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Ooms GI, Usman MA, Reed T, van den Ham HA, Mantel-Teeuwisse AK. The impact of scheduling ketamine as an internationally controlled substance on anaesthesia care in Sub-Saharan Africa: a case study and key informant interviews. BMC Health Serv Res 2024; 24:598. [PMID: 38715038 PMCID: PMC11077710 DOI: 10.1186/s12913-024-11040-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Access to anaesthesia and surgical care is a major problem for people living in Sub-Saharan Africa. In this region, ketamine is critical for the provision of anaesthesia care. However, efforts to control ketamine internationally as a controlled substance may significantly impact its accessibility. This research therefore aims to estimate the importance of ketamine for anaesthesia and surgical care in Sub-Saharan Africa and assess the potential impact on access to ketamine if it were to be scheduled. METHODS This research is a mixed-methods study, comprising of a cross-sectional survey at the hospital level in Rwanda, and key informant interviews with experts on anaesthesia care in Sub-Saharan Africa. Data on availability of four anaesthetic agents were collected from hospitals (n = 54) in Rwanda. Semi-structured interviews with 10 key informants were conducted, collecting information on the importance of ketamine, the potential impact of scheduling ketamine internationally, and opinions on misuse of ketamine. Interviews were transcribed verbatim and analysed using a thematic analysis approach. RESULTS The survey conducted in Rwanda found that availability of ketamine and propofol was comparable at around 80%, while thiopental and inhalational agents were available at only about half of the hospitals. Significant barriers impeding access to anaesthesia care were identified, including a general lack of attention given to the specialty by governments, a shortage of anaesthesiologists and migration of trained anaesthesiologists, and a scarcity of medicines and equipment. Ketamine was described as critical for the provision of anaesthesia care as a consequence of these barriers. Misuse of ketamine was not believed to be an issue by the informants. CONCLUSION Ketamine is critical for the provision of anaesthesia care in Sub-Saharan Africa, and its scheduling would have a significantly negative impact on its availability for anaesthesia care.
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Affiliation(s)
- Gaby I Ooms
- Health Action International, Overtoom 60-2, 1054HK, Amsterdam, The Netherlands.
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.
| | - Mohammed A Usman
- Federal University of Dutse, Dutse, Jigawa State, Nigeria
- Rasheed Shekoni Teaching Hospital, Dutse, Jigawa State, Nigeria
| | - Tim Reed
- Health Action International, Overtoom 60-2, 1054HK, Amsterdam, The Netherlands
| | - Hendrika A van den Ham
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
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Rajagopal S, Westra J, Raji MA, Wilkes D, Kuo YF. Access to Medications for Opioid Use Disorder During COVID-19: Retrospective Study of Commercially Insured Patients from 2019-2022. Am J Prev Med 2024; 66:635-644. [PMID: 37979624 DOI: 10.1016/j.amepre.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 11/11/2023] [Accepted: 11/13/2023] [Indexed: 11/20/2023]
Abstract
INTRODUCTION This study assesses disparities in medications for opioid use disorder in adults with opioid use disorder and examines the associations between state-level COVID-19 lockdown and telehealth policies and medications for opioid use disorder utilization rates during the COVID-19 pandemic. METHODS This retrospective cohort study of 396,872 adults with opioid use disorder analyzed monthly medications for opioid use disorder utilization rates between January 2019 and June 2022 using data from Clinformatics Data Mart Database. Primary outcome measure was monthly medications for opioid use disorder utilization rates. Variables of interest were patients' demographics and state-level characteristics (telehealth policies for controlled substance prescribing, COVID-19 lockdown policy, and registered buprenorphine providers/100,000). In multivariable analyses, time trend was grouped into four time periods: before COVID-19, early COVID-19, early vaccine, and Omicron-related COVID-19 surge and thereafter. RESULTS Medications for opioid use disorder rates increased from a 1.2% change in slope monthly on a log scale to 2% monthly from February 2021 to October 2021, after which the utilization rate increased to a lesser degree. Women had 28% lower odds of receiving medications for opioid use disorder than men; Hispanic, Black, and Asian patients had 40%, 34%, and 32% lower odds of receiving medications for opioid use disorder than White patients, respectively. These sex and racial disparities persisted throughout the pandemic. Regional medications for opioid use disorder rate differences, mediated by buprenorphine providers/100,000 state population, decreased during the pandemic. States with telehealth policies for controlled substance prescribing had greater percentages of patients on medications for opioid use disorder (11.7%) than states without such policies (10.4%). CONCLUSIONS Monthly medications for opioid use disorder rates increased during the pandemic, with higher rates in men, White individuals, and residents of the Northeast region. States with policies permitting telehealth prescribing of controlled substances also had higher medications for opioid use disorder rates, supporting a future expansion of medications for opioid use disorder-related telehealth to improve access to care.
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Affiliation(s)
- Shilpa Rajagopal
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Jordan Westra
- Department of Biostatistics & Data Science, School of Public and Population Health, University of Texas Medical Branch, Galveston, Texas
| | - Mukaila A Raji
- Division of Geriatrics & Palliative Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; Sealy Center On Aging, University of Texas Medical Branch, Galveston, Texas
| | - Denise Wilkes
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas
| | - Yong-Fang Kuo
- Department of Biostatistics & Data Science, School of Public and Population Health, University of Texas Medical Branch, Galveston, Texas; Division of Geriatrics & Palliative Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; Sealy Center On Aging, University of Texas Medical Branch, Galveston, Texas.
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Ashraf AR, Mackey TK, Fittler A. Search Engines and Generative Artificial Intelligence Integration: Public Health Risks and Recommendations to Safeguard Consumers Online. JMIR Public Health Surveill 2024; 10:e53086. [PMID: 38512343 PMCID: PMC10995787 DOI: 10.2196/53086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/27/2023] [Accepted: 01/04/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND The online pharmacy market is growing, with legitimate online pharmacies offering advantages such as convenience and accessibility. However, this increased demand has attracted malicious actors into this space, leading to the proliferation of illegal vendors that use deceptive techniques to rank higher in search results and pose serious public health risks by dispensing substandard or falsified medicines. Search engine providers have started integrating generative artificial intelligence (AI) into search engine interfaces, which could revolutionize search by delivering more personalized results through a user-friendly experience. However, improper integration of these new technologies carries potential risks and could further exacerbate the risks posed by illicit online pharmacies by inadvertently directing users to illegal vendors. OBJECTIVE The role of generative AI integration in reshaping search engine results, particularly related to online pharmacies, has not yet been studied. Our objective was to identify, determine the prevalence of, and characterize illegal online pharmacy recommendations within the AI-generated search results and recommendations. METHODS We conducted a comparative assessment of AI-generated recommendations from Google's Search Generative Experience (SGE) and Microsoft Bing's Chat, focusing on popular and well-known medicines representing multiple therapeutic categories including controlled substances. Websites were individually examined to determine legitimacy, and known illegal vendors were identified by cross-referencing with the National Association of Boards of Pharmacy and LegitScript databases. RESULTS Of the 262 websites recommended in the AI-generated search results, 47.33% (124/262) belonged to active online pharmacies, with 31.29% (82/262) leading to legitimate ones. However, 19.04% (24/126) of Bing Chat's and 13.23% (18/136) of Google SGE's recommendations directed users to illegal vendors, including for controlled substances. The proportion of illegal pharmacies varied by drug and search engine. A significant difference was observed in the distribution of illegal websites between search engines. The prevalence of links leading to illegal online pharmacies selling prescription medications was significantly higher (P=.001) in Bing Chat (21/86, 24%) compared to Google SGE (6/92, 6%). Regarding the suggestions for controlled substances, suggestions generated by Google led to a significantly higher number of rogue sellers (12/44, 27%; P=.02) compared to Bing (3/40, 7%). CONCLUSIONS While the integration of generative AI into search engines offers promising potential, it also poses significant risks. This is the first study to shed light on the vulnerabilities within these platforms while highlighting the potential public health implications associated with their inadvertent promotion of illegal pharmacies. We found a concerning proportion of AI-generated recommendations that led to illegal online pharmacies, which could not only potentially increase their traffic but also further exacerbate existing public health risks. Rigorous oversight and proper safeguards are urgently needed in generative search to mitigate consumer risks, making sure to actively guide users to verified pharmacies and prioritize legitimate sources while excluding illegal vendors from recommendations.
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Affiliation(s)
- Amir Reza Ashraf
- Department of Pharmaceutics, Faculty of Pharmacy, University of Pécs, Pécs, Hungary
| | - Tim Ken Mackey
- Global Health Program, Department of Anthropology, University of California, La Jolla, CA, United States
- Global Health Policy and Data Institute, San Diego, CA, United States
- S-3 Research, San Diego, CA, United States
| | - András Fittler
- Department of Pharmaceutics, Faculty of Pharmacy, University of Pécs, Pécs, Hungary
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Patel A, Chavan R, Rakovski C, Beuttler R, Yang S. Changes in real-world dispensing of ADHD stimulants in youth from 2019 to 2021 in California. Front Public Health 2024; 12:1302144. [PMID: 38504685 PMCID: PMC10948562 DOI: 10.3389/fpubh.2024.1302144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 02/14/2024] [Indexed: 03/21/2024] Open
Abstract
Introduction Attention-deficit/hyperactivity disorder (ADHD) is one of the most common pediatric neurobehavioral disorders in the U.S. Stimulants, classified as controlled substances, are commonly used for ADHD management. We conducted an analysis of real-world stimulants dispensing data to evaluate the pandemic's impact on young patients (≤ 26 years) in California. Methods Annual prevalence of patients on stimulants per capita across various California counties from 2019 and 2021 were analyzed and further compared across different years, sexes, and age groups. New patients initiating simulants therapy were also examined. A case study was conducted to determine the impact of socioeconomic status on patient prevalence within different quintiles in Los Angeles County using patient zip codes. Logistic regression analysis using R Project was employed to determine demographic factors associated with concurrent use of stimulants with other controlled substances. Results There was a notable reduction in prevalence of patients ≤26 years old on stimulants during and after the pandemic per 100,000 people (777 in 2019; 743 in 2020; 751 in 2021). These decreases were more evident among the elementary and adolescent age groups. The most prevalent age group on stimulants were adolescents (12-17 years) irrespective of the pandemic. A significant rise in the number of female patients using stimulants was observed, increasing from 107,957 (35.2%) in 2019 to 121,241 (41.1%) in 2021. New patients initiating stimulants rose from 102,754 in 2020 to 106,660 in 2021, with 33.2% being young adults. In Los Angeles County, there was an increasing trend in patient prevalence from Q1 to Q5 income quintiles among patients ≥6 years. Consistently each year, the highest average income quintile exhibited the highest per capita prevalence. Age was associated with higher risk of concurrent use of benzodiazepines (OR, 1.198 [95% CI, 1.195-1.201], p < 0.0001) and opioids (OR, 1.132 [95% CI, 1.130-1.134], p < 0.0001) with stimulants. Discussion Our study provides real-world information on dispensing of ADHD stimulants in California youth from 2019 to 2021. The results underscore the importance of optimizing evidence-based ADHD management in pediatric patients and young adults to mitigate disparities in the use of stimulants.
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Affiliation(s)
- Anika Patel
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, CA, United States
| | - Rishikesh Chavan
- Hyundai Cancer Institute, CHOC Children’s Hospital, Orange, CA, United States
| | - Cyril Rakovski
- Schmid College of Science of Technology, Chapman University, Orange, CA, United States
| | - Richard Beuttler
- Chapman University School of Pharmacy, Irvine, CA, United States
| | - Sun Yang
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, CA, United States
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Fortier CR. National Hospital and Health-System Controlled Substances Drug Diversion Prevention & Surveillance Program Assessment Survey - 2021. Am J Health Syst Pharm 2024; 81:137-145. [PMID: 37756623 DOI: 10.1093/ajhp/zxad222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
PURPOSE To present and discuss the results of the National Hospital and Health-System Controlled Substances Drug Diversion Prevention & Surveillance Program Assessment Survey. METHODS The survey was emailed to 1,529 chief pharmacy officers utilizing the list of directors of pharmacy from the American Society of Health-System Pharmacists. The survey opened September 15, 2021, and closed October 4, 2021. Forty-nine questions were included in 5 different sections, and participants were also given the option to respond to 39 additional questions. RESULTS The survey response rate was 12.75%, with the results showing consistencies in practice around drug security and human resource management. Sixty-two percent of sites had a formalized drug diversion committee, half of which had been implemented since 2018. Adoption of electronic controlled substance systems continues to increase, with 50% of sites having implemented such a system in the previous 3 years. At the time of the survey, 18% of organizations did not have an electronic system, but 90% of sites had implemented or intended to implement one by 2023. Over 40% of sites that utilized an electronic system were looking to upgrade to a next-generation system. Most organizations had 0.5 to 1 full-time equivalent dedicated to diversion prevention, and two-thirds of sites had a formalized diversion committee. The majority of sites defined "significant loss" by utilizing professional judgement, based on the scenario, as a percentage of inventory or as a range of units. Community practice consensus is needed around auditing adjustments to controlled substance inventory and for perpetual inventory processes. Respondents reported 1 to 2 (29%), 3 to 5 (26%), and more than 10 (26%) formal drug diversion investigations annually. CONCLUSION This first-time survey provided significant insight into the realities of drug diversion prevention practices in hospitals and health systems nationally.
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Haupt MR, Cuomo R, Cui M, Mackey TK. Is This Safe? Examining Safety Assessments of Illicit Drug Purchasing on Social Media Using Conjoint Analysis. Subst Use Misuse 2024; 59:999-1011. [PMID: 38319039 PMCID: PMC11019931 DOI: 10.1080/10826084.2024.2310507] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Background: Illicit substance sales facilitated by social media platforms are a growing public health issue given recent increases in overdose deaths, including an alarming rise in cases of fentanyl poisoning. However, little is known about how online users evaluate what features of social media posts convey safety, which can influence their intent to source illicit substances. Objectives: This study adapts conjoint analysis which assessed how attributes of social media posts (i.e., features) influence safety evaluations of mock posts selling illicit substances. 440 participants were recruited online for self-reporting use or purchase of controlled substances or prescription medicines recreationally. The following attributes were tested: drug packaging, drug offerings, profile photo of seller, payment info provided, and use of emojis. Results: Packaging was ranked the most important attribute (Average Importance =43.68, Offering=14.94, Profile=13.86, Payment=14.11, Emoji=13.41), with posts that displayed drugs in pill bottles assessed as the most safe. Attribute levels for advertising multiple drugs, having a blank profile photo, including payment information, and including emojis also ranked higher in perceived safety. Rankings were consistent across tested demographic factors (i.e., gender, age, and income). Survey results show that online pharmacies were most likely to be perceived as safe for purchasing drugs and medications. Additionally, those who were younger in age, had higher income, and identified as female were more likely to purchase from a greater number of platforms. Conclusions: These findings can assist in developing more precise content moderation for platforms seeking to address this ongoing threat to public safety.
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Affiliation(s)
- Michael Robert Haupt
- Department of Cognitive Science, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA
- Global Health Policy & Data Institute, San Diego, CA USA
| | - Raphael Cuomo
- Global Health Policy & Data Institute, San Diego, CA USA
- Department of Anesthesiology, University of California, San Diego School of Medicine, San Diego, CA USA
| | - Manying Cui
- Global Health Policy & Data Institute, San Diego, CA USA
| | - Tim K. Mackey
- Global Health Policy & Data Institute, San Diego, CA USA
- Global Health Program, Department of Anthropology, University of California, San Diego, CA USA
- S-3 Research LLC, San Diego, CA USA
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Miracle DK, Smith N, Slavova S, Stinson LK, Roberts MF, Rock P, Walsh SL, Freeman PR. Drug disposal deserts: An assessment of receptacle availability in Kentucky community pharmacies. J Rural Health 2024; 40:208-214. [PMID: 37491595 PMCID: PMC10808259 DOI: 10.1111/jrh.12786] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 03/27/2023] [Revised: 06/09/2023] [Accepted: 07/17/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE The purpose of this study was to describe the county-level availability of drug disposal receptacles in Kentucky community pharmacies and show the relationship between installed receptacles and opioid analgesic (OA)/controlled substance dispensing rates, stratifying where possible by urban-rural classification. METHODS Using 2020 data from the Kentucky All Schedule Prescription Electronic Reporting program and disposal receptacle data from the US Drug Enforcement Agency, county-level comparisons were made between number of receptacles and OA/controlled substance dispensing rates. Logistic and negative binomial regression models were used to assess for differences between rural/urban county designation and odds of ≥1 disposal receptacle and compare the rates of receptacles per dispensed OA dose in rural/urban counties. FINDINGS While rural counties saw higher OA and controlled substance dispensing rates, the majority (55.6%) of disposal receptacles were in urban locations. The odds of having at least 1 receptacle were higher in urban counties (OR 2.60, 95% CI: 1.15, 5.92) compared to rural. The estimated rate of disposal receptacles per million dispensed OA doses was found to be 0.47 (95% CI: 0.36, 0.61) in urban counties compared to 0.32 (95% CI: 0.25, 0.42) in rural counties, with an estimated rate ratio of 1.45 (95% CI: 1.01, 2.10). CONCLUSIONS A mismatch between the availability of county-level disposal receptacles in community pharmacies and the volume of dispensed OAs/controlled substances exists, resulting in fewer receptacles per dispensed OA in rural counties compared to urban counties. Future efforts are necessary to increase access to convenient disposal receptacles located in community pharmacies, particularly in rural communities.
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Affiliation(s)
- Dustin K Miracle
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Noah Smith
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Svetla Slavova
- Department of Biostatistics, University of Kentucky, Lexington, Kentucky, USA
| | - Laura K Stinson
- Substance Use Priority Research Area, University of Kentucky, Lexington, Kentucky, USA
| | - Monica F Roberts
- Substance Use Priority Research Area, University of Kentucky, Lexington, Kentucky, USA
| | - Peter Rock
- Substance Use Priority Research Area, University of Kentucky, Lexington, Kentucky, USA
| | - Sharon L Walsh
- Department of Behavioral Science, University of Kentucky, Lexington, Kentucky, USA
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
- Center for the Advancement of Pharmacy Practice, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
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Wong MJ, Wang Y, Blake L, Ke JXC. Preventing controlled substance diversion in perioperative settings: a narrative review. Can J Anaesth 2023; 70:1989-2001. [PMID: 37715047 DOI: 10.1007/s12630-023-02574-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 01/24/2023] [Accepted: 02/08/2023] [Indexed: 09/17/2023] Open
Abstract
PURPOSE Diversion of controlled substances in the perioperative setting is an ongoing challenge, with consequences for patients, anesthesiologists, perioperative staff, and health care facilities alike. Perioperative environments are at high risk for diversion, since controlled substances are frequently handled in these settings, with varying levels of oversight. In this narrative review, we summarize strategies for preventing diversion of controlled substances in perioperative settings (i.e., operating rooms, endoscopy suites, and postanesthesia recovery units). SOURCE We performed a targeted literature search in PubMed MEDLINE, Embase, Scopus, Web of Science, the Cochrane Register of Controlled trials, and the Cochrane Database of Systematic Reviews, as well as a manual search for additional references. We used terminology related to drug diversion, drug abuse, anesthesiologists, pharmacists, physicians, operating room personnel, and controlled substances. PRINCIPAL FINDINGS Many strategies have been described for preventing diversion in perioperative settings, and these are broadly categorized into: education, distribution, auditing, or provider screening. Some of these approaches may be time- and resource-intensive. There is limited evidence to inform anesthesia departments' choice of which strategies to adopt. CONCLUSION Although awareness of perioperative controlled substance diversion has been improving, there are too few data to suggest an optimal approach. Anesthesia departments will need to work collaboratively with hospital pharmacies and actively select strategies that are reasonable given local resources.
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Affiliation(s)
- Michael J Wong
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Saint John, NB, Canada.
| | - Yongjun Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lindsay Blake
- UAMS Library, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Janny X C Ke
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesia, St. Paul's Hospital/Providence Health Care, Vancouver, BC, Canada
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
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Goodchild JH, Donaldson M. The Controlled Substances Act: a primer for dentists. Gen Dent 2023; 71:14-18. [PMID: 37889239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
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Seymour RB, Wally MK, Hsu JR. Impact of clinical decision support on controlled substance prescribing. BMC Med Inform Decis Mak 2023; 23:234. [PMID: 37864226 PMCID: PMC10588193 DOI: 10.1186/s12911-023-02314-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 09/30/2022] [Accepted: 09/29/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Prescription drug overdose and misuse has reached alarming numbers. A persistent problem in clinical care is lack of easy, immediate access to all relevant information at the actionable time. Prescribers must digest an overwhelming amount of information from each patient's record as well as remain up-to-date with current evidence to provide optimal care. This study aimed to describe prescriber response to a prospective clinical decision support intervention designed to identify patients at risk of adverse events associated with misuse of prescription opioids/benzodiazepines and promote adherence to clinical practice guidelines. METHODS This study was conducted at a large multi-center healthcare system, using data from the electronic health record. A prospective observational study was performed as clinical decision support (CDS) interventions were sequentially launched (January 2016-July 2019). All data were captured from the medical record prospectively via the CDS tools implemented. A consecutive series of all patient encounters including an opioid/benzodiazepine prescription were included in this study (n = 61,124,172 encounters; n = 674,785 patients). Physician response to the CDS interventions was the primary outcome, and it was assessed over time using control charts. RESULTS An alert was triggered in 23.5% of encounters with a prescription (n = 555,626). The prescriber decision was influenced in 18.1% of these encounters (n = 100,301). As the number of risk factors increased, the rate of decision being influenced also increased (p = 0.0001). The effect of the alert differed by drug, risk factor, specialty, and facility. CONCLUSION The delivery of evidence-based, patient-specific information had an influence on the final prescription in nearly 1 in 5 encounters. Our intervention was sustained with minimal prescriber fatigue over many years in a large and diverse health system.
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Affiliation(s)
- Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA.
- Atrium Health Musculoskeletal Institute, 2001 Vail Avenue, 6th floor, Charlotte, NC, 28207, USA.
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA
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Kannarkat JT, Kannarkat JT, Torous J. Rebalancing Controlled Substance Regulations in Telemedicine. JAMA Health Forum 2023; 4:e233251. [PMID: 37862032 DOI: 10.1001/jamahealthforum.2023.3251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023] Open
Abstract
This Viewpoint elucidates major components of the proposed rules about controlled substance prescribing in telehealth, highlights evolving considerations with the US Drug Enforcement Agency’s approach, and offers potential improvements before finalization of the rules.
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Affiliation(s)
- Jacob T Kannarkat
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | | | - John Torous
- Department of Psychiatry at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Williams AR, Mauro CM, Feng T, Waples J, Martins SS, Haney M. Adult Medical Cannabinoid Use and Changes in Prescription Controlled Substance Use. Cannabis Cannabinoid Res 2023; 8:933-941. [PMID: 35486854 PMCID: PMC10589493 DOI: 10.1089/can.2021.0212] [Citation(s) in RCA: 1] [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] [Indexed: 12/21/2022] Open
Abstract
Introduction: Nonopioid-based strategies for managing chronic noncancer pain are needed to help reduce overdose deaths. Although lab studies and population-level data suggest that cannabinoids could provide opioid-sparing effects, among medical cannabis participants they may also impact overdose risk by modifying other controlled substance use such as sedative hypnotics. However, no study has combined observational data at the individual level to empirically address interactions between the use of cannabinoids and prescribed controlled substances. Methods: Electronic health records, including prescription drug monitoring program data, from a large multisite medical cannabis program in New York State were abstracted for all participants with noncancer pain and recently prescribed noncannabinoid controlled substances who completed a new intake visit from April 15, 2018-April 14, 2019 and who remained actively in treatment for >180 days. Participants were partitioned into two samples: those with recent opioid use and those with active opioid use and co-use of sedative hypnotics. A patient-month level analysis assessed total average equivalent milligrams by class of drug (i.e., cannabinoid distinguishing tetrahydrocannabinol [THC] vs. cannabidiol [CBD], opioids, and sedative-hypnotics) received as a time-varying outcome measure across each 30-day "month" period postintake for at least 6 months for all participants. Results: Sample 1 of 285 opioid users were 61.1 years of age (±13.5), 57.5% female, and using an average of 49.7 (±98.5) morphine equivalents daily at intake. Unadjusted analyses found a modest decline in morphine equivalents to 43.9 mg (±94.1 mg) from 49.7 (±98.5) in month 1 (p=0.047) while receiving relatively low doses of THC (2.93 mg/day) and CBD (2.15 mg/day). Sample 2 of 95 opioid and sedative-hypnotic users were 60.9 years of age (±13.1), 63.2% female, and using an average of 86.6 (±136.2) morphine equivalents daily, and an average of 4.3 (±5.6) lorazepam equivalents. Unadjusted analyses did not find significant changes in either morphine equivalents (p=0.81) or lorazepam equivalents (p=0.980), and patients similarly received relatively low doses of THC (2.32 mg/day) and CBD (2.24 mg/day). Conclusions: Findings demonstrated minimal to no change in either opioids or sedative hypnotics over the 6 months of medical cannabis use but may be limited by low retention rates, external generalizability, and an inability to account for nonprescribed substance use.
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Affiliation(s)
- Arthur Robin Williams
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, New York, New York, USA
- Research Foundation for Mental Hygiene, New York, New York, USA
| | - Christine M. Mauro
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Tianshu Feng
- Research Foundation for Mental Hygiene, New York, New York, USA
| | - Josef Waples
- City University of New York School of Professional Studies, New York, New York, USA
| | - Silvia S. Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Margaret Haney
- Research Foundation for Mental Hygiene, New York, New York, USA
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Millhollon R, Elenwo C, Lundberg A, Roberts W, Beaman J, Bray N, Hartwell M. Associations of clinical personnel characteristics and controlled substance prescribing practices. J Osteopath Med 2023; 123:451-458. [PMID: 37134110 DOI: 10.1515/jom-2022-0234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/24/2023] [Indexed: 05/04/2023]
Abstract
CONTEXT Over 68,000 deaths were attributed to opioid-related overdose in 2020. Evaluative studies have shown that states that utilized Prescription Drug Monitoring Program (PDMP) systems have decreased opioid-related deaths. With the growing use of PDMPs and an ongoing opioid epidemic, determining the demographics of physicians at risk of overprescribing can elucidate prescribing practices and inform recommendations to change prescribing behaviors. OBJECTIVES This study aims to assess prescribing behaviors by physicians in 2021 based on four demographics utilizing the National Electronic Health Record System (NEHRS): physician's age, sex, specialty, and degree (MD or Doctor of Osteopathic Medicine [DO]). METHODS We performed a cross-sectional study of the 2021 NEHRS to determine the relationship between physician characteristics and PDMP use on opioid-prescribing behaviors. Differences between groups were measured via design-based chi-square tests. We constructed multivariable logistic regression models to assess the relationships, via adjusted odds ratios (AOR), between physician characteristics and alternate prescribing patterns. RESULTS Compared to female physicians, male physicians were more likely to alter their original prescription to reduce morphine milligram equivalents (MMWs) prescribed for a patient (AOR: 1.60; CI: 1.06-2.39; p=0.02), to change to a nonopioid/nonpharmacologic option (AOR: 1.91; 95 % CI: 1.28-2.86; p=0.002), to prescribe naloxone (AOR=2.06; p=0.039), or to refer for additional treatment (AOR=2.07; CI: 1.36-3.16; p<0.001). Compared to younger physicians, those over the age of 50 were less likely to change their prescription to a nonopioid/nonpharmacologic option (AOR=0.63; CI: 0.44-0.90; p=0.01) or prescribe naloxone (AOR=0.56, CI: 0.33-0.92; p=0.02). CONCLUSIONS Our results showed a statistically significant difference between specialty category and frequency of prescribing controlled substances. After checking the PDMP, male physicians were more likely to alter their original prescription to include harm-reduction strategies. Optimizing the use of PDMP systems may serve to improve prescribing among US physicians.
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Affiliation(s)
- Robert Millhollon
- Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at Cherokee Nation, Tahlequah, OK, USA
| | - Covenant Elenwo
- Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at Cherokee Nation, Tahlequah, OK, USA
| | - Alex Lundberg
- Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at Cherokee Nation, Tahlequah, OK, USA
| | - Will Roberts
- Department of Anesthesia, Oklahoma State University Medical Center, Tulsa, OK, USA
| | - Jason Beaman
- National Center for Wellness and Recovery, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
- Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Natasha Bray
- Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at Cherokee Nation, Tahlequah, OK, USA
| | - Micah Hartwell
- Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at Cherokee Nation, Tahlequah, OK, USA
- Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
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Gupta S, Nguyen T, Freeman PR, Simon K. Competitive effects of federal and state opioid restrictions: Evidence from the controlled substance laws. J Health Econ 2023; 91:102772. [PMID: 37634274 DOI: 10.1016/j.jhealeco.2023.102772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 05/07/2023] [Accepted: 05/16/2023] [Indexed: 08/29/2023]
Abstract
A significant concern in the policy landscape of the U.S. opioid crisis is whether supply-side controls can reduce opioid prescribing without harmful substitution. We consider an unstudied policy: the federal Controlled Substance Act (CSA) restrictions placed in August 2014 on tramadol, the second most popular opioid medication. This was followed seven weeks later by CSA restrictions for hydrocodone combination products, the leading opioids on the market. Using regression discontinuity design (RDD) models, based on the timing of the (up-)scheduling changes, to explore spillover effects, we find that tightening prescribing restrictions on one opioid reduces its use, but increases prescribing of close competitors, leading to no reduction in total opioid prescriptions.This suggests that supply restrictions are not effective in reducing opioid prescribing the presence of close substitutes that remain unrestricted.
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Affiliation(s)
- Sumedha Gupta
- Department of Economics, IUPUI, Cavanaugh Hall, Room 523, 425 University Boulevard, Indianapolis, IN 46032, United States of America.
| | - Thuy Nguyen
- School of Public Health, University of Michigan, 1415 Washington Heights, M3234 SPH II, Ann Arbor, MI 48109, United States of America.
| | - Patricia R Freeman
- College of Pharmacy, University of Kentucky, Lee T. Todd. Jr. Building, Room 260, 789 S. Limestone Street, Lexington, KY 40536, United States of America.
| | - Kosali Simon
- O'Neill School of Public and Environmental Affairs, Indiana University and NBER, 1315 East Tenth Street, Room 443, Bloomington, IN 47405, United States of America.
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15
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Freeman PR, McAninch J, Dasgupta N, Oyler DR, Slavov K, Collins C, Hargrove S, Freeman E, Miracle D, Slavova S. Drugs involved in Kentucky drug poisoning deaths and relation with antecedent controlled substance prescription dispensing. Subst Abuse Treat Prev Policy 2023; 18:53. [PMID: 37658455 PMCID: PMC10474700 DOI: 10.1186/s13011-023-00561-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 06/27/2023] [Accepted: 08/21/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND The shift from prescription to illicit drugs involved in drug poisoning deaths raises questions about the current utility of prescription drug monitoring program (PDMP) data to inform drug poisoning (overdose) prevention efforts. In this study, we describe relations between specific drugs involved in Kentucky drug poisoning deaths and antecedent controlled substance (CS) dispensing. METHODS The study used linked death certificates and PDMP data for 2,248 Kentucky resident drug poisoning deaths in 2021. Death certificate literal text analysis identified drugs mentioned with involvement (DMI) in drug poisoning deaths. We characterized the concordance between each DMI and the CS dispensing history for this drug at varying timepoints since 2008. RESULTS Overall, 25.5% of all decedents had dispensed CS in the month before fatal drug poisoning. Over 80% of decedents were dispensed opioid(s) since 2008; the percentage was similar regardless of opioid involvement in the poisoning death. One-third of decedents had dispensed buprenorphine for treatment of opioid use disorder since 2008, but only 6.1% had dispensed buprenorphine in the month preceding death. Fentanyl/fentanyl analogs were DMI in 1,568 (69.8%) deaths, yet only 3% had received a fentanyl prescription since 2008. The highest concordance in the month preceding death was observed for clonazepam (43.6%). CONCLUSION Overall, concordance between CS dispensing history and the drugs involved in poisoning deaths was low, suggesting a need to reevaluate the complex relationships between prescription medication exposure and overdose death and to expand harm reduction interventions both within and outside the healthcare system to reduce drug poisoning mortality.
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Affiliation(s)
- Patricia R Freeman
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA.
| | - Jana McAninch
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Nabarun Dasgupta
- Injury Prevention Research Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Krassimir Slavov
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Candice Collins
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Sarah Hargrove
- Kentucky Injury Prevention and Research Center, University of Kentucky, Lexington, KY, USA
| | - Edward Freeman
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Dustin Miracle
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Svetla Slavova
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
- Kentucky Injury Prevention and Research Center, University of Kentucky, Lexington, KY, USA
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Nester T, Proffitt K, Anderson J, Hays A, Eidem L, Greszler C. Utilization of a technology-assisted workflow to prepare controlled substance oral syringes. Am J Health Syst Pharm 2023; 80:1063-1070. [PMID: 37210711 DOI: 10.1093/ajhp/zxad112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Indexed: 05/23/2023] Open
Abstract
PURPOSE Utilization of technology-assisted workflow (TAWF) systems has gained popularity in the sterile compounding setting. This study was designed to evaluate whether safety and efficiency could be seen when preparing oral controlled substance doses gravimetrically vs volumetrically. METHODS This 2-phase observational study combined manual data collection with automated logs generated by a single TAWF. During phase I, oral controlled substance solutions were prepared volumetrically. In phase II, the same subset of medications was to be prepared gravimetrically via the same TAWF. Findings from phases I and II were compared against each another to determine safety, efficiency, and documentation differences between the volumetric and gravimetric workflows. RESULTS Thirteen different medications were evaluated during phase I (1,495 preparations) and phase II (1,781 preparations) of this study. Mean compounding time (min:sec) increased in phase II when compared to phase I (1:49 vs 1:28; P < 0.01), with the deviation detection rate also increasing (7.9% vs 4.7%; P < 0.01). Despite a target in phase II of utilizing gravimetric analysis for more than 80% of preparations, only 45.5% (811 preparations) were prepared with this workflow, as adoption challenges and dose size limitations prevented compliance. Doses that were prepared gravimetrically had a mean accuracy rate of 100.6% (the mean achieved dose was 0.6% higher than the mean prescribed dose) and a rejection rate of 0.99% (compared to the phase I rejection rate of 1.07%; P = 0.67). CONCLUSION The gravimetric workflow provided accuracy and additional safety checks when compared to the volumetric alternative, all while providing users with greater access to data. Health systems should consider staffing, product sourcing, patient populations, and medication safety when determining the balance between volumetric and gravimetric workflows.
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Affiliation(s)
| | | | | | - Amanda Hays
- Becton, Dickinson and Company, San Diego, CA, USA
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17
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Friedman J, Godvin M, Molina C, Romero R, Borquez A, Avra T, Goodman-Meza D, Strathdee S, Bourgois P, Shover CL. Fentanyl, heroin, and methamphetamine-based counterfeit pills sold at tourist-oriented pharmacies in Mexico: An ethnographic and drug checking study. Drug Alcohol Depend 2023; 249:110819. [PMID: 37348270 PMCID: PMC10368172 DOI: 10.1016/j.drugalcdep.2023.110819] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/30/2023] [Accepted: 06/03/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Fentanyl- and methamphetamine-based counterfeit prescription drugs have driven escalating overdose death rates in the US, however their presence in Mexico has not been assessed. Our ethnographic team has conducted longitudinal research focused on illicit drug markets in Northern Mexico since 2018. In 2021-2022, study participants described the arrival of new, unusually potent tablets sold as ostensibly controlled substances, without a prescription, directly from pharmacies that cater to US tourists. AIMS To characterize the availability of counterfeit and authentic controlled substances at pharmacies in Northern Mexico available to English-speaking tourists without a prescription. METHODS We employed an iterative, exploratory, mixed methods design. Longitudinal ethnographic data was used to characterize tourist-oriented micro-neighborhoods and guide the selection of n=40 pharmacies in n=4 cities in Northern Mexico. In each pharmacy, samples of "oxycodone", "Xanax", and "Adderall" were sought as single pills, during English-language encounters, after which detailed ethnographic accounts were recorded. We employed immunoassay-based testing strips to check each pill for the presence of fentanyls, benzodiazepines, amphetamines, and methamphetamines. We used Fourier-Transform Infrared Spectroscopy to further characterize drug contents. RESULTS Of n=40 pharmacies, one or more of the requested controlled substances could be obtained with no prescription (as single pills or in bottles) at 28 (70.0%) and as single pills at 19 (47.5%). Counterfeit pills were obtained at 11 pharmacies (27.5%). Of n=45 samples sold as one-off controlled substances, 18 were counterfeit. 7 of 11 (63.6%) samples sold as "Adderall" contained methamphetamine, 8 of 27 (29.6%) samples sold as "Oxycodone" contained fentanyl, and 3 "Oxycodone" samples contained heroin. Pharmacies providing counterfeit drugs were uniformly located in tourist-serving micro-neighborhoods, and generally featured English-language advertisements for erectile dysfunction medications and "painkillers". Pharmacy employees occasionally expressed concern about overdose risk and provided harm reduction guidance. DISCUSSION The availability of fentanyl-, heroin-, and methamphetamine-based counterfeit medications in tourist-oriented independent pharmacies in Northern Mexico represents a public health risk, and occurs in the context of 1) the normalization of medical tourism as a response to rising unaffordability of healthcare in the US, 2) plummeting rates of opioid prescription in the US, affecting both chronic pain patients and the availability of legitimate pharmaceuticals on the unregulated market, 3) the rise of fentanyl-based counterfeit opioids as a key driver of the fourth, and deadliest-to-date, wave of the opioid crisis. It was not possible to distinguish counterfeit medications based on appearance of pills or geography of pharmacies, because identically-appearing authentic and counterfeit versions were often sold in close geographic proximity. Nevertheless, people who consume drugs may be more trusting of controlled substances purchased directly from pharmacies. Due to Mexico's limited opioid overdose surveillance infrastructure, the current death rate from these substances remains unknown.
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Affiliation(s)
- Joseph Friedman
- Center for Social Medicine and Humanities, University of California, Los Angeles, United States.
| | - Morgan Godvin
- The Action Lab, Center for Health Policy and Law, Northeastern University, United States
| | - Caitlin Molina
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, United States
| | - Ruby Romero
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, United States
| | - Annick Borquez
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, United States
| | - Tucker Avra
- David Geffen School of Medicine, University of California, Los Angeles, United States
| | - David Goodman-Meza
- Division of Infectious Diseases, University of California, Los Angeles, United States
| | - Steffanie Strathdee
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, United States
| | - Philippe Bourgois
- Center for Social Medicine and Humanities, University of California, Los Angeles, United States
| | - Chelsea L Shover
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, United States
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Baum SG, Jorgenson TL, Kominek C, Brooks A, Rose K. DEA-registered clinical pharmacist practitioners: Progressing practice to increase patient care access. Am J Health Syst Pharm 2023; 80:984-993. [PMID: 37156640 DOI: 10.1093/ajhp/zxad101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Indexed: 05/10/2023] Open
Abstract
PURPOSE This descriptive review aims to describe the impact of controlled substance prescriptive authority (CSPA) among Drug Enforcement Administration (DEA)-registered clinical pharmacist practitioners (pharmacists) within the Veterans Health Administration (VA). The practice perspectives of pharmacists with CSPA are also reviewed. A 3-part methodology included identification and query of DEA-registered pharmacists, practice impact data analysis, and time and motion prescribing analysis. SUMMARY Between quarter 1 of fiscal year 2018 and quarter 2 of fiscal year 2022, the number of DEA-registered pharmacists in the VA grew by 314%, from 21 to 87 pharmacists. Pharmacists in pain management and mental health reported benefits of CSPA, with the most common being practice autonomy (93%), increased efficiency (92%), and reduced burden on other prescribers (89%). Initial challenges to pharmacists obtaining DEA registration included a lack of incentive (46%) and concern about increased liability (37%). A time and motion analysis demonstrated that pharmacists with CSPA saved a median of 12 minutes for prescription writing compared to those without CSPA. CONCLUSION There is an opportunity for DEA-registered pharmacists to meet patient care needs to fill gaps in care from physician shortages, improve health equity, and provide quality healthcare for vulnerable, underserved populations, especially in areas where controlled substance prescribing is common. To fully optimize the role of the pharmacist, it is imperative that state practice acts be expanded to include pharmacist DEA authority as part of collaborative practice and that fair and equitable payment models be established for pharmacist comprehensive medication management.
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Affiliation(s)
- Shekinah G Baum
- Western North Carolina Veterans Affairs Health Care System (WNCVAHCS), Asheville, NC, USA
| | - Terri L Jorgenson
- Clinical Practice Integration and Model Advancement, Clinical Pharmacy Practice Office, Pharmacy Benefits Management (PBM), US Department of Veterans Affairs, Washington, DC, USA
| | | | - Abigail Brooks
- West Palm Beach Veterans Affairs Medical Center, West Palm Beach, FL, USA
| | - Kellie Rose
- VA MidSouth Healthcare Network, Nashville, TN, USA
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Gunadi C, Shi Y. Prescription drug monitoring programs use mandates and prescription stimulant and depressant quantities. BMC Public Health 2023; 23:1326. [PMID: 37434122 PMCID: PMC10334646 DOI: 10.1186/s12889-023-16256-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 02/09/2023] [Accepted: 07/06/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND While the mandate to check patients' prescription history in Prescription Drug Monitoring Program (PDMP) database before prescribing/dispensing controlled drugs has been shown to be an important tool to curb opioid abuse, less is known about whether the mandate can reduce the misuse of other commonly abused prescription drugs. We examined whether PDMP use mandates were associated with changes in prescription stimulant and depressant quantities. METHODS Using data from Automated Reports and Consolidate Ordering System (ARCOS), we employed difference-in-differences design to estimate the association between PDMP use mandates and prescription stimulant and depressant quantities in 50 U.S. states and the District of Columbia from 2006 to 2020. Limited PDMP use mandate was specific only to opioids or benzodiazepines. Expansive PDMP use mandate was non-specific to opioid or benzodiazepine and required prescribers/dispensers to check PDMP when prescribing/dispensing targeted controlled substances in Schedule II-V. The main outcomes were population-adjusted prescription stimulant (amphetamine, methylphenidate, lisdexamfetamine) and depressant (amobarbital, butalbital, pentobarbital, secobarbital) quantities in grams. RESULTS There was no evidence that limited PDMP use mandate was associated with a reduction in the prescription stimulant and depressant quantities. However, expansive PDMP use mandate that was non-specific to opioid or benzodiazepine and required prescribers/dispensers to check PDMP when prescribing/dispensing targeted controlled substances in Schedule II-V was associated with 6.2% (95% CI: -10.06%, -2.08%) decline in prescription amphetamine quantity. CONCLUSION Expansive PDMP use mandate was associated with a decline in prescription amphetamine quantity. Limited PDMP use mandate did not appear to change prescription stimulant and depressant quantities.
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Affiliation(s)
- Christian Gunadi
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0628, USA.
| | - Yuyan Shi
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0628, USA
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20
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Nguyen RV, Melton BL, Rohling BJ, Ward KS, Newell BJ. Impact of state mandates on electronic prescribing of acute opioid prescriptions for the treatment of pain in Kansas and Colorado. J Am Pharm Assoc (2003) 2023; 63:1150-1155. [PMID: 37236508 DOI: 10.1016/j.japh.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/19/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Government and health care entities are seeking solutions to optimize safe opioid prescribing practices. Electronic prescribing of controlled substance (EPCS) state mandates are becoming common, but lack thorough evaluation. OBJECTIVE This study aimed to evaluate whether EPCS state mandates affect opioid prescribing patterns for acute pain treatment. METHODS This retrospective study was designed to assess prescribing patterns via percent change for quantity, day supply, and prevalence of prescribing method utilized for opioid prescriptions 3 months pre- and post-EPCS mandate. Prescription data are extracted from two regional divisions of a large community-based pharmacy chain between April 1, 2021 to October 1, 2021. Relationships of patient geographical locations and prescribing methods were assessed. Likewise, the relationship of opioids prescribed between insurance types were evaluated. Data was evaluated utilizing Chi-Square and Mann-Whitney U tests, with an a-priori alpha of 0.05. RESULTS There was an increase before to after state mandate of quantity and day supply (0.8% and 1.3% [P = 0.02; P < 0.001], respectively). There were significant decreases in total daily dose and daily morphine milligram equivalent (2.0% and 1.9% [P < 001; P = 0.254], respectively). A 16.3% increase was seen in electronic prescribing before to after state mandate for prevalence of electronic prescribing versus other prescribing methods. CONCLUSION There is a correlation between EPCS and prescribing patterns for acute pain treatment with opioids. The use of electronic prescribing increased after state mandate. By promoting the use of electronic prescribing, the benefit of awareness and caution of opioid use draws attention to prescribers.
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Rodrigues CHP, Mariotto LS, Castro JS, Peruquetti PH, Silva-Junior NC, Bruni AT. Acute, chronic, and post-mortem toxicity: a review focused on three different classes of new psychoactive substances. Forensic Toxicol 2023; 41:187-212. [PMID: 36604359 DOI: 10.1007/s11419-022-00657-3] [Citation(s) in RCA: 1] [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: 08/27/2022] [Accepted: 12/22/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE New psychoactive substances (NPS) are not controlled under the Single Convention on Narcotic Drugs of 1961 or the 1971 Convention, but they may pose a public health threat. Knowledge of the main properties and toxicological effects of these substances is lacking. According to the current Drugs Law (Law n. 11.343/2006), the Brazilian Surveillance Agency issues directives for forbidden substances in Brazil, and structural classes of synthetic cannabinoids, cathinones, and phenylethylamines are considered illicit drugs. Considering that data on these controlled substances are scattered, the main objective of this work was to collect and organize data to generate relevant information on the toxicological properties of NPS. METHODS We carried out a literature review collecting information on the acute, chronic, and post-mortem toxicity of these classes of NSP. We searched info in five scientific databases considering works from 2017 to 2021 and performed a statistical evaluation of the data. RESULTS Results have shown a general lack of studies in this field given that many NPS have not had their toxicity evaluated. We observed a significant difference in the volume of data concerning acute and chronic/post-mortem toxicity. Moreover, studies on the adverse effects of polydrug use are scarce. CONCLUSIONS More in-depth information about the main threats involving NPS use are needed.
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Affiliation(s)
- Caio H P Rodrigues
- Department of Chemistry, Faculty of Philosophy, Science and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, 14040-901, Brazil
- INCT Forense - Department of Chemistry, Faculty of Philosophy, Science and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, 14040-901, Brazil
| | - Lívia S Mariotto
- Department of Chemistry, Faculty of Philosophy, Science and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, 14040-901, Brazil
- INCT Forense - Department of Chemistry, Faculty of Philosophy, Science and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, 14040-901, Brazil
| | - Jade S Castro
- Department of Chemistry, Faculty of Philosophy, Science and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, 14040-901, Brazil
- INCT Forense - Department of Chemistry, Faculty of Philosophy, Science and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, 14040-901, Brazil
| | - Paulo H Peruquetti
- Department of Chemistry, Faculty of Philosophy, Science and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, 14040-901, Brazil
| | - Newton C Silva-Junior
- Department of Chemistry, Faculty of Philosophy, Science and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, 14040-901, Brazil
- INCT Forense - Department of Chemistry, Faculty of Philosophy, Science and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, 14040-901, Brazil
| | - Aline T Bruni
- Department of Chemistry, Faculty of Philosophy, Science and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, 14040-901, Brazil.
- INCT Forense - Department of Chemistry, Faculty of Philosophy, Science and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, 14040-901, Brazil.
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22
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Mehta S, Brown W, Ferguson E, Najera J, Pantell MS. The association between prescription drug monitoring programs and controlled substance prescribing: a cross-sectional study using data from 2019 National Electronic Health Records Survey. J Am Med Inform Assoc 2023; 30:1042-1046. [PMID: 37011637 PMCID: PMC10198531 DOI: 10.1093/jamia/ocad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 12/01/2022] [Revised: 02/06/2023] [Accepted: 03/15/2023] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE The use of controlled medications such as opioids, stimulants, anabolic steroids, depressants, and hallucinogens has led to an increase in addiction, overdose, and death. Given the high attributes of abuse and dependency, prescription drug monitoring programs (PDMPs) were introduced in the United States as a state-level intervention. MATERIALS AND METHODS Using cross-sectional data from the 2019 National Electronic Health Records Survey, we assessed the association between PDMP usage and reduced or eliminated controlled substance prescribing as well as the association between PDMP usage and changing a controlled substance prescription to a nonopioid pharmacologic therapy or nonpharmacologic therapy. We applied survey weights to produce physician-level estimates from the survey sample. RESULTS Adjusting for physician age, sex, type of medical degree, specialty, and ease of PDMP, we found that physicians who reported "often" PDMP usage had 2.34 times the odds of reducing or eliminating controlled substance prescriptions compared to physicians who reported never using the PDMP (95% confidence interval [CI] 1.12-4.90). Adjusting for physician age, sex, type of doctor, and specialty, we found that physicians who reported "often" use of the PDMP had 3.65 times the odd of changing controlled substance prescriptions to a nonopioid pharmacologic therapy or nonpharmacologic therapy (95% CI: 1.61-8.26). DISCUSSION These results support the continued use, investment, and expansion of PDMPs as an effective intervention for reducing controlled substance prescription and changing to nonopioid/pharmacologic therapy. CONCLUSION Overall, frequent usage of PDMPs was significantly associated with reducing, eliminating, or changing controlled substance prescription patterns.
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Affiliation(s)
- Shivani Mehta
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - William Brown
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Medicine, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, California, USA
- Bakar Computational Health Science Institute, University of California, San Francisco, San Francisco, California, USA
- Center for Digital Health Innovation, University of California San Francisco School of Medicine, San Francisco, California, USA
- Department of Medicine, Division of Prevention Science, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, USA
| | - Erin Ferguson
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - James Najera
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Matthew S Pantell
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
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23
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Dai Z. Recent Advances in the Development of Portable Electrochemical Sensors for Controlled Substances. Sensors (Basel) 2023; 23:3140. [PMID: 36991851 PMCID: PMC10058808 DOI: 10.3390/s23063140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 06/19/2023]
Abstract
This review article summarizes recent achievements in developing portable electrochemical sensing systems for the detection and/or quantification of controlled substances with potential on-site applications at the crime scene or other venues and in wastewater-based epidemiology. Electrochemical sensors employing carbon screen-printed electrodes (SPEs), including a wearable glove-based one, and aptamer-based devices, including a miniaturized aptamer-based graphene field effect transistor platform, are some exciting examples. Quite straightforward electrochemical sensing systems and methods for controlled substances have been developed using commercially available carbon SPEs and commercially available miniaturized potentiostats. They offer simplicity, ready availability, and affordability. With further development, they might become ready for deployment in forensic field investigation, especially when fast and informed decisions are to be made. Slightly modified carbon SPEs or SPE-like devices might be able to offer higher specificity and sensitivity while they can still be used on commercially available miniaturized potentiostats or lab-fabricated portable or even wearable devices. Affinity-based portable devices employing aptamers, antibodies, and molecularly imprinted polymers have been developed for more specific and sensitive detection and quantification. With further development of both hardware and software, the future of electrochemical sensors for controlled substances is bright.
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Affiliation(s)
- Zhaohua Dai
- Forensic Science Program, Department of Chemistry and Physical Sciences, Pace University, New York, NY 10038, USA
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24
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Howell BA, Black AC, Grau LE, Lin HJ, Greene C, Lee H, Heimer R, Hawk KE, D'Onofrio G, Fiellin DA, Becker WC. Concordance between controlled substance receipt and post-mortem toxicology in opioid-detected overdose deaths: A statewide analysis. Drug Alcohol Depend 2023; 244:109788. [PMID: 36738634 PMCID: PMC9975083 DOI: 10.1016/j.drugalcdep.2023.109788] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/16/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND Opioid overdoses are a leading cause of preventable death in the United States. There is limited research linking decedents' receipt of controlled substances and presence of controlled substances on post-mortem toxicology (PMT). METHODS We linked data on opioid-detected deaths in Connecticut between May 3, 2016, and December 31, 2017 from the Office of the Chief Medical Examiner, Department of Consumer Protection, and Department of Mental Health and Addiction Services. Exposure was defined as receipt of an opioid or benzodiazepine prescription within 90 days prior to death. Our primary outcome was concordance between medication received and metabolites in PMT. RESULTS Our analysis included 1412 opioid-detected overdose deaths. 47 % received an opioid or benzodiazepine 90 days prior to death; 36 % received an opioid and 27 % received a benzodiazepine. Concordance between receipt of an opioid or benzodiazepine and its presence in PMT was observed in 30 % of opioid-detected deaths. Concordance with an opioid was present in 17 % of opioid-detected deaths and concordance with a benzodiazepine was present in 21 % of opioid-detected deaths. Receipt of an opioid or benzodiazepine and concordance with PMT were less common in fentanyl or heroin-detected deaths and more common in pharmaceutical opioid-detected deaths. DISCUSSION Our results suggest medically supplied opioids and benzodiazepines potentially contributed to a substantial number, though minority, of opioid-detected deaths during the study period. Efforts to reduce opioid and benzodiazepine prescribing may reduce risk of opioid-detected deaths in this group, but other approaches will be needed to address most opioid-detected deaths that involved non-pharmaceutical opioids.
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Affiliation(s)
- Benjamin A Howell
- SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT, the United States of America; Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, the United States of America; Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, the United States of America.
| | - Anne C Black
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, the United States of America; Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, the United States of America; VA Connecticut Healthcare System, West Haven, CT, the United States of America
| | - Lauretta E Grau
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, the United States of America; Yale School of Public Health, New Haven, CT, the United States of America
| | - Hsiu-Ju Lin
- School of Social Work, University of Connecticut, Storrs, CT, the United States of America; Department of Mental Health and Addiction Services, Hartford, CT, the United States of America
| | - Christina Greene
- U.S. Food and Drug Administration, Silver Spring, MD, the United States of America
| | - Hana Lee
- U.S. Food and Drug Administration, Silver Spring, MD, the United States of America
| | - Robert Heimer
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, the United States of America; Yale School of Public Health, New Haven, CT, the United States of America
| | - Kathryn E Hawk
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, the United States of America; Yale School of Public Health, New Haven, CT, the United States of America; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, the United States of America
| | - Gail D'Onofrio
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, the United States of America; Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, the United States of America; Yale School of Public Health, New Haven, CT, the United States of America; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, the United States of America
| | - David A Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, the United States of America; Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, the United States of America; Yale School of Public Health, New Haven, CT, the United States of America; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, the United States of America
| | - William C Becker
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, the United States of America; Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, the United States of America; VA Connecticut Healthcare System, West Haven, CT, the United States of America
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25
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Richwine C, Everson J. National Estimates and Physician-Reported Impacts of Prescription Drug Monitoring Program Use. J Gen Intern Med 2023; 38:881-888. [PMID: 36229762 PMCID: PMC10039204 DOI: 10.1007/s11606-022-07793-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 09/06/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Despite widespread adoption of state prescription drug monitoring programs (PDMPs), it is unclear how often PDMPs are accessed through an electronic health record system (EHR-PDMP integration), or whether efforts to make PDMPs easier to access and use have improved their utility. OBJECTIVE To produce national-level estimates on the use of PDMPs among office-based physicians and benefits associated with their use. DESIGN We use nationally representative survey data to produce descriptive statistics on PDMP use and associated benefits among office-based physicians in the USA. PARTICIPANTS 1398 office-based physicians who prescribe controlled substances. MAIN MEASURES We examined physician-reported ease and frequency of PDMP use, and how EHR-PDMP integration affects frequency and ease of use. Multivariate models were used to assess whether characteristics of PDMP use were related to physician-reported benefits such as reduced prescribing of controlled substances and perceived improvements in clinical decision-making. KEY RESULTS In 2019, two-thirds of office-based physicians in the USA reported frequent use of their state PDMP and over three-quarters reported they were easy to use. Both frequency and ease of use were positively correlated with PDMP integration status. Respondents who frequently checked their state's PDMP were 8.7 percentage points (95% CI -.4 to 17.8) more likely to report perceived benefits and reported 2.2 (95% CI 1.54 to 2.83) more benefits. Respondents who indicated their PDMP was easy to use were 12.7 percentage points (95% CI .040 to .214) more likely to report perceived benefits and reported 0.94 (95% CI 0.26 to 1.61) more benefits. CONCLUSIONS Our findings suggest efforts to make PDMPs easier to access and use aided physicians in making informed clinical decisions that may not be captured by reduced prescribing alone. Efforts to further increase frequency and ease of use-including advancing a standards-based approach to PDMP and EHR data interoperability-may further increase the benefit of PDMPs.
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Affiliation(s)
- Chelsea Richwine
- Office of Technology, Office of the National Coordinator for Health Information Technology, Washington, DC, USA.
| | - Jordan Everson
- Office of Technology, Office of the National Coordinator for Health Information Technology, Washington, DC, USA
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Abstract
BACKGROUND The Rhode Island State Legislature passed the Uniform Controlled Substances Act in 2016 to limit opioid prescriptions. We aimed to objectively evaluate its effect on opioid prescribing for hand surgery patients and also identify risk factors for prolonged opioid use. METHODS A 6-month period (January-June 2016) prior to passage of the law was compared with a period following its implementation (July-December 2017). Thumb carpometacarpal arthroplasty and distal radius fracture fixation were classified as "major surgery" and carpal tunnel and trigger finger release as "minor surgery." Prescription Drug Monitoring Database was used to review controlled substances filled during the study periods. RESULTS A total of 1380 patients met our inclusion criteria, with 644 prelaw and 736 postlaw patients. Patients undergoing "major surgery" saw a significant decrease in the number of pills issued in the first postoperative prescription (41.1 vs 21.0) and a corresponding decrease in morphine milligram equivalents (MMEs) (318.6 vs 159.2 MMEs) after implementation. A 30% decrease in MMEs was also seen in those undergoing "major surgery" in the first 30 days postoperatively (544.7 vs 381.7 MMEs). Risk factors for prolonged opioid use included male sex and preoperative opioid use. CONCLUSIONS In Rhode Island, opioid-limiting legislation resulted in a significant decrease in the number of pills and MMEs of the initial prescription and a 30% decrease in total MMEs in the 30-day postoperative period after "major hand surgery." Additional research is needed to explore the association between legislation and clinical outcomes.
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Loe H, Mosti MP, Wisløff U, Haberstroh C, Flemmen G. Cardiopulmonary and muscular effects of different doses of high-intensity physical training in substance use disorder patients: study protocol for a block allocated controlled endurance and strength training trial in an inpatient setting. BMJ Open 2022; 12:e061014. [PMID: 36167363 PMCID: PMC9516060 DOI: 10.1136/bmjopen-2022-061014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Patients with substance use disorder (SUD) have high prevalence of lifestyle-related comorbidities. Physical exercise is known to yield substantial prophylactic impact on disease and premature mortality, and there seems to be an inverse association between physical fitness and adverse health outcomes. High-intensity training is regarded as most effective for improving physical fitness, but less is known concerning the ideal training dose necessary to achieve clinically relevant effects in these patients. The aim of this study is to compare the effect of low-dose and high-dose, high-intensity training, on physical fitness in patients diagnosed with SUD. METHODS AND ANALYSIS This study will recruit 40 in-patients of mixed genders, aged 18-70 years. Participants will be block allocated to low-dose or high-dose training, encompassing 24 high-intensity interval and maximal strength training sessions (3/week × 8 weeks). After a 10 min warm-up, the low-dose group will perform 1×4 min intervals at ⁓90% of maximal heart rate and 2×4 repetitions strength training at ⁓90% of 1 repetition maximum. The high-dose group will perform 4×4 min intervals at ⁓90% of maximal heart rate and 4×4 repetitions strength training at ⁓90% of 1 repetition maximum. Clinical measurements and physical tests will be conducted at baseline, midway and on completion and a questionnaire on physical activity will be administered at baseline. ETHICS AND DISSEMINATION This protocol is in accordance with the Standard Protocol Items: Recommendations for Interventional Trials statement. All participants will sign a written informed consent. The Regional Committee of Medical Research Ethics, Norway has approved the study. A study of this kind is warranted, and the results will be published in an open access journal to ensure public access, and presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT04065334.
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Affiliation(s)
- Henrik Loe
- Department of Research and Development, Clinic of Substance use and Addicition Medicine, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - Mats Peder Mosti
- Department of Research and Development, Clinic of Substance use and Addicition Medicine, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ulrik Wisløff
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Carolin Haberstroh
- Department of Research and Development, Clinic of Substance use and Addicition Medicine, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - Grete Flemmen
- Department of Research and Development, Clinic of Substance use and Addicition Medicine, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
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28
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Coleman C, Lennon RP, Robinson JM, Tuan WJ, Sehgal N, Zgierska AE. Provider and patient sex disparities in opioid prescribing and patient outcomes. J Opioid Manag 2022; 18:435-445. [PMID: 36226783 DOI: 10.5055/jom.2022.0737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To assess sex disparities in opioid prescribing practices and patient outcomes. DESIGN A retrospective cross-sectional study. SETTING Thirty-three primary care clinics in an academic health system. PARTICIPANTS 2,738 adults prescribed 10+ outpatient opioid prescriptions within 12 months. MAIN OUTCOME MEASURE(S) Patient and primary care provider (PCP) sexbased differences in clinical outcomes, opioid prescribing, and rates of adherence to guideline-concordant opioid prescribing practices. RESULTS Female PCPs were more likely (p < 0.001) to prescribe lower morphineequivalent daily dose (MEDD) of opioids and complete risk assessment for opioid misuse than male PCPs. PCPs did not differ by sex in adherence rates to controlled substance agreements, urine drug, depression screening, or opioid-benzodiazepine coprescribing. Female patients were more likely (all p ≤ 0.01) to be screened for opioid misuse, treated with lower MEDD, receive opioid-benzodiazepine coprescriptions, have higher pain interference, anxiety and depression diagnoses, and have an overdose diagnosis; they were less likely (all p < 0.001) to report alcohol use or have an alcohol use disorder diagnosis and utilized health care at higher rates than male patients. CONCLUSIONS Sex differences were found in clinician opioid-prescribing practices and adherence to opioid prescribing guidelines and patient characteristics associated with long-term opioid therapy. Strategies to identify sex-related disparities and enhance guideline-concordant opioid prescribing and monitoring could contribute to improved patient care, and clinical and safety outcomes.
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Affiliation(s)
- Christa Coleman
- Departments of Psychiatry and Behavioral Health and Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, Pennsylvania. ORCID: https://orcid.org/0000-0003-4255-5592
| | - Robert P Lennon
- Department of Family and Community Medicine, Penn State College of Medicine, Affiliate Faculty, Penn State Law, University Park, Pennsylvania
| | - James M Robinson
- Center for Health Systems Research and Analysis, University of Wisconsin-Madison, Madison, Wisconsin
| | - Wen-Jan Tuan
- Department of Family and Community Medicine, and Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Nalini Sehgal
- Department of Orthopedic & Rehabilitation Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Aleksandra E Zgierska
- Departments of Family and Community Medicine, Public Health Sciences, and Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, Pennsylvania
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29
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Oyler DR, Slavova S, Freeman PR, Huang Z, Talbert J, Walsh SL, Westgate PM. Broadband internet subscription rates and opioid prescribing via telemedicine during the COVID-19 pandemic. J Rural Health 2022; 38:900-907. [PMID: 35224768 PMCID: PMC9115233 DOI: 10.1111/jrh.12653] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE In response to the COVID-19 pandemic, the US DEA allowed controlled substance prescriptions to be issued following a telemedicine encounter. This study evaluated changes in opioid prescribing in Kentucky counties with low and high rates of broadband subscription before, during, and after a series of statewide emergency declarations that may have affected health care access. METHODS The study used the prescription drug monitoring program to analyze records of opioid analgesic prescriptions dispensed to opioid-naïve individuals in high (N = 26) and low (N = 94) broadband access counties during 3 periods: before a state of emergency (SOE) and executive order (EO) limiting nonemergent health care services (January 2019-February 2020), while the EO was active (March-April 2020), and after health care services began reopening (May-December 2020). Marginal generalized estimating equations-type negative binomial models were fit to compare prescription counts by broadband access over the 3 periods. FINDINGS Rates of opioid dispensing to opioid-naïve individuals decreased significantly during the EO, but increased nearly to pre-SOE levels after health care services began reopening. Dispensing rates in low broadband counties were higher than those in high broadband counties during all time periods, although these differences were negligible after adjusting for potential confounders. During the EO, prescriptions were written for longer days' supply in both county types. CONCLUSIONS The overall dramatic reduction in opioid prescribing rates should be considered when evaluating annual opioid prescribing trends. However, broadband subscription rate did not appear to influence opioid prescriptions dispensed in Kentucky during the EO.
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Affiliation(s)
- Douglas R. Oyler
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky, USA
| | - Svetla Slavova
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
- Kentucky Injury Prevention and Research Center, University of Kentucky, Lexington, Kentucky, USA
| | - Patricia R. Freeman
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky, USA
| | - Zhengyan Huang
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Jeffery Talbert
- Department of Biomedical Informatics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Sharon L. Walsh
- Department of Behavioral Science, University of Kentucky, Lexington, Kentucky, USA
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Philip M. Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
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Chua KP, Waljee JF, Smith MA, Bahl S, Nalliah RP, Brummett CM. Estimation of the Prevalence of Delayed Dispensing Among Opioid Prescriptions From US Surgeons and Dentists. JAMA Netw Open 2022; 5:e2214311. [PMID: 35622363 PMCID: PMC9142869 DOI: 10.1001/jamanetworkopen.2022.14311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Dispensing of opioid prescriptions from dentists and surgeons more than 30 days after writing, or delayed dispensing, could be a potential indicator that opioids were used for reasons or during a time frame other than that intended by the prescriber. The prevalence of delayed dispensing is unknown. Whether laws can prevent delayed dispensing by shortening the maximum period between prescription writing and dispensing is also unknown. OBJECTIVE To estimate the prevalence of delayed dispensing among opioid prescriptions from surgeons and dentists, assess the maximum period US states allow between controlled substance prescription writing and dispensing, and evaluate whether laws shortening this period decrease delayed dispensing of opioid prescriptions from surgeons and dentists. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional analysis, data from the IQVIA Formulary Impact Analyzer (representing 63% of US prescriptions) were used to identify opioid prescriptions from surgeons and dentists dispensed from 2014 through 2019. MAIN OUTCOMES AND MEASURES Among opioid prescriptions dispensed in 2019, the proportion with delayed dispensing was calculated. Using legal databases, the maximum state-allowed period between controlled substance prescription writing and dispensing as of December 2019 was examined. Using a difference-in-differences design and 2014 to 2019 data, changes in delayed dispensing prevalence were evaluated among opioid prescriptions from surgeons and dentists after a Minnesota law was enacted in July 2019 precluding opioid prescription dispensing more than 30 days after writing. Control states allowed dispensing beyond this period. RESULTS In 2019, the database included 20 858 413 opioid prescriptions from surgeons and dentists for 14 789 984 patients; 8 582 029 (58.0%) were female. The mean (SD) patient age was 47.1 (19.3) years. Of prescriptions included, 194 452 (0.9%) had delayed dispensing. As of December 2019, the maximum period between drug writing and dispensing was 180 days in 18 and 43 states for Schedule II and III drugs, respectively. Compared with control states, Minnesota's law decreased delayed dispensing prevalence by 0.22 percentage points (95% CI, -0.32 to -0.13 percentage points). CONCLUSIONS AND RELEVANCE In this cross-sectional study, 194 452 opioid prescriptions from surgeons and dentists were dispensed more than 30 days after writing. To mitigate any prescription opioid misuse associated with delayed dispensing, policy makers could shorten the maximum period between writing and dispensing of opioid prescriptions from surgeons and dentists.
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Affiliation(s)
- Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Jennifer F. Waljee
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
| | | | - Shreya Bahl
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor
| | | | - Chad M. Brummett
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
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Cunningham JL, Bremseth KA, Crane SJ, Gazelka HM, Gilliam WP, Haag JD, Melin GJ, Lai B. Multidisciplinary Controlled Substance Advisory Group Provides Support to the Primary Care Provider. Mayo Clin Proc 2022; 97:830-834. [PMID: 35410748 DOI: 10.1016/j.mayocp.2022.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/03/2021] [Accepted: 01/25/2022] [Indexed: 10/18/2022]
Affiliation(s)
| | | | - Sarah J Crane
- Department of Community Internal Medicine, Mayo Clinic, Rochester, MN
| | - Halena M Gazelka
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Wesley P Gilliam
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | | | | | - Benjamin Lai
- Department of Family Medicine, Mayo Clinic, Rochester, MN.
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Ball SJ, McCauley JA, Pruitt M, Zhang J, Marsden J, Barth KS, Mauldin PD, Gebregziabher M, Moran WP. Academic detailing increases prescription drug monitoring program use among primary care practices. J Am Pharm Assoc (2003) 2021; 61:418-424.e2. [PMID: 33812783 PMCID: PMC8273068 DOI: 10.1016/j.japh.2021.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/13/2020] [Revised: 02/10/2021] [Accepted: 02/25/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Clinical review of a prescription drug monitoring program (PDMP) is considered a valuable tool for opioid prescribing risk mitigation; however, PDMP use is often low, even in states with mandatory registration and use policies. The objective was to evaluate the impact of an academic detailing (AD) outreach intervention on PDMP use among primary care prescribers. METHODS AD intervention was delivered to primary care based controlled substance prescribers (N = 87) and their associated PDMP delegates (n = 42) by a clinical pharmacist as 1 component of a large-scale, statewide initiative to improve opioid prescribing safety. Prescriber PDMP use behavior was assessed by prescriber self-report and analysis of objective 2016-2018 PDMP data regarding the number of monthly report requests. We compared means between pre- and postintervention using a paired t test and plotted the monthly average reports over time to assess the trend of mean reports over time. Generalized linear mixed model with a negative binomial distribution was used to assess the difference in the trend and magnitude of the combined count of reports for the entire sample and prescriber subsets that were segmented on the basis of the adoption status of PDMP. RESULTS The monthly mean of reports by combined prescribers and delegates significantly increased after the AD intervention (mean 28.1 pre vs. 53.0 post; P < 0.001), with the increase in delegate reports (mean 17.1 pre vs. 60.0 post; P < 0.001) driving the overall increase. Reports were requested 40.4 times more often than in the preintervention period (P < 0.001). Patterns of pre- to postchanges in mean monthly report requests differed by baseline PDMP adoption status. CONCLUSION The AD intervention was transformative in facilitating practice change to use delegates to run reports. Visits with both prescribers and delegates, including hands-on PDMP training and registration assistance, can be viewed as beneficial for practice facilitation.
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Affiliation(s)
- Sarah J. Ball
- Division of General Internal Medicine, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jenna A. McCauley
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Megan Pruitt
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, Medical University of South Carolina, USA
| | - Jingwen Zhang
- Division of General Internal Medicine, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Justin Marsden
- Division of General Internal Medicine, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kelly S. Barth
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Patrick D. Mauldin
- Division of General Internal Medicine, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, USA
| | - William P. Moran
- Division of General Internal Medicine, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
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Reynolds AM, Reynolds CJ, Craig-Rodriguez A. APRNs' controlled substance prescribing and readiness following Florida legislative changes. Nurse Pract 2021; 46:48-55. [PMID: 34004642 DOI: 10.1097/01.npr.0000751796.01625.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Two years after the Florida legislature expanded APRN prescribing to include schedule II-IV drugs in 2017, we studied APRN utilization of this prescriptive authority. Study results reveal that Florida APRNs are meeting the educational requirements to prescribe and apply the use of these drugs in practice, improving patient access to care.
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Campbell LS, Coomer TN, Jacob GK, Lenz RJ. Gabapentin controlled substance status. J Am Pharm Assoc (2003) 2021; 61:e218-e224. [PMID: 33674205 DOI: 10.1016/j.japh.2021.01.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/13/2021] [Accepted: 01/17/2021] [Indexed: 11/29/2022]
Abstract
Gabapentin is approved to treat postherpetic neuralgia and epilepsy with partial-onset seizures. The large majority of gabapentin prescribing is off label. Gabapentin may be abused for euphoria, potentiating the high from opiates, reduction of alcohol cravings, a cocaine-like high, as well as sedation or sleep. Individuals at the highest risk for abusing gabapentin include those with opioid abuse, mental illness, or previous history of prescription drug abuse. States are now taking action to track gabapentin use through prescription monitoring programs, and some states have reclassified it as a Schedule V controlled substance. This commentary summarizes gabapentin's abuse potential, identifies state-level actions regarding gabapentin monitoring, and discusses possible clinical implications and ways to enhance patient safety when prescribing gabapentin.
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Oh GY, Slavova S, Freeman PR. Characterization of gabapentin use in Kentucky after reclassification as a Schedule V controlled substance. J Am Pharm Assoc (2003) 2021; 61:e86-e92. [PMID: 33422420 DOI: 10.1016/j.japh.2020.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/07/2020] [Accepted: 12/13/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Owing to increasing concern over the potential for gabapentin misuse, gabapentin was reclassified as a schedule V controlled substance in Kentucky (July 2017). OBJECTIVE This study aimed to characterize gabapentin use among Kentucky residents in the first year after its scheduling. METHODS This study used Kentucky All Schedule Prescription Electronic Reporting data (2018). Gabapentin use was defined as having at least 1 dispensed gabapentin prescription, and high-dose gabapentin use was defined as an average daily dose of more than 3600 mg at the patient level. The prevalence of gabapentin use, concurrent use of gabapentin with opioid analgesics (OAs) (gabapentin-OA), and gabapentin with OAs and benzodiazepines (BDZs) (gabapentin-OA-BDZ) were assessed. Estimated prevalence rate ratio and its 95% CI were reported to compare gabapentin use rates across different demographic groups. RESULTS A total of 16% of all 2018 controlled substance prescriptions were for gabapentin, and approximately 20% of Kentucky residents with controlled substance prescriptions received gabapentin at least once in 2018. The overall prevalence of gabapentin use was 63 per 1000 residents, with the highest rates among residents aged 55-64 years (126.9 per 1000). The prevalence of gabapentin use was higher in females (74.6 per 1000) versus males (50.6 per 1000) and in residents living in the Appalachian region (88.57 per 1000) versus Central (51.78 per 1000) and Delta (66.41 per 1000) regions. Among gabapentin users, 1% were high-dose users; 27.4% and 11.9% received gabapentin-OA or gabapentin-OA-BDZ concurrently, respectively. As the average daily dose increased from less than 900 mg to high-dose, the percentage of concurrent gabapentin-OA use increased from 13.4% to 50.7%. CONCLUSION Gabapentin is widely prescribed in Kentucky, with higher rates of use observed in females, those older than 55 years and individuals living in the Appalachian region. Concurrent use of gabapentin and OAs is common, especially in those receiving high-dose gabapentin. Future studies are needed to assess the risks associated with gabapentin use.
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Knox R. Fourth Amendment Protections of Prescription Drug Monitoring Programs: Patient Privacy in the Opioid Crisis. Am J Law Med 2020; 46:375-411. [PMID: 33413012 DOI: 10.1177/0098858820975531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The opioid crisis is one of the largest public health problems in the history of the United States. Prescription drug monitoring programs ("PDMPs")-state databases containing the records of all prescriptions for controlled substances written in the state-have emerged as a means to track opioid prescribing and use. While PDMPs are typically used as a tool for physicians to inform their prescribing practices, many states also permit law enforcement to access PDMPs when investigating controlled substance distribution, often without prior judicial approval. Such law enforcement use of PDMPs raises serious questions of patient privacy. The Fourth Amendment protects individuals from unreasonable searches and seizures where they have a reasonable expectation of privacy and has been interpreted to require law enforcement have probable cause and a search warrant before infringing upon an individual's reasonable expectation of privacy. Several courts have held that patients have no reasonable expectation of privacy, or a severely diminished expectation of privacy, in their prescription drug records held in PDMPs. As support, courts rely on the third-party doctrine because the information is disclosed to physicians and then held by the state; the highly regulated nature of the prescription drug industry; and the statutory framework of the Controlled Substances Act. Such analysis disregards patients' expectation of privacy in their personal health information, the confidentiality in the physician-patient relationship, and the resulting patient incentives not to seek care. Therefore, this Article argues that law enforcement must have probable cause and a search warrant to access PDMPs because the exceptions to the Fourth Amendment's probable cause and warrant requirements do not apply.
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Affiliation(s)
- Ryan Knox
- Senior Research Fellow, Solomon Center for Health Law and Policy at Yale Law School. J.D., 2019, New York University School of Law; B.S., Health Science, 2016, Boston University. For helpful conversations and comments on earlier drafts of this article and the moot court problem which inspired this article, I would like to thank Nicholas Bagley, Mary Ann Chirba, Ariel Geist, Randy Hertz, Orin Kerr, Sylvia Law, Madhu Swarna, the staff of the N.Y.U. Moot Court Board, the judges and competitors in the 2019 Wendell F. Grimes Moot Court Competition at Boston College Law School, and the staff and anonymous peer reviewer of the American Journal of Law and Medicine. An extra special thank you to Mary Ann Chirba, who supervised my work on the moot court problem that inspired this piece and gave extensive comments on earlier drafts of this article. All opinions and errors are my own
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Usmani SA, Hollmann J, Goodin A, Hincapie-Castillo JM, Adkins LE, Ourhaan N, Oueini R, Bhagwandass H, Easey T, Vouri SM. Effects of hydrocodone rescheduling on opioid use outcomes: A systematic review. J Am Pharm Assoc (2003) 2020; 61:e20-e44. [PMID: 33127312 DOI: 10.1016/j.japh.2020.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate opioid prescribing, dispensing, and use in relation to hydrocodone-containing product (HCP) rescheduling. METHODS Seven biomedical databases and grey literature sources were searched with keywords and database-specific controlled vocabulary relevant to HCP rescheduling for items published between January 2014 and July 2019. We included English-language quasi-experimental studies that assessed changes in HCP and other opioid prescribing, dispensing, utilization, and opioid-related health outcomes before and after HCP rescheduling. A data extraction sheet was created for this review. Two authors evaluated risk of bias for each included study. Two of 4 authors each independently extracted patient demographics and opioid-related outcomes from the included studies. Conflicts were resolved by a third author. RESULTS All studies identified (n = 44) were quasi-experimental in design with 10 using an interrupted time series approach. A total of 24 studies reported a decrease in HCP prescribing by 3.1%-66.0%. Six studies reported a decrease in HCP days' supply or doses by 14.0%-80.8%. There was increased prescribing of oxycodone-containing products by 4.5%-13.9% in 5 studies, tramadol by 2.7%-53.0% in 9 studies, codeine-containing products by 0.8%-1352.9% in 8 studies). Five studies reported a decrease in morphine equivalents by at least 10%, whereas 2 studies reported an increase in morphine equivalents. Differences in populations, sample sizes, and approaches did not allow for a meta-analysis. Details regarding approach and findings were limited in published conference abstracts (n = 16). CONCLUSIONS Hydrocodone rescheduling was associated with reductions in prescribing and use of HCPs but was also associated with increased prescribing and use of other opioids, both schedule II and nonschedule II.
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Borrelli EP, Morphis B, Youssef R, Chambers LC, Hallowell BD, Bratberg J, Kogut SJ. Concurrent Utilization of Prescription Opioids and Non-opioid Controlled Substances: Rhode Island Prescription Drug Monitoring Program, 2018. R I Med J (2013) 2020; 103:53-58. [PMID: 33003681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To estimate the prevalence of concurrent prescription opioid and non-opioid controlled substance use in Rhode Island (RI). METHODS We conducted a cross sectional observational study using data from the RI Prescription Drug Monitoring Program on controlled substance prescriptions dispensed in 2018. We estimated the prevalence of concurrent use of other prescribed controlled substances among adults who received at least one opioid prescription. RESULTS In 2018, 142,692 RI adult residents received at least one opioid prescription, of whom 25.1% (99% confidence interval [CI]: 24.8-25.4) were concurrently prescribed at least one other controlled substance, including benzodiazepines (17.0%, 99% CI: 16.8-17.3), medications for insomnia (4.0%, 99% CI: 3.9-4.2), and stimulants (3.8%, 99% CI: 3.6-3.9). CONCLUSION The concurrent use of prescription opioids and other prescribed controlled substances is common. Our findings suggest an urgent need to implement focused initiatives to address controlled substance polypharmacy to reduce the risk of overdose.
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Affiliation(s)
- Eric P Borrelli
- PhD Candidate in Pharmaceutical Sciences, Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island
| | - Blake Morphis
- Director of Analytic Services, Healthcentric Advisors
| | - Rouba Youssef
- Health Information Analyst, Healthcentric Advisors. (during time of study)
| | | | | | - Jeffrey Bratberg
- Clinical Professor, Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island
| | - Stephen J Kogut
- Professor of Pharmacy Practice; Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island
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Penley B, Chen HH, Eckel SF, Ozawa S. Characteristics of online pharmacies selling Adderall. J Am Pharm Assoc (2003) 2020; 61:e103-e109. [PMID: 32912756 PMCID: PMC7476499 DOI: 10.1016/j.japh.2020.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/15/2020] [Accepted: 07/21/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Adderall (amphetamine-dextroamphetamine) is a controlled substance with harmful adverse effects if abused or misused. We assessed the availability of Adderall from common search engines, and evaluated the safety and marketing characteristics of online pharmacies selling Adderall. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS From December 2019 to February 2020, the phrase "buy Adderall online" was queried in four search engines: Google (N = 100), Bing (N = 100), Yahoo (N = 50) and DuckDuckGo (N = 50). Online pharmacies that claimed to sell Adderall and had unique Uniform Resource Locators, were active, free-access, and in English language were included. OUTCOME MEASURES Online pharmacies were categorized as rogue, unclassified, or legitimate on the basis of LegitScript classifications. Safety and marketing characteristics, and costs were collected. RESULTS Of the 62 online pharmacies found to sell Adderall, 61 were rogue or unclassified. Across all rogue and unclassified online pharmacies, prescriptions were not required (100%), pharmacist services were not offered (100%), and quantity limits were not placed on the number of Adderall purchases (100%). Rogue and unclassified online pharmacies appealed to cost, offering price discounts (61%), bulk discounts (67%), and coupon codes (70%). Contrary to their claims, cheaper prices were available for all formulations and dosages of Adderall from GoodRx than from these online pharmacies. Rogue and unclassified online pharmacies promoted and enabled the illicit purchase of Adderall, appealing to privacy (74%), offering purchase through cryptocurrency (74%), and claiming registration or accreditation of their sites (33%). CONCLUSION Rogue online pharmacies are pervasive in search engine results, enabling the illicit purchase of Adderall without a prescription. Consumers are at risk of purchasing Adderall, a medication with high abuse potential, from unsafe sources. Law enforcement, regulatory agencies, and search engines should work to further protect consumers from unregistered and illegitimate online pharmacies selling Adderall.
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Manders L, Abd-Elsayed A. Mandatory Review of Prescription Drug Monitoring Program Before Issuance of a Controlled Substance Results in Overall Reduction of Prescriptions Including Opioids and Benzodiazepines. Pain Physician 2020; 23:299-304. [PMID: 32517396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND To date, there is limited research on whether the various types of mandatory usage of prescription drug monitoring programs (PDMP) have any effects on prescribing patterns, drug usage, patient care, and drug diversion (8-10). Within the United States (US), there is wide variation in individual states' requirements for the usage of PDMPs. OBJECTIVE The objective of this study was to determine whether mandatory prescriber review of a PDMP prior to each issuance of a controlled substance resulted in a reduction in the total number of controlled substance prescriptions dispensed. STUDY DESIGN A retrospective review of the State of Wisconsin's PDMP controlled substance database from April 2015 to March 2019 was performed. The evaluation compared the number of prescriptions among individual drug classes (opioids, benzodiazepines, stimulants) dispensed throughout the state before and after April 1st, 2017, when implementation of a state law mandating the review of the PDMP during each patient encounter prior to issuing a prescription for a controlled substance took effect. SETTING Research was conducted using Wisconsin's PDMP controlled substance database from April 2015 to March 2019. During this time, controlled substance policy has come to the forefront of the nation due to issues with an opioid epidemic. METHODS Descriptive analysis was used to express data as n and % for categorical data and average ± standard deviation for numerical data. Before- and after-prescription totals were analyzed using a paired t test and Levene's test for equality of variances. The P value was considered significant at a level of less than or equal to .05. LIMITATIONS Limitations to this study included its retrospective design, focus on a single US state, and possible unforeseen contributors to cause and effect. RESULTS Prior to the enforcement of the state's mandatory PDMP legislation, an average of 844,314 controlled substance prescriptions were written monthly. Following the implementation of the law, the average monthly total prescriptions written within the state decreased to 708,063. This was an average monthly reduction of 136,251 prescriptions written or 16.1%. Statistically significant reductions were also seen in opioid and benzodiazepine subgroups (23.0%, 16.3%). CONCLUSION Our study suggests that state-enforced mandatory usage of a PDMP, which records all controlled substance prescriptions filled by a pharmacy such as opioids, benzodiazepines, amphetamines, etc. at every encounter prior to prescribing any controlled substance, can provide for a significant reduction in controlled substance prescriptions, specifically opioids and benzodiazepines. KEY WORDS Prescription drug monitoring program, opioids, mandatory usage, benzodiazepines, Wisconsin.
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Affiliation(s)
- Larry Manders
- Department of Physical Medicine and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Alaa Abd-Elsayed
- Department of Anesthesiology University of Wisconsin, School of Medicine and Public Health, Madison, WI
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Lohman D, Barrett D. Scheduling medicines as controlled substances: addressing normative and democratic gaps through human rights-based analysis. BMC Int Health Hum Rights 2020; 20:10. [PMID: 32316971 PMCID: PMC7171726 DOI: 10.1186/s12914-020-00231-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 04/06/2020] [Indexed: 12/03/2022]
Abstract
Recent years have seen contentious debate about efforts to schedule medicines such as ketamine and tramadol under the international drug control conventions. Proponents argue that misuse poses a significant risk to public health and that scheduling would help address these problems. However, scheduling of medicines can negatively affect their availability, accessibility and affordability for medical purposes, with serious health consequences for patients, especially in low and middle-income countries. The current process for scheduling medicines under the international drug control conventions does not provide sufficient normative standards through which balanced decisions may be reached. It is undemocratic in its structure and opaque in its reasoning. In this article, we argue that such decisions represent de facto limitations on the right to health and may engage the principle of non-retrogression. Using the examples of ketamine and tramadol, we propose that standard legal tests in international human rights law can help to address the normative and democratic deficits in the system and produce more rigorous, fairer and more transparent decisions.
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Affiliation(s)
- Diederik Lohman
- Dornsife School of Public Health, Drexel University, Nesbitt Hall, 3215 Market Street, Philadelphia, PA 19104 USA
| | - Damon Barrett
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 453, 405 30 Gothenburg, Sweden
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Mospan GA, Gillette C. Using MyDispense to simulate validation of controlled substance prescriptions in a pharmacy law course. Curr Pharm Teach Learn 2020; 12:193-202. [PMID: 32147162 DOI: 10.1016/j.cptl.2019.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 08/01/2019] [Accepted: 11/09/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND PURPOSE MyDispense is an innovative, web-based program which simulates a community pharmacy. Use of this software may assist students' comprehension of validating controlled substance prescriptions by determining if prescriptions contain errors or omissions. EDUCATIONAL ACTIVITY AND SETTING Fourteen MyDispense practice exercises were created and implemented into a required second-year pharmacy law course. Completion of the MyDispense exercises and performance on the pharmacy law midterm exam were recorded. A questionnaire was administered to students to receive feedback on the exercises. FINDINGS There were complete data on all 94 student pharmacists enrolled in the didactic course. Thirty-five students (37%) completed all MyDispense exercises, 15 students (16%) completed some of the exercises, and 44 (47%) did not complete any of the exercises. Linear regression results indicate that students who completed more MyDispense exercises were significantly more likely to score higher on the midterm than those who completed fewer exercises (β = 0.28, p = 0.02). Students reported moderate to high exercise value and a willingness to use the software in preparation for future pharmacy law examinations. SUMMARY MyDispense provided a platform for students to apply controlled substance laws to the prescription validation process in the community pharmacy setting. Completion of practice exercises in MyDispense was shown to positively impact student performance on a pharmacy law midterm. Students valued the innovative simulation tool and were willing to access the tool again to prepare for future examinations.
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Affiliation(s)
- Geoffrey A Mospan
- Wingate University School of Pharmacy, 515 N Main Street, Wingate, NC 28174, United States.
| | - Chris Gillette
- Wake Forest School of Medicine, Department of Physician Assistant Studies, 525 Vine St, Winston-Salem, NC 27101, United States
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Affiliation(s)
- Scott Burris
- From the Center for Public Health Law Research, Temple University Beasley School of Law (S.B.), and the School of Nursing and Perelman School of Medicine, University of Pennsylvania (E.D.A.) - all in Philadelphia; the Network for Public Health Law, Los Angeles (C.S.D.); and the School of Law, Bouvé College of Health Sciences, and Health in Justice Action Lab, Northeastern University, Boston (L.B.)
| | - Evan D Anderson
- From the Center for Public Health Law Research, Temple University Beasley School of Law (S.B.), and the School of Nursing and Perelman School of Medicine, University of Pennsylvania (E.D.A.) - all in Philadelphia; the Network for Public Health Law, Los Angeles (C.S.D.); and the School of Law, Bouvé College of Health Sciences, and Health in Justice Action Lab, Northeastern University, Boston (L.B.)
| | - Corey S Davis
- From the Center for Public Health Law Research, Temple University Beasley School of Law (S.B.), and the School of Nursing and Perelman School of Medicine, University of Pennsylvania (E.D.A.) - all in Philadelphia; the Network for Public Health Law, Los Angeles (C.S.D.); and the School of Law, Bouvé College of Health Sciences, and Health in Justice Action Lab, Northeastern University, Boston (L.B.)
| | - Leo Beletsky
- From the Center for Public Health Law Research, Temple University Beasley School of Law (S.B.), and the School of Nursing and Perelman School of Medicine, University of Pennsylvania (E.D.A.) - all in Philadelphia; the Network for Public Health Law, Los Angeles (C.S.D.); and the School of Law, Bouvé College of Health Sciences, and Health in Justice Action Lab, Northeastern University, Boston (L.B.)
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Krishnaswami S, Mukhopadhyay S, McPheeters M, Nechuta SJ. Prescribing patterns before and after a non-fatal drug overdose using Tennessee's controlled substance monitoring database linked to hospital discharge data. Prev Med 2020; 130:105883. [PMID: 31704283 DOI: 10.1016/j.ypmed.2019.105883] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 10/04/2019] [Accepted: 11/04/2019] [Indexed: 01/08/2023]
Abstract
We performed a statewide evaluation of prescribing patterns of controlled substances (CS) before and after an overdose, using Tennessee's Hospital Discharge Data System and the Controlled Substance Monitoring Database (CSMD). Adults' first non-fatal overdose discharges either from the emergency department (ED) or inpatient (IP) stay occurring between 2013 and 2016 were linked to prescriptions in the CSMD. The difference in the proportion of patients filling a prescription before versus after an overdose was calculated. Included were 49,398 patients with an overdose and a prescription record; most (60.5%) were treated in the ED. Among any drug type overdose the percentage of patients who filled a CS prescription within a year of experiencing an overdose was as follows: opioid analgesics: 59.1%, benzodiazepines: 37.3%, stimulants: 5.0%, muscle relaxants: 3.4%, concurrent opioid-benzodiazepines: 24.0% with the percent difference from before to after similar in both settings. Among patients treated for an opioid overdose, this represented a decrease in opioid analgesics filled by 9.7% (95%CI: -11.2, -8.3) among those treated in the ED, and by 7.1% (95% CI: -8.3, -5.9) among treated inpatients. Among patients treated for a heroin overdose, 12.2% (95%CI: -15.2, -9.3) fewer of those treated in the ED and 8.8% (95%CI: -15.0, -2.7%) fewer of treated inpatients filled a CS prescription in that year. The most common opioid analgesics included hydrocodone and oxycodone. The number of patients filling buprenorphine for treatment increased in the year after overdoses associated with any drug or opioids but decreased among those treated for a heroin overdose.
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Affiliation(s)
- Shanthi Krishnaswami
- Tennessee Department of Health, Office of Informatics and Analytics, 710 James Robertson Parkway, Nashville, TN 37243, United States.
| | - Sutapa Mukhopadhyay
- Tennessee Department of Health, Office of Informatics and Analytics, 710 James Robertson Parkway, Nashville, TN 37243, United States
| | - Melissa McPheeters
- Tennessee Department of Health, Office of Informatics and Analytics, 710 James Robertson Parkway, Nashville, TN 37243, United States; Departments of Health Policy and Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Avenue, 408B, Nashville, TN 37203, United States
| | - Sarah J Nechuta
- Tennessee Department of Health, Office of Informatics and Analytics, 710 James Robertson Parkway, Nashville, TN 37243, United States; Department of Public Health, Grand Valley State University, 500 Lafayette Ave Northeast, Grand Rapids, MI 49503, United States
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McMichael BJ, Van Horn RL, Viscusi WK. The impact of cannabis access laws on opioid prescribing. J Health Econ 2020; 69:102273. [PMID: 31865260 DOI: 10.1016/j.jhealeco.2019.102273] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 07/17/2019] [Accepted: 12/07/2019] [Indexed: 05/28/2023]
Abstract
While recent research has shown that cannabis access laws can reduce the use of prescription opioids, the effect of these laws on opioid use is not well understood for all dimensions of use and for the general United States population. Analyzing a dataset of over 1.5 billion individual opioid prescriptions between 2011 and 2018, which were aggregated to the individual provider-year level, we find that recreational and medical cannabis access laws reduce the number of morphine milligram equivalents prescribed each year by 11.8 and 4.2 percent, respectively. These laws also reduce the total days' supply of opioids prescribed, the total number of patients receiving opioids, and the probability a provider prescribes any opioids net of any offsetting effects. Additionally, we find consistent evidence that cannabis access laws have different effects across types of providers, physician specialties, and payers.
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Affiliation(s)
- Benjamin J McMichael
- Assistant Professor of Law, University of Alabama School of Law, Box 870382, 101 Paul W. Bryant Drive East, Tuscaloosa, AL, 35487, United States.
| | - R Lawrence Van Horn
- Associate Professor of Management and Law, Executive Director of Health Affairs, Owen Graduate School of Management, Vanderbilt University, 401 21st Avenue South, Nashville, TN, 37203, United States.
| | - W Kip Viscusi
- University Distinguished Professor of Law, Economics, and Management, Vanderbilt University Law School. 131 21st Avenue South, Nashville, TN, 37203, United States.
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Meadows AL, Strickland JC, Qalbani S, Conner KL, Su A, Rush CR. Comparing Changes in Controlled Substance Prescribing Trends by Provider Type. Am J Addict 2020; 29:35-42. [PMID: 31600029 PMCID: PMC6941737 DOI: 10.1111/ajad.12962] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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] [Received: 05/24/2019] [Revised: 09/03/2019] [Accepted: 09/06/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Forty-nine out of 50 states have implemented Prescription Drug Monitoring Programs (PDMPs) to monitor controlled substance (CS) prescribing. PDMPs change health care provider behavior, but few studies have examined changes in CS prescription by health care provider type. METHODS Aggregated yearly data, including number of CS prescriptions, doses, and doses per prescription by health care provider type (physician, advanced practice registered nurse [APRN], and dentist) for each year from 2011 to 2017 was provided by the state PDMP, Kentucky All Schedule Prescription Electronic Reporting System (KASPER). In aggregate, this data set included 64,578,307 total prescriptions and 3,982,130,994 total doses of Schedule II-V medications. RESULTS Physicians and dentists showed a trend of decreasing prescriptions and doses for Schedule II opioids from 2012 to 2017 (27-32% reduction in 2017 compared to 2011). APRNs showed a substantive increase in the number of doses and prescriptions (121-204% increase in 2017 compared to 2011), with increases remaining when controlling for number of providers. Physicians increased doses and prescriptions of Schedule II stimulants (37% increase for both doses and prescriptions), but by a smaller magnitude than APRN increases in stimulants (334-360% increase). Dentists showed decreases in Schedule II stimulants prescribed (69-80% reduction). Similar trends, but more modest in magnitude, were observed for Schedule III-IV. DISCUSSION AND CONCLUSIONS Although monitoring and continuing education requirements are similar across all providers in Kentucky, differences in prescription trends for Schedule II opioids and stimulants were noted for physicians, APRNs, and dentists. SCIENTIFIC SIGNIFICANCE Changes in prescribing following introduction of mandatory use of KASPER markedly differed based on provider type, with increases observed for APRNs compared with physicians and dentists. These findings advance prior research by providing a detailed examination of prescribing trends by provider type subsequent to a PDMPs mandatory use law. (Am J Addict 2019;00:00-00).
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Affiliation(s)
- Amy Lynn Meadows
- University of Kentucky College of Medicine Department of Psychiatry, 245 Fountain Court, Suite 225, Lexington KY 40509
| | - Justin C. Strickland
- University of Kentucky College of Arts and Sciences, Department of Psychology, Lexington, KY
| | - Shiraz Qalbani
- River Valley Behavioral Health, 1100 Walnut St. PO BOX 1637, Owensboro, KY 42302
| | - Kailyn L. Conner
- University of Kentucky College of Pharmacy, 789 S Limestone St, Lexington, KY 40506
| | - Amanda Su
- University of Kentucky College of Medicine, 800 Rose Street, Lexington, KY 40536
| | - Craig R. Rush
- University of Kentucky College of Medicine Department of Psychiatry, 245 Fountain Court, Suite 225, Lexington KY 40509
- University of Kentucky College of Medicine Department of Behavioral Science, Lexington, KY
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Hoang E, Keith DA, Kulich R. Controlled substance misuse risk assessment and prescription monitoring database use by dentists. J Am Dent Assoc 2019; 150:383-392. [PMID: 31029213 DOI: 10.1016/j.adaj.2019.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/30/2019] [Accepted: 02/01/2019] [Indexed: 11/17/2022]
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Ooms GI, Klatser P, van den Ham HA, Reed T. Barriers to Accessing Internationally Controlled Essential Medicines in Uganda: A Qualitative Study. J Pain Symptom Manage 2019; 58:835-843.e1. [PMID: 31302261 DOI: 10.1016/j.jpainsymman.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/28/2019] [Accepted: 07/03/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Access to internationally controlled essential medicines is a problem worldwide. More than five billion people cannot access opioids for pain and palliative care or do not have access to surgical care or anesthetics, 25 million people living with epilepsy do not have access to their medicines, and 120,000 women die annually owing to postpartum hemorrhage. In Uganda, access to controlled medicines is also problematic, but a lack of data on factors that influence access exists. OBJECTIVES The objective of this study was to identify the social, cultural, and regulatory barriers that influence access to internationally controlled essential medicines in Uganda. METHODS Semistructured interviews with 15 key stakeholders with knowledge on controlled medicines from relevant institutions in Uganda. Interviews were transcribed verbatim and analyzed using the Access to Medicines from a Health System Perspective framework. RESULTS Barriers in accessing controlled medicines were experienced owing to lack of prioritization, difficulties in finding the balance between access and control, deficiencies in the workings of the estimate and distribution system, lack of knowledge, inadequate human resources, expenses related to use and access, and stigma. It was believed that some abuse of specific controlled medicines occurred. CONCLUSION The findings of this research indicate that to improve access to internationally controlled essential medicines in Uganda, health system strengthening is needed on multiple fronts. Active engagement and concerted efforts are needed from all stakeholders to ensure access and prevent abuse.
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Affiliation(s)
- Gaby Isabelle Ooms
- Health Action International, Amsterdam, The Netherlands; WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.
| | | | - Hendrika A van den Ham
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Tim Reed
- Health Action International, Amsterdam, The Netherlands
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Roberts AW, Skinner AC, Lauffenburger JC, Galt KA. The lock-in loophole: Using mixed methods to explain patient circumvention of a Medicaid opioid restriction program. Subst Abus 2019; 41:510-518. [PMID: 31644398 PMCID: PMC7176522 DOI: 10.1080/08897077.2019.1674239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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] [Indexed: 10/25/2022]
Abstract
BACKGROUND Lock-in programs are proliferating among private and public payers to restrict access to controlled substance prescriptions and enhance care coordination for patients exhibiting high-risk use of, primarily, opioids. Patients enrolled in lock-in programs are required to seek opioids from a designated provider and pharmacy for insurance coverage of their opioid and benzodiazepine prescriptions. Lock-in program restrictions are often circumvented by patients through out-of-pocket cash purchases of opioid prescriptions, undermining the program's intended function. This study sought to construct and explain trajectories of Medicaid-covered and cash pay opioid prescription fills among adults enrolled in an opioid lock-in program. Methods: We used sequential explanatory mixed methods, which involved a quantitative retrospective cohort analysis of opioid fill trajectories using North Carolina Medicaid administrative claims data linked with state prescription drug monitoring program data, followed by qualitative semi-structured interviews with North Carolina pharmacists. The quantitative component included adults enrolled in the North Carolina Medicaid lock-in program between 10/1/2010-3/31/2012. The qualitative component included a maximum variation sample of community pharmacists in North Carolina delivering care to lock-in patients. Quantitative outcomes included group-based trajectories of monthly Medicaid-covered and cash pay opioid prescription fills six months before and after LIP enrollment, and qualitative analyses generated themes explaining observed trajectories. Results: Two-thirds of subjects exhibited reduced Medicaid-covered opioid prescription fills and no increase in cash pay fills after lock-in enrollment, with one-third exhibiting increased cash pay fills after lock-in. Pharmacists attributed increases in cash pay fills primarily to illicit behaviors, while some cash pay behavior likely reflected new unintended barriers to care. Conclusions: Lock-in programs appear to reduce prescription opioid use for most enrolled patients. However, lock-in programs may have limited capacity to deter illicit behaviors among patients intent on abusing, misusing, or diverting these medications and may introduce new access barriers to necessary care for some.
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Affiliation(s)
- Andrew W. Roberts
- Department of Population Health, Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Asheley C. Skinner
- Department of Population Health Sciences, Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Julie C. Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Center for Healthcare Delivery Sciences, Brigham and Women’s Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Kimberly A. Galt
- Department of Pharmacy Sciences, Creighton University School of Pharmacy and Health Professions, Creighton University, Omaha, Nebraska, USA
- Center for Health Services Research and Patient Safety, Creighton University, Omaha, Nebraska, USA
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Alexander JC, Silge J, Jones S, Joshi GP. Evaluation of Opioid Prescribing Habits Based on Analysis of a State Prescription Drug Monitoring Program. Pain Physician 2019; 22:E425-E433. [PMID: 31561654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND The current opioid epidemic is perhaps the greatest public health crisis in the United States. Although multiple factors led to the rise of this epidemic, it is without question associated with the rise in opioid prescribing. OBJECTIVES Better understanding of the opioid prescribing may provide insights into population-level trends contributing to this epidemic, and opportunities to decrease the magnitude of opioid overdose-related death. Therefore we assessed trends in opioid prescribing habits based on analysis of the Texas Prescription Drug Monitoring Program (PDMP) and geographic, ethnic, and income-related data from the US Census Bureau. STUDY DESIGN Multiple linear regression analysis of Texas PDMP and US Census Bureau data were performed to assess for correlations to opioid prescribing based on geographic, ethnic, income, and time-related variables. SETTING All controlled substances prescribed in the state of Texas from April 2015 to May 2018 were analyzed. METHODS We obtained data from the Texas PDMP for all controlled substances from April 2015 to May 2018. We performed multiple linear regression analysis of these data along with US Census Bureau data to assess for correlations based on geographic, ethnic, income, and time-related variables. We hypothesized that there would be substantial variability in opioid prescribing habits based on geographic, ethnic, and economic variables. RESULTS Approximately 200 million pills of controlled substances were prescribed per month over the studied time frame. Overall, high geographic variability was noted, and this strongly correlated to race and ethnicity. Opioid prescribing increased along with the proportion of white residents within a county, but a similar negative correlation was noted with increasing Hispanic population proportion. This correlation was noted throughout the study period, but up until 2017, lower income levels among higher white population had even higher correlation with increased opioid prescribing. Cumulative opioid prescriptions throughout the state fell beginning in 2017. LIMITATIONS This analysis does not include opioids obtained illicitly or from prescriptions outside the state of Texas. The specificity of geographic data are limited to the county level due to irregular entry of zip code data by prescribing pharmacies. CONCLUSIONS In the state of Texas over the studied time period, there was strong correlation for higher rates of opioid prescribing as white population increased despite overall decreased opioid prescribing starting in 2017. Until 2017, this correlation grew stronger as low-income white population increased. KEY WORDS Opioid, opioid epidemic, opioid utilization.
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Affiliation(s)
- John C Alexander
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, TX
| | | | - Stephanie Jones
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, TX
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, TX
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