the prevalence of health disorders that warrant their prescription. Reasons for this include strict regulatory frameworks, limited financial resources, lack of appropriate training amongst the medical profession and fear of addiction in both general practitioners and the wider population. Consequently, the weak opioid tramadol has become the analgesic most frequently used in the region to treat moderate to severe pain.

Methods

To obtain a clearer picture of the current role and clinical use of tramadol in Southeast Asia, pain specialists from 7 countries in the region were invited to participate in a survey, using a questionnaire to gather information about their individual use and experience of this analgesic.

Results

Fifteen completed questionnaires were returned and the responses analyzed. Tramadol is used to manage acute and chronic pain caused by a wide range of conditions. Almost all the specialists treat moderate cancer pain with tramadol, and every one considers it to be significant or highly significant in the treatment of moderate to severe non-cancer pain. The reasons for choosing tramadol include efficacy, safety and tolerability, ready availability, reasonable cost, multiple formulations and patient compliance. Its safety profile makes tramadol particularly appropriate for use in elderly patients, outpatients, and for long-term treatment. The respondents strongly agreed that tighter regulation of tramadol would reduce its medical availability and adversely affect the quality of pain management. In some countries, there would no longer be any appropriate medication for cancer pain or the long-term treatment of chronic pain.

Conclusions

In Southeast Asia, tramadol plays an important part in the pharmacological management of moderate to severe pain, and may be the only available treatment option. If it were to become a controlled substance, the standard of pain management in the region would decline.

The Opioid Abuse Risk Screener predicts aberrant same-day urine drug tests and 1-year controlled substance database checks: A brief report

The Opioid Abuse Risk Screener was developed to support well-informed decision-making in opioid analgesic prescribing by extending the breadth of psychiatric risk factors evaluated relative to other non–clinician-administered measures. We examined the preliminary predictive validity of the Opioid Abuse Risk Screener relative to the widely used Screener and Opioid Assessment for Patients with Pain–Revised in predicting aberrant urine drug tests and controlled substance database checks. The Opioid Abuse Risk Screener is significantly different from the Screener and Opioid Assessment for Patients with Pain–Revised in predicting aberrant same-day urine drug tests (Z = 2.912, p = 0.0036) and controlled substance database checks within 1 year of assessment (Z = 3.731, p = 0.0002). Promising preliminary analyses using machine learning methods are also discussed.

Correlates of Prescription Opioid Legitimacy Judgments Among Community Pharmacists

BACKGROUND

Community pharmacists are legally required to evaluate and confirm the legitimacy of prescription opioids (POs) prior to dispensing. Yet, previous research has indicated community pharmacists perceive nearly 50% of dispensed POs to be issued lacking a legitimate medical purpose.

OBJECTIVE

To analyze correlates of PO legitimacy judgments across pharmacist and pharmacy setting characteristics.

METHODS

A cross-sectional study of 2000 Tennessee pharmacists was conducted during October and November of 2012. Community pharmacists' self-reported attitudes, beliefs, and behaviors specific to PO legitimacy were elicited. Step-wise multinomial logistic regression techniques were used to model correlates of PO legitimacy across low, moderate and high PO legitimacy estimations.

RESULTS

Being female, practicing in a chain or independent practice setting, fear of employer disciplinary action if PO legitimacy is questioned, and self-confidence in one's ability to detect PO abuse increased the odds of low (vs. high) PO legitimacy estimation (p < 0.05). Employment in chain and independent pharmacies, having POs as a greater percent of total prescriptions filled, and having the perception of PO abuse as a problem in the practice setting were significant positive correlates of moderate (vs high) PO legitimacy estimation (p < 0.05).

CONCLUSIONS

Both modifiable and non-modifiable correlates were statistically significantly associated with PO legitimacy judgments. Distinct correlates were noted across low and moderate as compared to high estimations of PO legitimacy. Legitimacy judgments can inform theoretical exploration of PO dispensing behaviors and inform intervention development targeted at reducing and preventing prescription drug abuse.

Development and evaluation of a record linkage protocol for Utah's Controlled Substance Database

Utah's Controlled Substance Database prescription registry does not include master identifiers to link records for individual patients. We describe and evaluate a linkage protocol for Utah's Controlled Substance Database. Prescriptions (N = 22,401,506) dated 2005-2009 were linked using The Link King software and patient identifiers (e.g. names, dates of birth) for 2,232,725 patients. Review of 998 randomly selected record pairs classified 46 percent as definitely correct links and 54 percent as probably correct links. A correct link could not be confirmed for <1 percent. None were classified as probably incorrect links or definitely incorrect links. Record set reviews (N = 100 patients/set for 10 set sizes, randomly selected) classified 27-49 percent as definitely correct links and 39-63 percent as probably correct links. Fewer had too little information to confirm a link (5%-22%) or were probably incorrect (0%-6%). None were definitely incorrect. Overall, results suggest that Utah's Controlled Substance Database records were correctly linked. These data may be useful for cross-sectional and longitudinal studies of patient-controlled substance prescription histories.

Professional Roles Evolve With Changing Landscape of Legal Risk

Opioid-use monitoring, medication-error prevention, and counseling/duty-to-warn issues illustrate new or emerging legal risks for pharmacists as their roles expand.

U.S. Pharmacist Opinions Regarding the Rescheduling of Hydrocodone Combination Products: A Pilot Study

In October 2014, the Drug Enforcement Administration in the U.S. reclassified hydrocodone combination products (HCPs) from Schedule III to Schedule II, initiating one of the most significant and controversial regulatory changes for opioids in recent national history. The aim of the present study was to determine community pharmacist opinions on the effect of the rescheduling of HCPs on their personal practice. A web-based pilot survey was emailed to a convenience sample through online newsletters of professional pharmacy organizations in Pennsylvania, Kentucky and West Virginia in April/May 2015. A total of 62 surveys were initiated, yielding 56 complete responses. More than 75% of respondents noted increases in their workload as a result of the rescheduling of HCPs. Opinions regarding the intended outcomes of rescheduling were only weakly positive, with only 37.5% of respondents believing it has increased safety and 44.6% of respondents believing it has lessened abuse/diversion. For overall attitudes regarding the rescheduling, respondents were split between positive (26.8%), neutral (26.8%) and negative (46.4%). These initial data suggest that pharmacists have encountered barriers in practice resulting from the rescheduling. Further expanded work is necessary to verify these results from the small sample, and to assess the intended effects of the rescheduling upon the safe and effective use of hydrocodone.

Abuse-deterrent formulations: transitioning the pharmaceutical market to improve public health and safety

This article evaluates abuse-deterrent formulations (ADFs) as a method to reduce prescription drug abuse while ensuring access to vital medications for individuals with legitimate need; assesses the pros and cons of ADFs and the current state of ADF adoption in the market; and develops policy recommendations to transition the market to ADFs. Although abuse-deterrent technology is still in its nascent stages, ADFs have been proven to reduce prescription drug abuse and its consequences, and even an incremental reduction in abuse can have a significant impact on the nation by reducing the costly social, physical, mental, and public health problems resulting from abuse. Federal ADF policy does not reflect the urgency of the prescription drug abuse epidemic and does not go far enough toward changing the status quo. Policies must be implemented to encourage innovation and a market shift toward ADFs by ensuring any generic medication that references a branded ADF demonstrates that it does not have abuse-deterrent properties inferior to the branded ADF product. Policies must also require federal prescription drug benefit plans to cover ADFs to ensure consumers have access to such medications.

Considerations for the appropriate use of skeletal muscle relaxants for the management of acute low back pain

For patients with low back pain, skeletal muscle relaxants are often initiated after failure of first-line analgesics. However, these medications (reviewed in this article) are controversial alternatives that carry risks of adverse effects and increased cost.