The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction

Public health authorities have described, with growing alarm, an unprecedented increase in morbidity and mortality associated with use of opioid pain relievers (OPRs). Efforts to address the opioid crisis have focused mainly on reducing nonmedical OPR use. Too often overlooked, however, is the need for preventing and treating opioid addiction, which occurs in both medical and nonmedical OPR users. Overprescribing of OPRs has led to a sharp increase in the prevalence of opioid addiction, which in turn has been associated with a rise in overdose deaths and heroin use. A multifaceted public health approach that utilizes primary, secondary, and tertiary opioid addiction prevention strategies is required to effectively reduce opioid-related morbidity and mortality. We describe the scope of this public health crisis, its historical context, contributing factors, and lines of evidence indicating the role of addiction in exacerbating morbidity and mortality, and we provide a framework for interventions to address the epidemic of opioid addiction.

Prescription Opioid Analgesics Commonly Unused After Surgery: A Systematic Review

Importance

Prescription opioid analgesics play an important role in the treatment of postoperative pain; however, unused opioids may be diverted for nonmedical use and contribute to opioid-related injuries and deaths.

Objective

To quantify how commonly postoperative prescription opioids are unused, why they remain unused, and what practices are followed regarding their storage and disposal.

Evidence Review

MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched from database inception to October 18, 2016, for studies describing opioid oversupply for adults after a surgical procedure. The primary outcome-opioid oversupply-was defined as the number of patients with either filled but unused opioid prescriptions or unfilled opioid prescriptions. Two reviewers independently screened studies for inclusion, extracted data, and assessed the study quality.

Findings

Six eligible studies reported on a total of 810 unique patients (range, 30-250 patients) who underwent 7 different types of surgical procedures. Across the 6 studies, 67% to 92% of patients reported unused opioids. Of all the opioid tablets obtained by surgical patients, 42% to 71% went unused. Most patients stopped or used no opioids owing to adequate pain control, and 16% to 29% of patients reported opioid-induced adverse effects. In 2 studies examining storage safety, 73% to 77% of patients reported that their prescription opioids were not stored in locked containers. All studies reported low rates of anticipated or actual disposal, but no study reported US Food and Drug Administration-recommended disposal methods in more than 9% of patients.

Conclusions and Relevance

Postoperative prescription opioids often go unused, unlocked, and undisposed, suggesting an important reservoir of opioids contributing to nonmedical use of these products, which could cause injuries or even deaths.

Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States

CONTEXT

Despite concerns about drug safety, current information on older adults' use of prescription and over-the-counter medications and dietary supplements is limited.

OBJECTIVE

To estimate the prevalence and patterns of medication use among older adults (including concurrent use), and potential major drug-drug interactions.

DESIGN, SETTING, AND PARTICIPANTS

Three thousand five community-residing individuals, aged 57 through 85 years, were drawn from a cross-sectional, nationally representative probability sample of the United States. In-home interviews, including medication logs, were administered between June 2005 and March 2006. Medication use was defined as prescription, over-the-counter, and dietary supplements used "on a regular schedule, like every day or every week." Concurrent use was defined as the regular use of at least 2 medications.

MAIN OUTCOME MEASURE

Population estimates of the prevalence of medication use, concurrent use, and potential major drug-drug interactions, stratified by age group and gender.

RESULTS

The unweighted survey response rate was 74.8% (weighted response rate, 75.5%). Eighty-one percent (95% confidence interval [CI], 79.4%-83.5%) used at least 1 prescription medication, 42% (95% CI, 39.7%-44.8%) used at least 1 over-the-counter medication, and 49% (95% CI, 46.2%-52.7%) used a dietary supplement. Twenty-nine percent (95% CI, 26.6%-30.6%) used at least 5 prescription medications concurrently; this was highest among men (37.1%; 95% CI, 31.7%-42.4%) and women (36.0%; 95% CI, 30.2%-41.9%) aged 75 to 85 years. Among prescription medication users, concurrent use of over-the-counter medications was 46% (95% CI, 43.4%-49.1%) and concurrent use of dietary supplements was 52% (95% CI, 48.8%-55.5%). Overall, 4% of individuals were potentially at risk of having a major drug-drug interaction; half of these involved the use of nonprescription medications. These regimens were most prevalent among men in the oldest age group (10%; 95% CI, 6.4%-13.7%) and nearly half involved anticoagulants. No contraindicated concurrent drug use was identified.

CONCLUSIONS

In this sample of community-dwelling older adults, prescription and nonprescription medications were commonly used together, with nearly 1 in 25 individuals potentially at risk for a major drug-drug interaction.

The abbreviated profile of hearing aid benefit

OBJECTIVE

To develop and evaluate a shortened version of the Profile of Hearing Aid Benefit, to be called the Abbreviated Profile of Hearing Aid Benefit, or APHAB.

DESIGN

The Profile of Hearing Aid Benefit (PHAB) is a 66-item self-assessment, disability-based inventory that can be used to document the outcome of a hearing aid fitting, to compare several fittings, or to evaluate the same fitting over time. Data from 128 completed PHABs were used to select items for the Abbreviated PHAB. All subjects were elderly hearing-impaired who wore conventional analog hearing aids. Statistics of score distributions and psychometric properties of each of the APHAB subscales were determined. Data from 27 similar subjects were used to examine the test-retest properties of the instrument. Finally, equal-percentile profiles were generated for unaided, aided and benefit scores obtained from successful wearers of linear hearing aids.

RESULTS

The APHAB uses a subset of 24 of the 66 items from the PHAB, scored in four 6-item subscales. Three of the subscales, Ease of Communication, Reverberation, and Background Noise address speech understanding in various everyday environments. The fourth subscale, Aversiveness of Sounds, quantifies negative reactions to environmental sounds. The APHAB typically requires 10 minutes or less to complete, and it produces scores for unaided and aided performance as well as hearing aid benefit. Test-retest correlation coefficients were found to be moderate to high and similar to those reported in the literature for other scales of similar content and length. Critical differences for each subscale taken individually were judged to be fairly large, however, smaller differences between two tests from the same individual can be significant if the three speech communication subscales are considered jointly.

CONCLUSIONS

The APHAB is a potentially valuable clinical instrument. It can be useful for quantifying the disability associated with a hearing loss and the reduction of disability that is achieved with a hearing aid.

National Trends in Ambulatory Oral Anticoagulant Use

BACKGROUND

Four direct oral anticoagulants (DOACs) have been brought to market for the treatment of nonvalvular atrial fibrillation and venous thromboembolism. Many forces, including numerous positive trial results, emerging safety concerns, marketing, and promotion, may shape DOAC adoption by providers. However, relatively little is known regarding their ambulatory utilization compared with warfarin, as well as the degree to which they have decreased under-treatment of atrial fibrillation.

METHODS

We used the IMS Health National Disease and Therapeutic Index, a nationally representative audit of outpatient office visits, to estimate the use of warfarin and DOACs between 2009 and 2014.

RESULTS

Overall, visits with anticoagulation use increased from 2.05 (95% confidence interval [CI], 1.82-2.27) to 2.83 (95% CI, 2.49-3.17) million (M) quarterly visits (P < .001). Of these, DOAC use has grown to 4.21M (95% CI, 3.63M-4.79M; 38.2% of total) treatment visits in 2014 since their introduction in 2010. Use of all oral anticoagulants in treatment visits for atrial fibrillation has increased from 0.88M (95% CI, 0.74M-1.02M) to 1.72M (95% CI, 1.47M-1.97M; P < .001), with similar DOAC and warfarin use in 2014. Atrial fibrillation visits with anticoagulant use increased from 51.9% (95% CI, 50.4%-53.8%) to 66.9% (95% CI, 65.0%-69.3%) between 2009 and 2014 (P < .001). In 2014, rivaroxaban was the most commonly prescribed DOAC for atrial fibrillation (47.9% of office visits), followed by apixaban (26.5%) and dabigatran (25.5%).

CONCLUSIONS

Direct oral anticoagulants have been adopted rapidly, matching the use of warfarin, and are associated with increased use of oral anticoagulation for patients with atrial fibrillation.

Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011

IMPORTANCE

Prescription and over-the-counter medicines and dietary supplements are commonly used, alone and together, among older adults. However, the effect of recent regulatory and market forces on these patterns is not known.

OBJECTIVES

To characterize changes in the prevalence of medication use, including concurrent use of prescription and over-the-counter medications and dietary supplements, and to quantify the frequency and types of potential major drug-drug interactions.

DESIGN, SETTING, AND PARTICIPANTS

Descriptive analyses of a longitudinal, nationally representative sample of community-dwelling older adults 62 to 85 years old. In-home interviews with direct medication inspection were conducted in 2005-2006 and again in 2010-2011. The dates of the analysis were March to November 2015. We defined medication use as the use of at least 1 prescription or over-the-counter medication or dietary supplement at least daily or weekly and defined concurrent use as the regular use of at least 2 medications. We used Micromedex to identify potential major drug-drug interactions.

MAIN OUTCOMES AND MEASURES

Population estimates of the prevalence of medication use (in aggregate and by therapeutic class), concurrent use, and major drug-drug interactions.

RESULTS

The study cohort comprised 2351 participants in 2005-2006 and 2206 in 2010-2011. Their mean age was 70.9 years in 2005-2006 and 71.4 years in 2010-2011. Fifty-three percent of participants were female in 2005-2006, and 51.6% were female in 2010-2011. The use of at least 1 prescription medication slightly increased from 84.1% in 2005-2006 to 87.7% in 2010-2011 (P = .003). Concurrent use of at least 5 prescription medications increased from 30.6% to 35.8% (P = .02). While the use of over-the-counter medications declined from 44.4% to 37.9%, the use of dietary supplements increased from 51.8% to 63.7% (P < .001 for both). There were clinically significant increases in the use of statins (33.8% to 46.2%), antiplatelets (32.8% to 43.0%), and omega-3 fish oils (4.7% to 18.6%) (P < .05 for all). In 2010-2011, approximately 15.1% of older adults were at risk for a potential major drug-drug interaction compared with an estimated 8.4% in 2005-2006 (P < .001). Most of these interacting regimens involved medications and dietary supplements increasingly used in 2010-2011.

CONCLUSIONS AND RELEVANCE

In this study, the use of prescription medications and dietary supplements, and concurrent use of interacting medications, has increased since 2005, with 15% of older adults potentially at risk for a major drug-drug interaction. Improving safety with the use of multiple medications has the potential to reduce preventable adverse drug events associated with medications commonly used among older adults.

Barriers to cadaveric renal transplantation among blacks, women, and the poor

CONTEXT

Cadaveric renal transplantation rates differ greatly by race, sex, and income. Previous efforts to lessen these differences have focused on the transplant waiting list. However, the transplantation process involves a series of steps related to medical suitability, interest in transplantation, pretransplant workup, and movement up a waiting list to eventual transplantation.

OBJECTIVE

To determine the relative importance of each step in explaining differences in cadaveric renal transplantation rates.

DESIGN

Prospective cohort study.

SETTING AND PATIENTS

A total of 7125 patients beginning long-term dialysis between January 1993 and December 1996 in Indiana, Kentucky, and Ohio.

MAIN OUTCOME MEASURES

Completion of 4 separate steps during each patient-year of follow-up: (A) being medically suitable and possibly interested in transplantation; (B) being definitely interested in transplantation; (C) completing the pretransplant workup; and (D) moving up a waiting list and receiving a transplant.

RESULTS

Compared with whites, blacks were less likely to complete steps B (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.61-0.76), C (OR, 0.56; 95% CI, 0.48-0.65), and D (OR, 0.50; 95% CI, 0.40-0.62) after adjustment for age, sex, cause of renal failure, years receiving dialysis, and median income of patient ZIP code. Compared with men, women were less likely to complete each of the 4 steps, with ORs of 0.90, 0.89, 0.80, and 0.82, respectively. Poor individuals were less likely than wealthy individuals to complete steps A, B, and C, with ORs of 0.67, 0.78, and 0.77, respectively.

CONCLUSIONS

Barriers at several steps are responsible for sociodemographic differences in access to cadaveric renal transplantation. Efforts to allocate kidneys equitably must address each step of the transplant process.

Use and Content of Primary Care Office-Based vs Telemedicine Care Visits During the COVID-19 Pandemic in the US

Importance

Little is known about the association between the coronavirus disease 2019 (COVID-19) pandemic and the level and content of primary care delivery in the US.

Objective

To quantify national changes in the volume, type, and content of primary care delivered during the COVID-19 pandemic, especially with regard to office-based vs telemedicine encounters.

Design, Setting, and Participants

Analysis of serial cross-sectional data from the IQVIA National Disease and Therapeutic Index, a 2-stage, stratified nationally representative audit of outpatient care in the US from the first calendar quarter (Q1) of 2018 to the second calendar quarter (Q2) of 2020.

Main Outcomes and Measures

Visit type (office-based or telemedicine), overall and stratified by patient population and geographic region; assessment of blood pressure or cholesterol measurement; and initiation or continuation of prescription medications.

Results

In the 8 calendar quarters between January 1, 2018, and December 31, 2019, between 122.4 million (95% CI, 117.3-127.5 million) and 130.3 million (95% CI, 124.7-135.9 million) quarterly primary care visits occurred in the US (mean, 125.8 million; 95% CI, 121.7-129.9 million), most of which were office-based (92.9%). In 2020, the total number of encounters decreased to 117.9 million (95% CI, 112.6-123.2 million) in Q1 and 99.3 million (95% CI, 94.9-103.8 million) in Q2, a decrease of 21.4% (27.0 million visits) from the average of Q2 levels during 2018 and 2019. Office-based visits decreased 50.2% (59.1 million visits) in Q2 of 2020 compared with Q2 2018-2019, while telemedicine visits increased from 1.1% of total Q2 2018-2019 visits (1.4 million quarterly visits) to 4.1% in Q1 of 2020 (4.8 million visits) and 35.3% in Q2 of 2020 (35.0 million visits). Decreases occurred in blood pressure level assessment (50.1% decrease, 44.4 million visits) and cholesterol level assessment (36.9% decrease, 10.2 million visits) in Q2 of 2020 compared with Q2 2018-2019 levels, and assessment was less common during telemedicine than during office-based visits (9.6% vs 69.7% for blood pressure; P < .001; 13.5% vs 21.6% for cholesterol; P < .001). New medication visits in Q2 of 2020 decreased by 26.0% (14.1 million visits) from Q2 2018-2019 levels. Telemedicine adoption occurred at similar rates among White individuals and Black individuals (19.3% vs 20.5% of patient visits, respectively, in Q1/Q2 of 2020), varied by region (low of 15.1% of visits [East North Central region], high of 26.8% of visits [Pacific region]), and was not correlated with regional COVID-19 burden.

Conclusions and Relevance

The COVID-19 pandemic has been associated with changes in the structure of primary care delivery, with the content of telemedicine visits differing from that of office-based encounters.

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

BACKGROUND

In comparison to warfarin, non-vitamin K antagonist oral anticoagulants (NOACs) have the advantages of ease of dosing, fewer drug interactions, and lack of need for ongoing monitoring. We sought to evaluate whether these advantages translate to improved adherence and whether adherence is associated with improved outcomes in patients with atrial fibrillation.

METHODS AND RESULTS

We performed a retrospective cohort analysis by using a large US commercial insurance database to identify 64 661 patients with atrial fibrillation who initiated warfarin, dabigatran, rivaroxaban, or apixaban treatment between November 1, 2010, and December 31, 2014. During a median of 1.1 y of follow-up, 47.5% of NOAC patients had a proportion of days covered of ≥80%, compared with 40.2% in warfarin patients (P<0.001). Patients with CHA2DS2-VASc (risk based on the presence of congestive heart failure, hypertension age 65-74 y, age ≥75 y, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, sex category) score ≥4 were at increased risk of stroke when they were not taking anticoagulation ≥1 month versus <1 week (1-3 months: hazard ratio [HR] 1.96, 3-6 months: HR 2.64, ≥6 months: HR 3.66; all P<0.001). Patients with CHA2DS2-VASc score 2 or 3 were at increased risk of stroke when they were not taking anticoagulation ≥6 months (HR 2.73, P<0.001). In these patients with CHA2DS2-VASc score ≥2, nonadherence was not associated with intracranial hemorrhage. Among patients with CHA2DS2-VASc score 0 or 1, time not taking anticoagulation was not associated with stroke, but not taking anticoagulation ≥3 months was associated with a significant reduction of bleeding.

CONCLUSIONS

Adherence to anticoagulation is poor in practice and may be modestly improved with NOACs. Adherence to therapy appears to be most important in patients with CHA2DS2-VASc score ≥2, whereas the benefits of anticoagulation may not outweigh the harms in patients with CHA2DS2-VASc score 0 or 1.

Increasing off-label use of antipsychotic medications in the United States, 1995-2008

OBJECTIVE

To evaluate patterns of antipsychotic use. DESIGN, SETTING, AND MEASUREMENTS: We used nationally representative data from the IMS Health National Disease and Therapeutic Index to describe outpatient antipsychotic use. The primary outcome was the volume of visits where antipsychotics were used for specific indications (treatment visits). We also quantified use without U.S. Food and Drug Administration approval (off-label use) and off-label use with compendium data suggesting an uncertain evidence base.

RESULTS

Antipsychotic use increased from 6.2 million (M) treatment visits (95% CI, 5.4-7.0) in 1995 to 16.7 M visits (15.5-18.2) in 2006, then declined to 14.3 M visits (13.0-15.6) by 2008. A shift occurred from typical agents in 1995 (84% of all antipsychotic visits) to atypical agents by 2008 (93%). As they declined, typical medications shifted toward use in schizophrenia (30% in 1995 to 48% 2008). In contrast, use of atypical agents expanded for bipolar affective disorder (10 to 34%), remained stable for depression (12 to 14%), and declined for schizophrenia (56 to 23%). Overall, antipsychotic use for indications without FDA approval increased from 4.4 M visits in 1995 to 9.0 M in 2008. The estimated cost associated with off-label use in 2008 was US$6.0 billion.

CONCLUSIONS

Atypical use has grown far beyond substitution for the now infrequently used typical agents. Antipsychotics are increasingly used for conditions where FDA approval and associated clinical evidence is less certain. Despite the value of innovation, the benefits of widening atypical antipsychotic use should be weighed against their cost, regulatory status, and incomplete nature of available evidence.

Patient-physician communication about out-of-pocket costs

CONTEXT

Out-of-pocket costs account for approximately one fifth of health care expenditures and are increasing. Previous research suggests that these costs are associated with medication nonadherence and considerable economic burden among some patients. Little is known about patient-physician communication regarding these costs.

OBJECTIVE

To identify patients' and physicians' beliefs and practices regarding discussions of out-of-pocket costs.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional paired surveys of 133 general internists and 484 of their outpatients, aged 18 years or older, in 3 academic and 18 community general medicine practices in the Chicago metropolitan area, March-November 2002.

MAIN OUTCOME MEASURES

Patient and physician beliefs regarding discussions of out-of-pocket costs, frequency and predictors of discussions, and physician recognition of patient burden from out-of-pocket costs.

RESULTS

Sixty-three percent of patients reported a desire to talk with their physician about their out-of-pocket costs, and 79% of physicians believed that patients in general want to discuss these costs. By contrast, only 35% of physicians and 15% of patients reported ever having discussed the study patient's out-of-pocket costs. Multivariate analysis indicated that discussions were significantly more likely to occur with patients burdened by their out-of-pocket costs (prevalence ratio [PR], 2.55; 95% confidence intervals [CI], 1.62-3.76) and with those patients seen in a community practice (PR, 5.19; CI, 1.86-8.93). Among patients burdened by out-of-pocket costs, physicians were substantially more likely to recognize this burden when a prior discussion regarding out-of-pocket costs had taken place (80% vs 51%).

CONCLUSIONS

Among respondents, both patients and physicians believed that discussions of out-of-pocket costs were important, yet these discussions occurred infrequently. Physician communication with patients about out-of-pocket costs may be an important yet neglected aspect of current clinical practice. Further research should identify the prevalence of this problem in broader populations, investigate its causes, and evaluate the impact of enhanced communication about out-of-pocket costs on patient satisfaction, utilization of care, and outcomes.

Comparative risk of gastrointestinal bleeding with dabigatran, rivaroxaban, and warfarin: population based cohort study

OBJECTIVE

To determine the real world risk of gastrointestinal bleeding associated with the use of the novel oral anticoagulants dabigatran and rivaroxaban compared with warfarin.

DESIGN

Retrospective, propensity matched cohort study.

SETTING

Optum Labs Data Warehouse, a large database including administrative claims data on privately insured and Medicare Advantage enrollees.

PARTICIPANTS

New users of dabigatran, rivaroxaban, and warfarin from 1 November 2010 to 30 September 2013.

MAIN OUTCOME MEASURES

Incidence rates (events/100 patient years) and propensity score matched Cox proportional hazards models were used to estimate rates of total gastrointestinal bleeds, upper gastrointestinal bleeds, and lower gastrointestinal bleeds for the novel oral anticoagulants compared with warfarin in patients with and without atrial fibrillation. Heterogeneity of treatment effect related to age was examined using a marginal effects model.

RESULTS

The incidence of gastrointestinal bleeding associated with dabigatran was 2.29 (95% confidence interval 1.88 to 2.79) per 100 patient years and that associated with warfarin was 2.87 (2.41 to 3.41) per 100 patient years in patients with atrial fibrillation. In non-atrial fibrillation patients, the incidence of gastrointestinal bleeding was 4.10 (2.47 to 6.80) per 100 patient years with dabigatran and 3.71 (2.16 to 6.40) per 100 patient years with warfarin. With rivaroxaban, 2.84 (2.30 to 3.52) gastrointestinal bleeding events per 100 patient years occurred in atrial fibrillation patients (warfarin 3.06 (2.49 to 3.77)/100 patient years) and 1.66 (1.23 to 2.24) per 100 patient years in non-atrial fibrillation patients (warfarin 1.57 (1.25 to 1.99)/100 patient years). In propensity score matched models, the risk of gastrointestinal bleeding with novel oral anticoagulants was similar to that with warfarin in atrial fibrillation patients (dabigatran v warfarin, hazard ratio 0.79 (0.61 to 1.03); rivaroxaban v warfarin, 0.93 (0.69 to 1.25)) and in non-AF patients (dabigatran v warfarin, hazard ratio 1.14 (0.54 to 2.39); rivaroxaban v warfarin, 0.89 (0.60 to 1.32)). The risk of gastrointestinal bleeding increased after age 65, such that by age 76 the risk exceeded that with warfarin among atrial fibrillation patients taking dabigatran (hazard ratio 2.49 (1.61 to 3.83)) and patients with and without atrial fibrillation taking rivaroxaban (2.91 (1.65 to 4.81) and 4.58 (2.40 to 8.72), respectively).

CONCLUSIONS

The risk of gastrointestinal bleeding related to novel oral anticoagulants was similar to that for warfarin. Caution should be used when prescribing novel oral anticoagulants to older people, particularly those over 75 years of age.

National trends in oral anticoagulant use in the United States, 2007 to 2011

BACKGROUND

Little is known regarding the adoption of direct thrombin inhibitors in clinical practice. We examine trends in oral anticoagulation for the prevention of thromboembolism in the United States.

METHODS AND RESULTS

We used the IMS Health National Disease and Therapeutic Index, a nationally representative audit of office-based providers, to quantify patterns of oral anticoagulant use among all subjects and stratified by clinical indication. We quantified oral anticoagulant expenditures using the IMS Health National Prescription Audit. Between 2007 and 2011, warfarin treatment visits declined from ≈2.1 million (M) quarterly visits to ≈1.6M visits. Dabigatran use increased from 0.062M quarterly visits (2010Q4) to 0.363M visits (2011Q4), reflecting its increasing share of oral anticoagulant visits from 3.1% to 18.9%. In contrast to warfarin, the majority of dabigatran visits have been for atrial fibrillation, though this proportion decreased from 92% (2010Q4) to 63% (2011Q4), with concomitant increases in dabigatran's off-label use. Among atrial fibrillation visits, warfarin use decreased from 55.8% visits (2010Q4) to 44.4% (2011Q4), whereas dabigatran use increased from 4.0% to 16.9%. Of atrial fibrillation visits, the fraction not treated with any oral anticoagulants has remained unchanged at ≈40%. Expenditures related to dabigatran increased rapidly from $16M in 2010Q4 to $166M in 2011Q4, exceeding expenditures on warfarin ($144M) in 2011Q4.

CONCLUSIONS

Dabigatran has been rapidly adopted into ambulatory practice in the United States, primarily for treatment of atrial fibrillation, but increasingly for off-label indications. We did not find evidence that it has increased overall atrial fibrillation treatment rates.

An Epidemic in the Midst of a Pandemic: Opioid Use Disorder and COVID-19

The COVID-19 pandemic is a particularly grave risk to the millions of Americans with opioid use disorder, who—already vulnerable and marginalized—are heavily dependent on face-to-face health care delivery. These authors propose rapid and coordinated action on the part of clinicians and policymakers to mitigate risks of disrupted care for these patients.

Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010

BACKGROUND

Escalating rates of prescription opioid use and abuse have occurred in the context of efforts to improve the treatment of nonmalignant pain.

OBJECTIVE

The aim of the study was to characterize the diagnosis and management of nonmalignant pain in ambulatory, office-based settings in the United States between 2000 and 2010.

DESIGN, SETTING, AND PARTICIPANTS

Serial cross-sectional and multivariate regression analyses of the National Ambulatory Medical Care Survey (NAMCS), a nationally representative audit of office-based physician visits, were conducted.

MEASURES

(1) Annual visit volume among adults with primary pain symptom or diagnosis; (2) receipt of any pain treatment; and (3) receipt of prescription opioid or nonopioid pharmacologic therapy in visits for new musculoskeletal pain.

RESULTS

Primary symptoms or diagnoses of pain consistently represented one-fifth of visits, varying little from 2000 to 2010. Among all pain visits, opioid prescribing nearly doubled from 11.3% to 19.6%, whereas nonopioid analgesic prescribing remained unchanged (26%-29% of visits). One-half of new musculoskeletal pain visits resulted in pharmacologic treatment, although the prescribing of nonopioid pharmacotherapies decreased from 38% of visits (2000) to 29% of visits (2010). After adjusting for potentially confounding covariates, few patient, physician, or practice characteristics were associated with a prescription opioid rather than a nonopioid analgesic for new musculoskeletal pain, and increases in opioid prescribing generally occurred nonselectively over time.

CONCLUSIONS

Increased opioid prescribing has not been accompanied by similar increases in nonopioid analgesics or the proportion of ambulatory pain patients receiving pharmacologic treatment. Clinical alternatives to prescription opioids may be underutilized as a means of treating ambulatory nonmalignant pain.

Outpatient Hypertension Treatment, Treatment Intensification, and Control in Western Europe and the United States

BACKGROUND

Hypertension guidelines in the United States tend to have more aggressive treatment recommendations than those in European countries.

METHODS

To explore international differences in hypertension treatment, treatment intensification, and hypertension control in western Europe and the United States, we conducted cross-sectional analyses of the nationally representative CardioMonitor 2004 survey, which included 21 053 hypertensive patients visiting 291 cardiologists and 1284 primary care physicians in 5 western European countries and the United States. The main outcome measures were latest systolic and diastolic blood pressure (BP) levels, hypertension control (latest BP level, <140/90 mm Hg), and medication increase (dose escalation or an addition to or switch of drug therapy) for inadequately controlled hypertension.

RESULTS

At least 92% of patients in each country received antihypertensive drug treatment. The initial pretreatment BP levels were lowest and the use of combination drug therapy (>or=2 antihypertensive drug classes) was highest in the United States. Multivariate analyses controlling for age, sex, current smoking, and physician specialty indicated that, compared with US patients, European patients had higher latest systolic BP levels (by 5.3-10.2 mm Hg across countries examined) and diastolic BP levels (by 1.9-5.3 mm Hg), a smaller likelihood of hypertension control (odds ratios, 0.27-0.50), and a smaller likelihood of medication increase for inadequately controlled hypertension (odds ratios, 0.29-0.65) (all P<.001). In addition, controlling for initial pretreatment BP level attenuated the differences in latest systolic and diastolic BP levels and the likelihood of hypertension control.

CONCLUSION

Lower treatment thresholds and more intensive treatment contribute to better hypertension control in the United States compared with the western European countries studied.

Estimated Costs of Pivotal Trials for Novel Therapeutic Agents Approved by the US Food and Drug Administration, 2015-2016

IMPORTANCE

A critical question in health care is the extent of scientific evidence that should be required to establish that a new therapeutic agent has benefits that outweigh its risks. Estimating the costs of this evidence of efficacy provides an important perspective.

OBJECTIVE

To estimate costs and assess scientific characteristics of pivotal efficacy trials that supported the approval of new therapeutic agents by the US Food and Drug Administration (FDA) from 2015 to 2016.

DESIGN AND SETTING

This study identified 59 novel therapeutic drugs using the annual summary reports from the FDA Center for Drug Evaluation and Research. ClinicalTrials.gov, FDA reviews, and peer-reviewed publications that were publicly available in 2017 were used to identify 52 characteristics of each efficacy trial. Costs were calculated with a global clinical trial cost assessment tool available to contract research organizations and pharmaceutical sponsors.

MAIN OUTCOMES AND MEASURES

Estimated mean cost and 95% CIs based on industry benchmark data from 60 countries. Measures of trials' scientific characteristics included trial design (no control group, placebo, and active drug), end point (surrogate outcome, clinical scale, and clinical outcome), patient enrollment, and treatment duration.

RESULTS

A total of 138 pivotal clinical trials provided the basis for approval of 59 new therapeutic agents by the FDA from 2015 to 2016, with a median estimated cost of $19.0 million (interquartile range, $12.2 million-$33.1 million). Estimated costs ranged from less than $5 million for trials without a control group for 3 orphan drugs with fewer than 15 patients each to $346.8 million (95% CI, $252.0 million-$441.5 million) for a noninferiority trial with end points assessing clinical benefit. Twenty-six of 138 trials (18.8%) were uncontrolled, with a mean estimated cost of $13.5 million (95% CI, $10.1 million-$16.9 million). Trials designed with placebo or active drug comparators had an estimated mean cost of $35.1 million (95% CI, $25.4 million-$44.8 million). Costs also varied by trial end point, treatment duration, patient enrollment, and therapeutic area.

CONCLUSIONS AND RELEVANCE

The highest-cost trials were those in which the new agent had to be proved to be noninferior with clinical benefit end points compared with an agent already available or those that required larger patient populations to achieve statistical power to document smaller treatment effects or accrue infrequently occurring end points.

Measuring Satisfaction with Amplification in Daily Life: the SADL scale

OBJECTIVE

To develop a self-report inventory to quantify satisfaction with hearing aids.

DESIGN

The inventory was developed in several stages. To determine the elements that are most important to satisfaction for most people, we conducted structured interviews and then designed a questionnaire. Hearing aid owners responded to the questionnaire, indicating the relative importance of 14 different elements in their hearing aid satisfaction. Analyses indicated that the elements could be placed into four importance content areas. Trial satisfaction items were designed for each content area and submitted to focus groups to identify highly salient items as well as ambiguous items. A 25-item satisfaction questionnaire then was developed and disseminated to hearing aid owners. Results were obtained from 257 individuals. These data were analyzed to generate the final questionnaire.

RESULTS

Fifteen items, divided into four subscales, were selected for the final Satisfaction with Amplification in Daily Life (SADL) questionnaire. The questionnaire yields a Global satisfaction score and a profile of subscale scores, which address Positive Effects, Service and Cost, Negative Features, and Personal Image. A preliminary evaluation of retest stability was conducted with 104 subjects. Ninety percent critical differences for the various scores ranged from 0.9 to 2.0 score intervals on a 7 point scale.

CONCLUSIONS

The SADL scale is both brief enough to be clinically acceptable and comprehensive enough to provide a valid assessment of an inherently multidimensional variable. Additional assessment is necessary to refine understanding of its test-retest properties, explore validity issues, and determine clinical, research, and administrative applications of the data.

Effect of Florida's Prescription Drug Monitoring Program and Pill Mill Laws on Opioid Prescribing and Use

IMPORTANCE

Prescription Drug Monitoring Program (PDMP) and pill mill laws are among the principal means states use to reduce prescription drug abuse and diversion, yet little high-quality evidence exists regarding their effect.

OBJECTIVE

To quantify the effect of Florida's PDMP and pill mill laws on overall and high-risk opioid prescribing and use.

DESIGN, SETTING, AND PARTICIPANTS

We applied comparative interrupted time-series analyses to IMS Health LifeLink LRx data to characterize the effect of PDMP and pill mill law implementation on a closed cohort of prescribers, retail pharmacies, and patients from July 2010 through September 2012 in Florida (intervention state) compared with Georgia (control state). We conducted sensitivity analyses, including varying length of observation and modifying requirements for continuous observation of individuals throughout the study period.

MAIN OUTCOMES AND MEASURES

Total opioid volume, mean morphine milligram equivalent (MME) per transaction, mean days' supply per transaction, and total number of opioid prescriptions dispensed. Analyses were conducted per prescriber and per patient, in aggregate and after stratifying by volume of baseline opioid prescribing for prescribers and use for patients.

RESULTS

From July 2010 through September 2012, a cohort of 2.6 million patients, 431,890 prescribers, and 2829 pharmacies was associated with approximately 480 million prescriptions in Florida and Georgia, 7.7% of which were for opioids. Total monthly opioid volume, MME per transaction, days' supply, and prescriptions dispensed were higher in Florida than Georgia before implementation. Florida's laws were associated with statistically significant declines in opioid volume (2.5 kg/mo, P<.05; equivalent to approximately 500,000 5-mg tablets of hydrocodone bitartrate per month) and MME per transaction (0.45 mg/mo, P<.05), without any change in days' supply. Twelve months after implementation, the policies were associated with approximately a 1.4% decrease in opioid prescriptions, 2.5% decrease in opioid volume, and 5.6% decrease in MME per transaction. Reductions were limited to prescribers and patients with the highest baseline opioid prescribing and use. Sensitivity analyses, varying time windows, and enrollment criteria supported the main results.

CONCLUSIONS AND RELEVANCE

Florida's PDMP and pill mill laws were associated with modest decreases in opioid prescribing and use. Decreases were greatest among prescribers and patients with the highest baseline opioid prescribing and use.

National trends in treatment of type 2 diabetes mellitus, 1994-2007

BACKGROUND

Diabetes mellitus is common, costly, and increasingly prevalent. Despite innovations in therapy, little is known about patterns and costs of drug treatment.

METHODS

We used the National Disease and Therapeutic Index to analyze medications prescribed between 1994 and 2007 for all US office visits among patients 35 years and older with type 2 diabetes. We used the National Prescription Audit to assess medication costs between 2001 and 2007.

RESULTS

The estimated number of patient visits for treated diabetes increased from 25 million (95% confidence interval [CI], 23 million to 27 million) in 1994 to 36 million (95% CI, 34 million to 38 million) by 2007. The mean number of diabetes medications per treated patient increased from 1.14 (95% CI, 1.06-1.22) in 1994 to 1.63 (1.54-1.72) in 2007. Monotherapy declined from 82% (95% CI, 75%-89%) of visits during which a treatment was used in 1994 to 47% (43%-51%) in 2007. Insulin use decreased from 38% of treatment visits in 1994 to a nadir of 25% in 2000 and then increased to 28% in 2007. Sulfonylurea use decreased from 67% of treatment visits in 1994 to 34% in 2007. By 2007, biguanides (54% of treatment visits) and glitazones (thiazolidinediones) (28%) were leading therapeutic classes. Increasing use of glitazones, newer insulins, sitagliptin phosphate, and exenatide largely accounted for recent increases in the mean cost per prescription ($56 in 2001 to $76 in 2007) and aggregate drug expenditures ($6.7 billion in 2001 to $12.5 billion in 2007).

CONCLUSIONS

Increasingly complex and costly diabetes treatments are being applied to an increasing population. The magnitude of these rapid changes raises concerns about whether these more costly therapies will result in proportionately improved outcomes.

Trends and Variation in Oral Anticoagulant Choice in Patients with Atrial Fibrillation, 2010-2017

OBJECTIVE

Since 2010, several non-vitamin K antagonist oral anticoagulants (NOACs) have been brought to the U.S. market, yet little is known regarding their evolving adoption for prophylaxis of atrial fibrillation (AF)-related stroke. We examined temporal trends in choice of oral anticoagulants (OACs) among incident OAC users with AF and its association with patient demographic and clinical characteristics.

METHODS

We conducted a serial cross-sectional analysis of medical and pharmacy claims for commercial and Medicare Advantage enrollees in a large, private, U.S. health plan. We identified 112,187 adults with nonvalvular AF starting OACs between October 2010 and March 2017. Multivariable logistic regression was used to examine the associations of patient characteristics with prescription of NOACs versus warfarin. Multinomial logistic regression was used to test the associations of patient characteristics with choice among NOACs.

RESULTS

The prescription of NOACs has increased dramatically since their introduction in October 2010. In the first quarter of 2017 (2017Q1), 7502 patients started OACs, of whom 78.9% used NOACs and 21.1% warfarin. For NOACs, 3.8% used dabigatran, 25.0% rivaroxaban, and 50.1% apixaban. In multivariable analyses, factors associated with choice of NOACs versus warfarin included younger age, lower stroke or bleeding risk, fewer comorbidities, higher education level or household net worth, and prescription by cardiologists (all p<0.001). There was no sex difference in likelihood of filling NOACs versus warfarin in 2010Q4-2012, but women had higher odds of starting NOACs (odds ratio = 1.19; 95% confidence interval = 1.14-1.25) in 2015-2017Q1. Among NOAC users, the odds of apixaban prescription increased with age, female sex, stroke or bleeding risk, and comorbidities (all p<0.05).

CONCLUSION

NOAC prescriptions have increased substantially among incident OAC users with nonvalvular AF, predominantly driven by increased prescription of apixaban. Warfarin and apixaban were generally preferred for elderly patients, patients with higher stroke or bleeding risk, and patients with more comorbidities.

Impact of FDA drug risk communications on health care utilization and health behaviors: a systematic review

OBJECTIVE

To review literature on the impact of The Food and Drug Administration (FDA) drug risk communications on medication utilization, health care services use, and health outcomes.

DATA SOURCES

The authors searched MEDLINE and the Web of Science for manuscripts published between January 1990 and November 2010 that included terms related to drug utilization, the FDA, and advisories or warnings. We manually searched bibliographies and works citing selected articles and consulted with experts to guide study selection.

STUDY SELECTION

Studies were included if they involved an empirical analysis evaluating the impact of an FDA risk communication.

DATA EXTRACTION

We extracted the drug(s) analyzed, relevant FDA communication(s), data source, analytical method, and main outcome(s) assessed.

RESULTS

Of the 1432 records screened, 49 studies were included. These studies covered 16 medicines or therapeutic classes; one third examined communications regarding antidepressants. Most used medical or pharmacy claims and a few rigorously examined patient-provider communication, decision making, or risk perceptions. Advisories recommending increased clinical or laboratory monitoring generally led to decreased drug use, but only modest, short-term increases in monitoring. Communications targeting specific subpopulations often spilled over to other groups. Repeated or sequential advisories tended to have larger but delayed effects and decreased incident more than prevalent use. Drug-specific warnings were associated with particularly large decreases in utilization, although the magnitude of substitution within therapeutic classes varied across clinical contexts.

CONCLUSIONS

Although some FDA drug risk communications had immediate and strong impacts, many had either delayed or had no impact on health care utilization or health behaviors. These data demonstrate the complexity of using risk communication to improve the quality and safety of prescription drug use, and suggest the importance of continued assessments of the effect of future advisories and label changes. Identifying factors that are associated with rapid and sustained responses to risk communications will be important for informing future risk communication efforts.

Impact of FDA black box advisory on antipsychotic medication use

BACKGROUND

In April 2005, the US Food and Drug Administration (FDA) issued an advisory and subsequent black box warning regarding the risks of atypical anti psychotic use among elderly patients with dementia. The impact of these warnings on atypical drug use is unknown.

METHODS

We used quasi-experimental, interrupted time-series analyses to examine nationally representative data from IMS Health's National Disease and Therapeutic Index from January 2003 through December 2008. The primary measurement from this audit of office-based physicians was the use of an atypical antipsychotic agent. We quantified the impact of the advisory on atypical antipsychotic use among all individuals and those 65 years or older with dementia.

RESULTS

From January 2003 to March 2005, mentions of total atypical antipsychotic drugs increased at an annual rate of 34%, and among patients with dementia, 16%. In the year prior to the FDA advisory, there were approximately 13.6 million atypical drug mentions, including 0.8 million among those with dementia. In the year following the advisory, atypical drug mentions fell 2% overall and 19% among those with dementia. In 2004, 19% (0.8 of 4.1 million) of drug mentions for dementia were for an atypical agent. By 2008, this proportion decreased to 9% (0.4 of 4.3 million). Atypical drug use slowed for both FDA-approved and off-label indications and declined through 2008 for all populations examined.

CONCLUSION

The FDA advisory was associated with decreases in the use of atypical antipsychotics, especially among elderly patients with dementia.