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Daubresse M, Alexander GC, Crews DC, Segev DL, Lentine KL, McAdams-DeMarco MA. High-dose opioid utilization and mortality among individuals initiating hemodialysis. BMC Nephrol 2021; 22:65. [PMID: 33622271 PMCID: PMC7901089 DOI: 10.1186/s12882-021-02266-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 02/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Individuals undergoing hemodialysis in the United States frequently report pain and receive three-fold more opioid prescriptions than the general population. While opioid use is appropriate for select patients, high-dose utilization may contribute to an increased risk of death due to possible accumulation of opioid metabolites. METHODS We studied high-dose opioid utilization (≥120 morphine milligram equivalents [MME] per day) among adults initiating hemodialysis in the United States between 2007 and 2014 using national registry data. We calculated the cumulative incidence (%) of high-dose utilization and depicted trends in the average percentage of days individuals were exposed to opioids. We used adjusted Cox proportional hazards models to identify which opioid doses were associated with mortality. RESULTS Among 327,344 adults undergoing hemodialysis, the cumulative incidence of high-dose utilization was 14.9% at 2 years after initiating hemodialysis. Among patients with ≥1 opioid prescription during follow-up, the average percentage of days exposed to high-dose utilization increased from 13.9% in 2007 to 26.1% in 2014. Compared to 0MME per day, doses < 60MME were not associated with an increased risk of mortality, but high-dose utilization was associated with a 1.63-fold (95% CI, 1.57, 1.69) increased risk of mortality. The risk of mortality associated with opioid dose was highest in the first year after hemodialysis initiation. CONCLUSIONS The risk of mortality associated with opioid utilization among individuals on hemodialysis increases as doses exceed 60MME per day and is greatest during periods of high-dose utilization. Patients and clinicians should carefully weigh the risks and benefits of opioid doses exceeding 60MME per day.
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Affiliation(s)
- Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA
- Division of Surgery, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Krista L Lentine
- Division of Nephrology, Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Mara A McAdams-DeMarco
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA.
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA.
- Division of Surgery, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Muzaale AD, Daubresse M, Bae S, Chu NM, Lentine KL, Segev DL, McAdams-DeMarco M. Benzodiazepines, Codispensed Opioids, and Mortality among Patients Initiating Long-Term In-Center Hemodialysis. Clin J Am Soc Nephrol 2020; 15:794-804. [PMID: 32457228 PMCID: PMC7274292 DOI: 10.2215/cjn.13341019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Mortality from benzodiazepine/opioid interactions is a growing concern in light of the opioid epidemic. Patients on hemodialysis suffer from a high burden of physical/psychiatric conditions, which are treated with benzodiazepines, and they are three times more likely to be prescribed opioids than the general population. Therefore, we studied mortality risk associated with short- and long-acting benzodiazepines and their interaction with opioids among adults initiating hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The cohort of 69,368 adults initiating hemodialysis (January 2013 to December 2014) was assembled by linking US Renal Data System records to Medicare claims. Medicare claims were used to identify dispensed benzodiazepines and opioids. Using adjusted Cox proportional hazards models, we estimated the mortality risk associated with benzodiazepines (time varying) and tested whether the benzodiazepine-related mortality risk differed by opioid codispensing. RESULTS Within 1 year of hemodialysis initiation, 10,854 (16%) patients were dispensed a short-acting benzodiazepine, and 3262 (5%) patients were dispensed a long-acting benzodiazepine. Among those who were dispensed a benzodiazepine during follow-up, codispensing of opioids and short-acting benzodiazepines occurred among 3819 (26%) patients, and codispensing of opioids and long-acting benzodiazepines occurred among 1238 (8%) patients. Patients with an opioid prescription were more likely to be subsequently dispensed a short-acting benzodiazepine (adjusted hazard ratio, 1.66; 95% confidence interval, 1.59 to 1.74) or a long-acting benzodiazepine (adjusted hazard ratio, 1.11; 95% confidence interval, 1.03 to 1.20). Patients dispensed a short-acting benzodiazepine were at a 1.45-fold (95% confidence interval, 1.35 to 1.56) higher mortality risk compared with those without a short-acting benzodiazepine; among those with opioid codispensing, this risk was 1.90-fold (95% confidence interval, 1.65 to 2.18; Pinteraction<0.001). In contrast, long-acting benzodiazepine dispensing was inversely associated with mortality (adjusted hazard ratio, 0.84; 95% confidence interval, 0.72 to 0.99) compared with no dispensing of long-acting benzodiazepine; there was no differential risk by opioid dispensing (Pinteraction=0.72). CONCLUSIONS Codispensing of opioids and short-acting benzodiazepines is common among patients on dialysis, and it is associated with higher risk of death.
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Affiliation(s)
- Abimereki D. Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sunjae Bae
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Krista L. Lentine
- Department of Medicine, St. Louis University School of Medicine, St. Louis, Missouri
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Segal JB, Onasanya O, Daubresse M, Lee CY, Moechtar M, Pu X, Dutcher SK, Romanelli RJ. Determinants of Generic Drug Substitution in the United States. Ther Innov Regul Sci 2019. [DOI: 10.1177/2168479018820050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jodi B. Segal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Oluwadamilola Onasanya
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chia-Ying Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mischka Moechtar
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Xia Pu
- Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Sarah K. Dutcher
- Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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Daubresse M, Alexander GC, Crews DC, Segev DL, McAdams-DeMarco MA. Trends in Opioid Prescribing Among Hemodialysis Patients, 2007-2014. Am J Nephrol 2018; 49:20-31. [PMID: 30544114 PMCID: PMC6341485 DOI: 10.1159/000495353] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/08/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Hemodialysis (HD) patients frequently experience pain. Previous studies of HD patients suggest increased opioid prescribing through 2010. It remains unclear if this trend continued after 2010 or declined with national trends. METHODS Longitudinal cohort study of 484,745 HD patients in the United States Renal Data System/Medicare data. We used Poisson/negative binomial regression to estimate annual incidence rates of opioid prescribing between 2007 and 2014. We compared prescribing rates with the general US population using IQVIA's National Prescription Audit data. Outcomes included the following: percent of HD patients receiving an opioid prescription, rate of opioid prescriptions, quantity, days supply, morphine milligram equivalents (MME) dispensed per 100 person-days, and prescriptions per person. RESULTS In 2007, 62.4% of HD patients received an opioid prescription. This increased to 63.2% in 2010 then declined to 53.7% by 2014. Opioid quantity peaked in 2011 at 73.5 pills per 100 person-days and declined to 62.6 pills per 100 person-days in 2014. MME peaked between 2010 and 2012 then declined through 2014. In 2014, MME rates were 1.8-fold higher among non-Hispanic patients and 1.6-fold higher among low-income patients. HD patients received 3.2-fold more opioid prescriptions per person compared to the general US population and were primarily prescribed oxycodone and hydrocodone. Between 2012 and 2014, HD patients experienced greater declines in opioid prescriptions per person (18.2%) compared to the general US population (7.1%). CONCLUSION Opioid prescribing among HD patients declined between 2012 and 2014. However, HD patients continue receiving substantially more opioids than the general US population.
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Affiliation(s)
- Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dorry L Segev
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Surgery, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mara A McAdams-DeMarco
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA,
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland, USA,
- Division of Surgery, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
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McAdams-DeMarco MA, Daubresse M, Bae S, Gross AL, Carlson MC, Segev DL. Dementia, Alzheimer's Disease, and Mortality after Hemodialysis Initiation. Clin J Am Soc Nephrol 2018; 13:1339-1347. [PMID: 30093374 PMCID: PMC6140560 DOI: 10.2215/cjn.10150917] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 06/04/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Older patients with ESKD experience rapid declines in executive function after initiating hemodialysis; these impairments might lead to high rates of dementia and Alzheimer's disease in this population. We estimated incidence, risk factors, and sequelae of diagnosis with dementia and Alzheimer's disease among older patients with ESKD initiating hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied 356,668 older (age ≥66 years old) patients on hemodialysis (January 1, 2001 to December 31, 2013) from national registry data (US Renal Data System) linked to Medicare. We estimated the risk (cumulative incidence) of diagnosis of dementia and Alzheimer's disease and studied factors associated with these disorders using competing risks models to account for death, change in dialysis modality, and kidney transplant. We estimated the risk of subsequent mortality using Cox proportional hazards models. RESULTS The 1- and 5-year risks of diagnosed dementia accounting for competing risks were 4.6% and 16% for women, respectively, and 3.7% and 13% for men, respectively. The corresponding Alzheimer's disease diagnosis risks were 0.6% and 2.6% for women, respectively, and 0.4% and 2.0% for men, respectively. The strongest independent risk factors for diagnosis of dementia and Alzheimer's disease were age ≥86 years old (dementia: hazard ratio, 2.11; 95% confidence interval, 2.04 to 2.18; Alzheimer's disease: hazard ratio, 2.11; 95% confidence interval, 1.97 to 2.25), black race (dementia: hazard ratio, 1.70; 95% confidence interval, 1.67 to 1.73; Alzheimer's disease: hazard ratio, 1.78; 95% confidence interval, 1.71 to 1.85), women (dementia: hazard ratio, 1.10; 95% confidence interval, 1.08 to 1.12; Alzheimer's disease: hazard ratio, 1.12; 95% confidence interval, 1.08 to 1.16), and institutionalization (dementia: hazard ratio, 1.36; 95% confidence interval, 1.33 to 1.39; Alzheimer's disease: hazard ratio, 1.10; 95% confidence interval, 1.05 to 1.15). Older patients on hemodialysis with a diagnosis of dementia were at 2.14-fold (95% confidence interval, 2.07 to 2.22) higher risk of subsequent mortality; those with a diagnosis of Alzheimer's disease were at 2.01-fold (95% confidence interval, 1.89 to 2.15) higher mortality risk. CONCLUSIONS Older patients on hemodialysis are at substantial risk of diagnosis with dementia and Alzheimer's disease, and carrying these diagnoses is associated with a twofold higher mortality.
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Affiliation(s)
- Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Epidemiology and
| | | | - Sunjae Bae
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alden L. Gross
- Departments of Epidemiology and
- Johns Hopkins University Center on Aging and Health, Baltimore, Maryland
| | - Michelle C. Carlson
- Mental Health, Bloomberg School of Public Health, Baltimore, Maryland; and
- Johns Hopkins University Center on Aging and Health, Baltimore, Maryland
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Epidemiology and
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Abstract
BACKGROUND Buprenorphine-naloxone treatment for opioid use disorder has rapidly expanded, yet little is known about treatment outcomes among patients in the general population. OBJECTIVE To examine predictors of treatment duration, dosage, and continuity in a diverse community setting. RESEARCH DESIGN We examined QuintilesIMS Real World Data, an all-payer, pharmacy claims database, to conduct an analysis of individuals age 18 years and above initiating buprenorphine-naloxone treatment between January 2010 and July 2012 in 11 states. We used logistic regression to assess treatment duration longer than 6 months. We used accelerated failure time models to assess risk of treatment discontinuation. We used ordinary least squares regression to assess mean daily dosage. For patients with ≥3 fills, we also used logistic regression to assess whether ;an individual had a medication possession ratio of <80% and/or gaps in treatment >14 days. Models adjusted for individual demographics, prescribing physician specialty, state, and county-level variables. RESULTS Overall, 41% of individuals were retained in treatment for at least 6 months and the mean treatment length was 266 days. Compared with individuals who paid primarily for treatment with cash, adjusted odds of 6 month retention were significantly lower for individuals with primary payment from Medicaid fee-for-service, Medicare part D, and third-party commercial. There were substantial differences in 6-month retention across states with the lowest in Arizona and highest in New York. Low-possession ratios occurred for 30% of individuals and 26% experienced treatment episodes with gaps >14 days. Odds of low-possession and treatment gaps were largely similar across demographic groups and geographic areas. CONCLUSIONS Current initiatives to improve access and quality of buprenorphine-naloxone treatment should examine geographic barriers as well as the potential role of insurance benefit design in restricting treatment length.
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Affiliation(s)
- Brendan Saloner
- *Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health †Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore ‡Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health §Department of Medicine, Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD
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Daubresse M, Saloner B, Pollack HA, Alexander GC. Non-buprenorphine opioid utilization among patients using buprenorphine. Addiction 2017; 112:1045-1053. [PMID: 28107580 DOI: 10.1111/add.13762] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/19/2016] [Accepted: 01/19/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Buprenorphine is commonly used to treat opioid use disorder; however, non-buprenorphine prescription opioid use among these patients is not well defined. We sought to estimate the prevalence of non-buprenorphine opioid use among incident buprenorphine users and quantify levels of opioid use prior to, during and after the first treatment episode. DESIGN We used QuintilesIMS anonymized, individual-level, all-payer pharmacy claims to identify incident users of buprenorphine between January 2010 and July 2012 from a large cohort of approximately 50 million patients filling two or more prescriptions for any opioid during any calendar year between 2006 and 2013 in 11 states of interest. SETTING Eleven states within the United States. PARTICIPANTS Of the individuals who met our inclusion criteria (n = 38 096), 55% were female and half were aged between 29 and 54 years. Median length of the first treatment episode was 55 days [interquartile range (IQR) = 28-168 days]. MEASUREMENTS We calculated four measures of non-buprenorphine opioid use: (1) number of prescriptions, (2) quantity dispensed, (3) days of supply and (4) total morphine milligram equivalents (MME) before, during and after the first treatment episode. Our primary outcome was the MME per opioid day supplied during each time period. FINDINGS Approximately two-fifths (43%) of buprenorphine recipients filled an opioid prescription during the treatment episode and two-thirds (67%) filled an opioid prescription following treatment. The mean total of MME per opioid day supplied 12 months prior to treatment declined from 57 mg/per day [95% confidence interval (CI) = 57, 58] to 54 mg/per day (95% CI = 54, 55) during the treatment episode, then remained constant at 55 mg/per day (95% CI = 54, 56) following the treatment episode. CONCLUSIONS The use of buprenorphine for the treatment of opioid use disorder has increased markedly in the United States. However, a substantial proportion of patients fill prescriptions for non-buprenorphine opioids during and following such treatment.
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Affiliation(s)
- Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Harold A Pollack
- School of Social Service Administration, University of Chicago, Chicago, IL, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA.,Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
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Daubresse M, Andersen M, Riggs KR, Alexander GC. Effect of Prescription Drug Coupons on Statin Utilization and Expenditures: A Retrospective Cohort Study. Pharmacotherapy 2016; 37:12-24. [PMID: 27455456 DOI: 10.1002/phar.1802] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
IMPORTANCE Drug coupons are widely used, but their effects are not well understood. OBJECTIVE To quantify the effect of coupons on statin use and expenditures. DESIGN Retrospective cohort analysis of IMS Health LRx LifeLink database. SETTING U.S. retail pharmacy transactions. PARTICIPANTS Incident statin users who initiated branded atorvastatin or rosuvastatin between June 2006 and February 2013. MAIN OUTCOMES AND MEASURES Monthly statin utilization (pill-days of therapy), switching (filling a different statin), termination (failure to refill statin for 6 mo), and out-of-pocket and total costs. RESULTS Of 1.1 million incident atorvastatin and rosuvastatin users, 2% used a coupon for at least one statin fill. At 1 year, compared with noncoupon users, those who used a statin coupon on their first fill were dispensed an equal number of monthly pill-days (23.7 vs 23.8), were less likely to switch statins (14.4% vs 16.3%), and were less likely to have terminated statin therapy (31.3% vs 39.2%). At 4 years, coupon users were more likely to have switched (45.5% vs 40.8%) and less likely to have terminated statin therapy (50.6% vs 61.1%) compared with noncoupon users. Those who used greater numbers of coupons were substantially less likely to switch and terminate statin therapies. Monthly out-of-pocket costs were lower among coupon than noncoupon users at 1 year ($9.7 vs $15.1), but total monthly costs were qualitatively similar ($115.5 vs $116.9). At 4 years, monthly out-of-pocket costs among coupon users remained lower ($14.3 vs $16.6) compared with noncoupon users. Sensitivity analyses supported the main results. CONCLUSIONS Coupons for branded statins are associated with higher utilization and lower rates of discontinuation and short-term switching to other statin products.
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Affiliation(s)
- Matthew Daubresse
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Martin Andersen
- Department of Economics, University of North Carolina at Greensboro, Greensboro, North Carolina
| | - Kevin R Riggs
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland.,Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, Maryland.,Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, Maryland
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Lyapustina T, Rutkow L, Chang HY, Daubresse M, Ramji AF, Faul M, Stuart EA, Alexander GC. Effect of a "pill mill" law on opioid prescribing and utilization: The case of Texas. Drug Alcohol Depend 2016; 159:190-7. [PMID: 26778760 PMCID: PMC4976392 DOI: 10.1016/j.drugalcdep.2015.12.025] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 12/09/2015] [Accepted: 12/17/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND States have attempted to reduce prescription opioid abuse through strengthening the regulation of pain management clinics; however, the effect of such measures remains unclear. We quantified the impact of Texas's September 2010 "pill mill" law on opioid prescribing and utilization. METHODS We used the IMS Health LRx LifeLink database to examine anonymized, patient-level pharmacy claims for a closed cohort of individuals filling prescription opioids in Texas between September 2009 and August 2011. Our primary outcomes were derived at a monthly level and included: (1) average morphine equivalent dose (MED) per transaction; (2) aggregate opioid volume; (3) number of opioid prescriptions; and (4) quantity of opioid pills dispensed. We compared observed values with the counterfactual, which we estimated from pre-intervention levels and trends. RESULTS Texas's pill mill law was associated with declines in average MED per transaction (-0.57 mg/month, 95% confidence interval [CI] -1.09, -0.057), monthly opioid volume (-9.99 kg/month, CI -12.86, -7.11), monthly number of opioid prescriptions (-12,200 prescriptions/month, CI -15,300, -9,150) and monthly quantity of opioid pills dispensed (-714,000 pills/month, CI -877,000, -550,000). These reductions reflected decreases of 8.1-24.3% across the outcomes at one year compared with the counterfactual, and they were concentrated among prescribers and patients with the highest opioid prescribing and utilization at baseline. CONCLUSIONS Following the implementation of Texas's 2010 pill mill law, there were clinically significant reductions in opioid dose, volume, prescriptions and pills dispensed within the state, which were limited to individuals with higher levels of baseline opioid prescribing and utilization.
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Affiliation(s)
- Tatyana Lyapustina
- Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD 21205, United States.
| | - Lainie Rutkow
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, 624 N. Broadway St., Baltimore, MD 21205, United States
| | - Hsien-Yen Chang
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, 624 N. Broadway St., Baltimore, MD 21205, United States
| | - Matthew Daubresse
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N Wolfe St. W6027, Baltimore, MD 21205, United States,Johns Hopkins Bloomberg School of Public Health, Center for Drug Safety and Effectiveness, 615 N Wolfe St. W6035, Baltimore, MD 21205, United States
| | - Alim F. Ramji
- Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD 21205, United States
| | - Mark Faul
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 4770 Buford Hwy, NE Mail Stop MS F-63 Atlanta, GA 30341-3717, United States
| | - Elizabeth A. Stuart
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, 624 N. Broadway St., Baltimore, MD 21205, United States,Johns Hopkins Bloomberg School of Public Health, Department of Mental Health, Hampton House, 624 N. Broadway, 8th Floor, Baltimore, MD 21205, United States,Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics, 615 N. Wolfe St., Baltimore, MD 21205, United States
| | - G. Caleb Alexander
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N Wolfe St. W6027, Baltimore, MD 21205, United States,Johns Hopkins Bloomberg School of Public Health, Center for Drug Safety and Effectiveness, 615 N Wolfe St. W6035, Baltimore, MD 21205, United States,Johns Hopkins Medicine, Division of General Internal Medicine, 1800 Orleans St., Baltimore, MD 21287, United States
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10
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Rutkow L, Chang HY, Daubresse M, Webster DW, Stuart EA, Alexander GC. Effect of Florida's Prescription Drug Monitoring Program and Pill Mill Laws on Opioid Prescribing and Use. JAMA Intern Med 2015; 175:1642-9. [PMID: 26280092 DOI: 10.1001/jamainternmed.2015.3931] [Citation(s) in RCA: 179] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Lainie Rutkow
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland2Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Matthew Daubresse
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Daniel W Webster
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth A Stuart
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland2Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland4Department of Mental Health, Jo
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland6Division of General Internal Medicine, Johns Ho
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Kim Y, Kornfield R, Shi Y, Vera L, Daubresse M, Alexander GC, Emery S. Effects of Televised Direct-to-Consumer Advertising for Varenicline on Prescription Dispensing in the United States, 2006-2009. Nicotine Tob Res 2015; 18:1180-7. [PMID: 26385926 DOI: 10.1093/ntr/ntv198] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 09/01/2015] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Televised direct-to-consumer advertising (DTCA) for prescription drugs is controversial, especially for tobacco cessation products such as varenicline, given safety concerns that arose only after its market approval. We aim to quantify the extent to which DTCA influenced varenicline use. METHODS We linked monthly DTCA television ratings with monthly prescription data from IMS Health's National Prescription Audit across top 75 media markets in 2006-2009. We used Poisson models with Generalized Estimating Equations to analyze effects of exposures to DTCA for both varenicline and nicotine replacement therapies on rate of dispensed varenicline prescriptions among smokers, controlling for population characteristics and varenicline-related events. RESULTS Varenicline prescriptions increased dramatically following DTCA launch and declined sharply after safety risks were publicized and US Food and Drug Administration (FDA) issued an advisory. DTCA had significant impact on new prescription dispensing in the subsequent month: before the FDA advisory, one additional exposure to varenicline DTCA was associated with a 1.8% (rate ratio [RR] = 1.018 [1.015-1.021]) higher rate of new prescriptions; no effect was observed after the advisory (RR = 1.000 [0.997-1.003]). Prior to the advisory, cross-product effects of nicotine replacement therapy advertising on varenicline prescribing were negligible (RR = 1.002 [0.999-1.004]); after the advisory, effects were positive (RR = 1.015 [1.012-1.019]). CONCLUSIONS DTCA for varenicline had a significant impact on varenicline prescribing when the drug's safety profile was not well characterized, supporting arguments to limit DTCA for newly approved products whose real-world safety is unclear. IMPLICATIONS We examined the fluctuations in varenicline use in association with DTCA for varenicline and other tobacco cessation aids. To our knowledge this is the first study to quantify the effects of televised DTCA for varenicline and other tobacco cessation aids on varenicline prescription dispensing. We believe that understanding these relationships is critical for formulating effective public health policy and interventions.
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Affiliation(s)
- Yoonsang Kim
- Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL;
| | - Rachel Kornfield
- School of Journalism and Mass Communication, University of Wisconsin-Madison, Madison, WI
| | - Yaru Shi
- Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL
| | - Lisa Vera
- Moores Cancer Center, University of California San Diego, La Jolla, CA
| | - Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Johns Hopkins Center for Drug Safety and Effectiveness, Baltimore, MD
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Johns Hopkins Center for Drug Safety and Effectiveness, Baltimore, MD; Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD
| | - Sherry Emery
- Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL
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Daubresse M, Hutfless S, Kim Y, Kornfield R, Qato DM, Huang J, Miller K, Emery SL, Alexander GC. Effect of Direct-to-Consumer Advertising on Asthma Medication Sales and Healthcare Use. Am J Respir Crit Care Med 2015; 192:40-6. [PMID: 25879303 DOI: 10.1164/rccm.201409-1585oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The United States is one of only two countries that permit direct-to-consumer advertising (DTCA) of prescription drugs, and many questions remain regarding its effects. OBJECTIVES To quantify the association between asthma-related DTCA, pharmacy sales, and healthcare use. METHODS This was an ecological study from 2005 through 2009 using linked data from Nielsen (DTCA television ratings), the IMS Health National Prescription Audit (pharmacy sales), and the MarketScan Commercial Claims data (healthcare use) for 75 designated market areas in the United States. We used multilevel Poisson regression to model the relationship between DTCA and rates of prescriptions and use within and across designated market areas. Main outcome measures include (1) volume of total, new, and refilled prescriptions for advertised products based on pharmacy sales; (2) prescription claims for asthma medications; and asthma-related (3) emergency department use, (4) hospitalizations, and (5) outpatient encounters among the commercially insured. MEASUREMENTS AND MAIN RESULTS Four Food and Drug Administration-approved asthma medicines were advertised during the period examined: (1) fluticasone/salmeterol (Advair), (2) mometasone furoate (Asmanex), (3) montelukast (Singulair), and (4) budesonide/formoterol (Symbicort). After adjustment, each additional televised advertisement was associated with 2% (incident rate ratio, 1.02; 95% confidence interval, 1.01-1.03) higher pharmacy sales rate from 2005 through 2009, although this effect varied across the three consistently advertised therapies examined. Among the commercially insured, DTCA was positively and significantly associated with emergency room visits related to asthma (incident rate ratio, 1.02; 95% confidence interval, 1.01-1.04), but there was no relationship with hospitalizations or outpatient encounters. CONCLUSIONS Among this population, DTCA was associated with higher prescription sales and asthma-related emergency department use.
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Affiliation(s)
- Matthew Daubresse
- 1 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,2 Center for Drug Safety and Effectiveness
| | - Susan Hutfless
- 1 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,2 Center for Drug Safety and Effectiveness.,3 Division of Gastroenterology and Hepatology, Department of Medicine, and
| | | | | | - Dima M Qato
- 5 Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, and.,6 Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois; and
| | | | - Kay Miller
- 7 Truven Health Analytics, Santa Barbara, California
| | | | - G Caleb Alexander
- 1 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,2 Center for Drug Safety and Effectiveness.,8 Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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Zhou M, Daubresse M, Stafford RS, Alexander GC. National trends in the ambulatory treatment of hypertension in the United States, 1997-2012. PLoS One 2015; 10:e0119292. [PMID: 25738503 PMCID: PMC4349596 DOI: 10.1371/journal.pone.0119292] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/29/2015] [Indexed: 11/18/2022] Open
Abstract
Importance Hypertension is common and costly. Over the past decade, new antihypertensive therapies have been developed, several have lost patent protection and additional evidence regarding the safety and effectiveness of these agents has accrued. Objective To examine trends in the use of antihypertensive therapies in the United States between 1997 and 2012. Design, Setting and Participants We used nationally representative audit data from the IMS Health National Disease and Therapeutic Index to examine the ambulatory pharmacologic treatment of hypertension. Outcome Measures Our primary unit of analysis was a visit where hypertension was a reported diagnosis and treated with a pharmacotherapy (treatment visit). We restricted analyses to the use of six therapeutic classes of antihypertensive medications among individuals 18 years or older. Results Annual hypertension treatment visits increased from 56.9 million treatment visits (95% confidence intervals [CI], 53.9–59.8) in 1997 to 83.3 million visits (CI 79.2–87.3) in 2008, then declined steadily to 70.9 million visits (CI 66.7–75.0) by 2012. Angiotensin receptor blocker utilization increased substantially from 3% of treatment visits in 1997 to 18% by 2012, whereas calcium channel blocker use decreased from 27% to 18% of visits. Rates of diuretic and beta-blocker use remained stable and represented 24%–30% and 14–16% of visits, respectively. Use of direct renin inhibitor accounted for fewer than 2% of annual visits. The proportion of visits treated using fixed-dose combination therapies increased from 28% to 37% of visits. Conclusions Several important changes have occurred in the landscape of antihypertensive treatment in the United States during the past decade. Despite their novel mechanism of action, the adoption rate of direct renin inhibitors remains low.
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Affiliation(s)
- Meijia Zhou
- Department of Epidemiology, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Matthew Daubresse
- Department of Epidemiology, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Randall S. Stafford
- Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, United States of America
| | - G. Caleb Alexander
- Department of Epidemiology, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
- * E-mail:
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Affiliation(s)
- Lee M. Hampton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew Daubresse
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland
| | - Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - G. Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland
| | - Daniel S. Budnitz
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Affiliation(s)
- M Daubresse
- 1] Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA [2] Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
| | - G C Alexander
- 1] Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA [2] Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA [3] Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
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Abstract
IMPORTANCE In 2011, an estimated 26.8 million US adults used prescription medications for mental illness. OBJECTIVE To estimate the numbers and rates of adverse drug event (ADE) emergency department (ED) visits involving psychiatric medications among US adults between January 1, 2009, and December 31, 2011. DESIGN AND SETTING Descriptive analyses of active, nationally representative surveillance of ADE ED visits using the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance system and of drug prescribing during outpatient visits using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. PARTICIPANTS Medical records from national probability samples of ED and outpatient visits by adults 19 years or older were reviewed and analyzed. EXPOSURES Antidepressants, antipsychotics, lithium salts, sedatives and anxiolytics, and stimulants. MAIN OUTCOMES AND MEASURES National estimates of ADE ED visits resulting from therapeutic psychiatric medication use and of psychiatric medication ADE ED visits per 10,000 outpatient visits at which psychiatric medications were prescribed. RESULTS From 2009 through 2011, there were an estimated 89,094 (95% CI, 68,641-109,548) psychiatric medication ADE ED visits annually, with 19.3% (95% CI, 16.3%-22.2%) resulting in hospitalization and 49.4% (95% CI, 46.5%-52.4%) involving patients aged 19 to 44 years. Sedatives and anxiolytics, antidepressants, antipsychotics, lithium salts, and stimulants were implicated in an estimated 30,707 (95% CI, 23,406-38,008), 25,377 (95% CI, 19,051-31,704), 21,578 (95% CI, 16,599-26,557), 3620 (95% CI, 2311-4928), and 2779 (95% CI, 1764-3794) respective ADE ED visits annually. Antipsychotics and lithium salts were implicated in 11.7 (95% CI, 10.1-13.2) and 16.4 (95% CI, 13.0-19.9) ADE ED visits per 10,000 outpatient prescription visits, respectively, compared with 3.6 (95% CI, 3.2-4.1) for sedatives and anxiolytics, 2.9 (95% CI, 2.3-3.5) for stimulants, and 2.4 (95% CI, 2.1-2.7) for antidepressants. The commonly used sedative zolpidem tartrate was implicated in 11.5% (95% CI, 9.5%-13.4%) of all adult psychiatric medication ADE ED visits and in 21.0% (95% CI, 16.3%-25.7%) of visits involving adults 65 years or older, in both cases significantly more than any other psychiatric medication. CONCLUSIONS AND RELEVANCE Psychiatric medications are implicated in many ADEs treated in US EDs. Efforts to reduce ADEs should include adults of all ages but might prioritize medications causing high numbers and rates of ED visits.
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Affiliation(s)
- Lee M. Hampton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew Daubresse
- Center for Drug Safety and Effectiveness, The Johns Hopkins University, Baltimore, Maryland3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Hsien-Yen Chang
- Center for Drug Safety and Effectiveness, The Johns Hopkins University, Baltimore, Maryland4Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - G. Caleb Alexander
- Center for Drug Safety and Effectiveness, The Johns Hopkins University, Baltimore, Maryland3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland5Department of Medicine, The Johns Hopkins University School of Med
| | - Daniel S. Budnitz
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Chang HY, Daubresse M, Kruszewski SP, Alexander GC. Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. Am J Emerg Med 2014; 32:421-31. [PMID: 24560834 DOI: 10.1016/j.ajem.2014.01.015] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 01/13/2014] [Accepted: 01/14/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To describe changes in the prevalence and severity of pain and prescribing of non-opioid analgesics in US emergency departments (EDs) from 2000 to 2010. METHODS Analysis of serial cross-sectional data regarding ED visits from the National Hospital Ambulatory Medical Care Survey. Visits were limited to patients ≥18 years old without malignancy. Outcome measures included annual volume of visits among adults with a primary symptom or diagnosis of pain, annual rates of patient-reported pain severity, and predictors of non-opioid receipt for non-malignant pain. RESULTS Rates of pain remained stable, representing approximately 45% of visits from 2000 through 2010. Patients reported pain as their primary symptom twice as often as providers reported a primary pain diagnosis (40% vs 20%). The percentage of patients reporting severe pain increased from 25% (95% confidence intervals [CI] 22%-27%) in 2003 to 40% (CI 37%-42%) in 2008. From 2000 to 2010, the proportion of pain visits treated with pharmacotherapies increased from 56% (CI 53%-58%) to 71% (CI 69%-72%), although visits treated exclusively with non-opioids decreased 21% from 28% (CI 27%-30%) to 22% (CI 20%-23%). The adjusted odds of non-opioid rather than opioid receipt were greater among visits for patients 18 to 24 years old (odds ratio [OR] 1.35, CI 1.24-1.46), receiving fewer medicines (OR 2.91, CI 2.70-3.15) and those with a diagnosis of mental illness (OR 2.24, CI 1.99-2.52). CONCLUSIONS Large increases in opioid utilization in EDs have coincided with reductions in the use of non-opioid analgesics and an unchanging prevalence of pain among patients.
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Affiliation(s)
- Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
| | - Stefan P Kruszewski
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA; Stefan P. Kruszewski, M.D. & Associates, Harrisburg, PA, USA; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA; Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD, USA.
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Daubresse M, Chang HY, Yu Y, Viswanathan S, Shah ND, Stafford RS, Kruszewski SP, Alexander GC. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010. Med Care 2013; 51:870-8. [PMID: 24025657 PMCID: PMC3845222 DOI: 10.1097/mlr.0b013e3182a95d86] [Citation(s) in RCA: 238] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland
| | - Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yuping Yu
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland
| | - Shilpa Viswanathan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nilay D. Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Randall S. Stafford
- Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, California
| | - Stefan P. Kruszewski
- Stefan P. Kruszewski, M.D. & Associates, Harrisburg, Pennsylvania
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - G. Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, Maryland
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Daubresse M, Gleason PP, Peng Y, Shah ND, Ritter ST, Alexander GC. Impact of a drug utilization review program on high-risk use of prescription controlled substances. Pharmacoepidemiol Drug Saf 2013; 23:419-27. [PMID: 23881609 DOI: 10.1002/pds.3487] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 04/09/2013] [Accepted: 06/25/2013] [Indexed: 01/02/2023]
Abstract
BACKGROUND Prescription drug abuse has prompted considerable concern. We evaluated a retrospective drug utilization review program to reduce controlled substance use among individuals with high-risk utilization. METHODS We analyzed pharmacy claims from a large pharmaceutical benefits manager. For each eligible member, we calculated a controlled substance score based on the number and type of claims, prescribers and pharmacies, and utilization patterns over three months. Two state health plans sent controlled substance letters to prescribers of members meeting or exceeding a plan- and pre-specified controlled substance score. Two different state health plans did not send such letters. We used a difference-in-difference design and generalized estimating equations to quantify the impact of the program on the mean difference in reduction of the controlled substance score over six months. RESULTS Eligible members in the intervention and comparison states had similar baseline mean controlled substance scores (19.0 vs. 18.6, p = 0.36). Adjusting for individuals' age, sex and pharmacy risk group score, reductions in the mean controlled substance score were greater in the intervention than comparison cohort (5.67 vs. 4.31, p = 0.01), corresponding with a 34.0% reduction in the intervention cohort compared to a 25.5% reduction in the comparison cohort. Changes were driven primarily by reductions in the number of controlled substance claims filled (30.5% vs. 23.1%, p = 0.01), as well as by a non-statistically significant trend towards reductions in the number of prescribers and pharmacies used (26.9% vs. 20.1%, p = 0.07). CONCLUSIONS Retrospective drug utilization review programs may reduce controlled substance scores and claims among individuals with patterns suggesting high-risk utilization.
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Affiliation(s)
- Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Affiliation(s)
- Kevin Fain
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205, USA
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