Early Refills Research Articles

Rates of Anomalous Bupropion Prescriptions in Ontario, Canada.

Reports of bupropion misuse have increased since it was first reported in 2002. The purpose of this study was to explore trends in bupropion prescribing suggestive of misuse or diversion in Ontario, Canada. A serial cross-sectional study was conducted of Ontarians aged younger than 65 years who received prescriptions under Ontario's public drug program from April 1, 2000, to March 31, 2013. We determined the number of potentially inappropriate prescriptions in each quarter, defined as early refills dispensed within 50% of the duration of the preceding prescription, as well as potentially duplicitous prescriptions, defined as similarly early refills originating from a different prescriber and different pharmacy. We replicated these analyses for citalopram and sertraline, antidepressants not known to be prone to abuse. We identified 1,780,802 prescriptions for bupropion, 3,402,462 for citalopram, and 1,775,285 for sertraline. Rates of early refills for bupropion declined during the study from 4.8% to 3.1%. In the final quarter, rates of early refills for bupropion were more common than for citalopram (3.1% vs 2.2%) (P <.001) but not for sertraline (3.1% vs 2.9%) (P =.16). Potentially duplicitous prescriptions for bupropion increased dramatically, from <0.05% of all prescriptions in early 2000 to 0.47% in early 2013 and by the final quarter were more common than both citalopram (0.11%) and sertraline (0.12%) (P <.001). Although no marked differences were seen for early refills of bupropion relative to its comparators, potentially duplicitous prescriptions have increased dramatically in Ontario, suggesting growing misuse of the drug.

Harmonizing post-market surveillance of prescription drug misuse: a systematic review of observational studies using routinely collected data (2000-2013).

Prescription drug misuse is a growing public health concern globally. Routinely collected data provide a valuable tool for quantifying prescription drug misuse. To synthesize the global literature investigating prescription drug misuse utilizing routinely collected, person-level prescription/dispensing data to examine reported measures, documented extent of misuse and associated factors. The MEDLINE, EMBASE, CINAHL, MEDLINE In Process, Scopus citations and Google Scholar databases were searched for relevant articles published between 1 January 2000 and 31 July 2013. A total of 10,803 abstracts were screened and 281 full-text manuscripts were retrieved. Fifty-two peer-reviewed, English-language manuscripts met our inclusion criteria-an aim/method investigating prescription drug misuse in adults and a measure of misuse derived exclusively from prescription/dispensing data. Four proxies of prescription drug misuse were commonly used across studies: number of prescribers, number of dispensing pharmacies, early refills and volume of drugs dispensed. Overall, 89 unique measures of misuse were identified across the 52 studies, reflecting the heterogeneity in how measures are constructed: single or composite; different thresholds, cohort definitions and time period of assessment. Consequently, it was not possible to make definitive comparisons about the extent (range reported 0.01-93.5%), variations and factors associated with prescription drug misuse. Routine data collections are relatively consistent across jurisdictions. Despite the heterogeneity of the current literature, our review identifies the capacity to develop universally accepted metrics of misuse applied to a core set of variables in prescription/dispensing claims. Our timely recommendations have the potential to unify the global research field and increase the capacity for routine surveillance of prescription drug misuse.

Optimal early refill rules for Danjiangkou Reservoir

Water levels in reservoirs are generally not allowed to exceed the flood-limited water level during the flood season, which means that huge amounts of water spill in order to provide adequate storage for flood prevention and that it is difficult to fill the reservoir fully at the end of year. Early reservoir refill is an effective method for addressing the contradiction between the needs of flood control and of comprehensive utilization. This study selected the Danjiangkou Reservoir, which is the water source for the middle route of the South-North Water Diversion Project (SNWDP) in China, as a case study, and analyzed the necessity and operational feasibility of early reservoir refill. An early reservoir refill model is proposed based on the maximum average storage ratio, optimized by the progressive optimality algorithm, and the optimal scheduling schemes were obtained. Results show that the best time of refill operation for the Danjiangkou Reservoir is September 15, and the upper limit water level during September is 166 m. The proposed early refill scheme, in stages, can increase the annual average storage ratio from 77.51% to 81.99%, and decrease spilled water from 2.439 × 109 m3 to 1.692 × 109 m3, in comparison to the original design scheme. The suggested early reservoir refill scheme can be easily operated with significant comprehensive benefits, which may provide a good reference for scheduling decision-making.

Simulation May Improve Trainee Skills With Agitated or Violent Patients

Simulation May Improve Trainee Skills With Agitated or Violent Patients

Adherence to prescription opioid monitoring guidelines among residents and attending physicians in the primary care setting.

The aim of this study was to compare adherence to opioid prescribing guidelines and potential opioid misuse in patients of resident vs attending physicians. Retrospective cross-sectional study. Large primary care practice at a safety net hospital in New England. Patients 18-89 years old, with at least one visit to the primary care clinic within the past year and were prescribed long-term opioid treatment for chronic noncancer pain. Data were abstracted from the electronic medical record by a trained data analyst through a clinical data warehouse. The primary outcomes were adherence to any one of two American Pain Society Guidelines: (1) documentation of at least one opioid agreement (contract) ever and (2) any urine drug testing in the past year, and evidence of potential prescription misuse defined as ≥2 early refills. We employed logistic regression analysis to assess whether patients' physician status predicts guideline adherence and/or potential opioid misuse. Similar proportions of resident and attending patients had a controlled substance agreement (45.1% of resident patients vs. 42.4% of attending patient, P = 0.47) or urine drug testing (58.6% of resident patients vs. 63.6% of attending patients, P = 0.16). Resident patients were more likely to have two or more early refills in the past year relative to attending patients (42.8% vs. 32.5%; P = 0.004). In the adjusted regression analysis, resident patients were more likely to receive early refills (odds ratio 1.82, 95% confidence interval 1.26-2.62) than attending patients. With some variability, residents and attending physicians were only partly compliant with national guidelines. Residents were more likely to manage patients with a higher likelihood of opioid misuse.

Variability in opioid prescription monitoring and evidence of aberrant medication taking behaviors in urban safety-net clinics.

Little is known about variability in primary care providers' (PCPs) adherence to opioid-monitoring guidelines for patients. We examined variability of adherence to monitoring guidelines among PCPs and ascertained the relationship between PCP adherence and opioid misuse by their patients. We included primary care patients receiving long-term opioids (≥3 prescriptions within 6 months) for chronic noncancer pain and PCPs with ≥4 eligible patients. We examined guideline adherence using: (1) electronic health record documentation of opioid treatment agreement, (2) past-year urine drug screen (UDS), and (3) evidence of misuse through early refills (≥2 opioid prescriptions written 7-25 days after the previous prescription). Covariates included morphine equivalent daily opioid medication dose (MED, >50 mg/d vs ≤50mg/d). Multilevel regression models assessed variability among PCPs, and odds ratios examined associations among patient-level binary outcomes. Sixty-seven PCPs prescribed opioids to 1546 patients. Significant variability was found between PCPs in use of agreement (variance = 1.27, P < 0.001), UDS (variance = 1.75, P < 0.001), and early refills (variance = 0.29, P = 0.002). Primary care providers had a mean of 48% of patients with agreement (range, 9%-84%), 56% with ≥1 UDS (range, 7%-91%) and 36% with early refills (range, 19%-60%). High MED among patients was associated with increased odds of agreement (1.93, confidence interval [CI], 1.53-2.44), UDS (2.65, CI: 2.06-3.41), and early refill (2.92, CI: 2.30-3.70). Primary care providers varied significantly in adherence to opioid prescription guidelines. Increased patient risk was associated with increased monitoring and with greater misuse. Future work should study system-level interventions to enable clinical monitoring and support opioid guideline adherence.

丹江口水库洪水资源调控技术研究

丹江口水库既是汉江中下游地区的控制性防洪工程，又是南水北调中线工程的水源地，承担着防洪、供水、发电、航运等重要功能。本文把资料系列延长至2014年并进行设计洪水复核，开展汛期分期、运行水位动态控制和提前蓄水研究。结果表明：在不降低防洪标准的前提下，利用1~5 d预见期信息，夏汛期(6月21日至8月20日)和秋汛期(9月1日到10月10日)的运行水位分别在160.0~162.9 m和163.5~ 165.7 m区间浮动，年均可增加蓄水量31.6~49.98亿m³，或增加发电量9.96~100.21 M kW•h；汛末提前蓄水时间为9月15日，蓄水水位上限值为166 m，与原设计方案相比，水库蓄满年份从4年增加到12年，年均多蓄水8.98亿m³。 The Danjiangkou Reservoir is both a key flood control project for the middle and lower reaches of the Han River and water source of the South-to-North Water Diversion Project in China. It is a multi-purpose reservoir, including flood control, water supply, hydropower generation, navigation, etc. The hydrological data series were extended to 2014 and the design flood values were rechecked. The flood seasonal identification, dynamic control of water levels during flood season and early refill of reservoir were studied. Results show that with 1 - 5 d forecasting information, dynamic control bounds of water level during summer flood season (Jun. 21 - Aug. 20) and autumn flood season (Sep. 1 - Oct. 10) are 160.0 - 162.9 m and 163.5 - 165.7 m respectively without decreasing flood protection standards, which can increase 3.16 - 4.998 billion m³ storage water or 9.96 - 100.21 MkW•h hydropower generation annually. It is also shown that reservoir’s early refill starts on Sep. 15 with the maximum water level limited to 166 m during September; the full storage rate can increase from 4 years to 12 years, and the storage water increases 0.898 billion m³ annually.

Exploring the effects of alcohol and marijuana use on experience of teen dating violence among high school students in Maryland

had≥one positive urine drug tests for cocaine. Receipt of BZD prescription was associated with an increased hazard of having≥ two early opioid refills, adjusted hazard ratio (HR) =1.54 (95% CI, 1.09–2.18); but was not associated with increased odds for a positive cocaine test, adjusted odds ratio =1.07 (95% CI, 0.55–2.23). Conclusions: Among primary care patients receiving chronic opioid therapy, BZD prescription was associated with≥ two early opioid refills but not with cocaine use. Because alternative therapies exist for the primary indications for BZD prescription, further research should better elucidate the risks and benefits of prescribing BZDs to patients receiving chronic opioid therapy. Financial support: R01DA034252-01, R25DA033211.

THU0441 Adherence and Persistence with Triple Non-Biologic Disease Modifying Antirheumatic Drug Therapy and Etanercept-Methotrexate Combination Therapy in US Patients with Rheumatoid Arthritis

BackgroundA recent randomized controlled trial in patients with rheumatoid arthritis (RA) showed non-inferiority of clinical benefit when starting on triple therapy (sulfasalazine (SSZ)+hydroxychloroqiune (HCQ)+methotrexate (MTX)) as compared to etanercept (ETN)...

Pharmacists’ training, perceived roles, and actions associated with dispensing controlled substance prescriptions

ObjectivesTo examine situations that prompt pharmacists to access a prescription drug monitoring program (PDMP) database and management of opioid abuse/addiction; assess pharmacists’ actions when abuse is suspected; describe pharmacists’ tasks when dispensing controlled substance prescriptions (CSPs); and their continuing pharmacy education (CPE). DesignCross-sectional mail survey of 1,000 randomly selected pharmacists. SettingTexas from February 2012 to April 2012. Participants1,000 Texas community pharmacists. InterventionMail survey instrument. Main outcome measuresPrompts to use a PDMP and pharmacists' views actions, and related CPE programs. ResultsThe usable response rate was 26.2%. Pharmacists were more supportive of mandated PDMP use by physicians than by pharmacists (mean ± SD 4.1± versus 3.2 ± 1.5; P <0.001), based on a 5-point Likert scale (1, strongly disagree, to 5, strongly agree). Most pharmacists would be prompted to use a PDMP if the prescription contains mistakes (68.1%) or the patient requests an early refill (66.3%). Bivariate statistics showed that men pharmacists, those with BSPharm degrees, and pharmacists ≥50 years of age reported a greater number of CPE hours related to prescription opioid abuse and pain management. An analysis of variance showed that pharmacy owners reported significantly more (P <0.05) CPE compared with manager and staff pharmacists. ConclusionOlder pharmacists with a BSPharm degree may be more willing to provide counseling to patients with opioid addiction based on their work experience and additional CPE related to controlled substances. As PDMP use becomes more prevalent, pharmacists should be prepared to interact and counsel patients identified with aberrant controlled prescription drug use and properly deliver pain management care. Additionally, schools of pharmacy curricula must prepare new pharmacists to prevent abuse and diversion, as well as intervene when aberrant use is identified.

Prevalence of substance misuse in new patients in an outpatient psychiatry clinic using a prescription monitoring program.

Objective: To investigate the value of a prescription monitoring program in identifying prescription drug misuse among patients presenting to a resident physician outpatient psychiatry clinic at an academic medical center.Method: Participants were 314 new patients aged 18 years or older presenting to the clinic from October 2011 to June 2012. Resident physicians completed a data collection form for each participant using information from the patient interview and from the prescription monitoring program report. Prescription drug misuse was defined as having any 1 of the following 5 criteria in the prescription monitoring program report: (1) filled prescriptions for 2 or more controlled substances, (2) obtained prescriptions from 2 or more providers, (3) obtained early refills, (4) used 3 or more pharmacies, and (5) the prescription monitoring program report conflicted with the patient’s report.Results: At least 1 indicator of prescription drug misuse was found in 41.7% of patients. Over 69% of the patients that the residents believed were misusing prescription drugs actually met 1 of the criteria for prescription drug misuse. The prescription monitoring program report changed the management only 2.2% of the time. Patients with prior benzodiazepine use (χ21 = 17.68, P < .001), prior opioid use (χ21 = 19.98, P < .001), a personality disorder (χ21 = 7.22, P < .001), and chronic pain (χ21 = 14.31, P < .001) had a higher percentage of prescription drug misuse compared to patients without these factors.Conclusion: Using the prescription monitoring program to screen patients with prior benzodiazepine and opioid use, with a personality disorder, and/or with chronic pain may be useful in confirming the suspicion of prescription drug misuse identified at the initial evaluation.

Clinical psychiatric pharmacist involvement in an outpatient buprenorphine program

Background: Approximately nineteen million individuals in the United States are diagnosed with a substance use disorder (SUD), including many veterans enrolled in the Veterans Health Administration (VHA). The prevalence of SUD within the veteran population has been steadily increasing, resulting in increased utilization of substance abuse services, such as buprenorphine programs for opioid dependence. As this population grows, there is an increased need for multidisciplinary services. Clinical psychiatric pharmacists do not have prescriptive authority for buprenorphine, but can play a vital role in outpatient buprenorphine programs. Description of Innovative Service: The clinical psychiatric pharmacist is involved in many aspects of the outpatient buprenorphine program. There are over 100 patients enrolled in the buprenorphine program at the White River Junction Veterans Affairs Medical Center (WRJVAMC). The clinical pharmacist devotes approximately ten hours per week to the program, which includes dispensing the medication, monitoring lab values, patient counseling and random medication counts. A spreadsheet is maintained and updated weekly to monitor doses, refill dates and urine toxicology results. The clinical pharmacist is also involved in the dispensing process in the outpatient pharmacy; this allows for open communication between the clinical pharmacist and patient. Impact on Patient Care: The clinical psychiatric pharmacist has been involved in the outpatient buprenorphine program at the WRJVAMC for approximately two years. Prior to this, the program included less than 100 patients, pharmacy wait times were over sixty minutes and early refills were frequent. Since clinical pharmacy involvement, the pharmacy wait time is approximately 30 minutes or less and early refills are infrequent. Patient satisfaction has also significantly improved. The clinical pharmacist has helped open the lines of communication between the patient, the pharmacy and the prescriber. Conclusion: Substance use disorder programs, such as buprenorphine programs, can benefit from clinical pharmacy involvement. Even with limited prescriptive authority, clinical psychiatric pharmacists can play an important and active role in outpatient buprenorphine programs.

Risedronate Slows or Partly Reverses Cortical and Trabecular Microarchitectural Deterioration in Postmenopausal Women

During early menopause, steady-state bone remodeling is perturbed; the number of basic multicellular units (BMUs) excavating cavities upon the endosteal surface exceeds the number (generated before menopause) concurrently refilling. Later in menopause, steady-state is restored; the many BMUs generated in early menopause refill as similarly large numbers of BMUs concurrently excavate new cavities. We hypothesized that risedronate reduces the number of cavities excavated. However, in younger postmenopausal women, the fewer cavities excavated will still exceed the fewer BMUs now refilling, so net porosity increases, but less than in controls. In older postmenopausal women, the fewer cavities excavated during treatment will be less than the many (generated during early menopause) now refilling, so net porosity decreases and trabecular volumetric bone mineral density (vBMD) increases. We recruited 324 postmenopausal women in two similarly designed double-blind placebo-controlled studies that included 161 younger (Group 1, ≤ 55 years) and 163 older (Group 2, ≥ 55 years) women randomized 2:1 to risedronate 35 mg/week or placebo. High-resolution peripheral computed tomography was used to image the distal radius and tibia. Cortical porosity was quantified using the StrAx1.0 software. Risedronate reduced serum carboxyterminal cross-linking telopeptide of type 1 bone collagen (CTX-1) and serum amino-terminal propeptide of type 1 procollagen (P1NP) by ∼50%. In the younger group, distal radius compact-appearing cortex porosity increased by 4.2% ± 1.6% (p = 0.01) in controls. This was prevented by risedronate. Trabecular vBMD decreased by 3.6% ± 1.4% (p = 0.02) in controls and decreased by 1.6% ± 0.6% (p = 0.005) in the risedronate-treated group. In the older group, changes did not achieve significance apart from a reduction in compact-appearing cortex porosity in the risedronate-treated group (0.9% ± 0.4%, p = 0.047). No between-group differences reached significance. Results were comparable at the distal tibia. Between-group differences were significant for compact-appearing cortex porosity (p = 0.005). Risedronate slows microstructural deterioration in younger and partly reverses it in older postmenopausal women, features likely to contribute to antifracture efficacy.

Benzodiazepine Use among Older Adults with Chronic Obstructive Pulmonary Disease

Patients with chronic obstructive pulmonary disease (COPD) may receive benzodiazepines for a variety of reasons, including as treatment for insomnia, as treatment for depression and anxiety, and to help relieve refractory dyspnoea. However, benzodiazepines have been linked to adverse physiological respiratory outcomes in individuals with COPD. The potential adverse respiratory effects of benzodiazepines in COPD may also be heightened in older adults given their altered pharmacokinetics that increase benzodiazepine half-life. There is minimal information on the scope and nature of benzodiazepine use in the older adult COPD population. The purpose of this study was to describe patterns of benzodiazepine use among older adults with COPD. A validated algorithm was applied to Ontario healthcare administrative data to identify older adults with COPD. Incident oral benzodiazepine receipt between 1 April 2004 and 31 March 2009, defined as no benzodiazepines dispensed in the year prior to incident prescription, was examined. Regression techniques were used to identify patient characteristics associated with new benzodiazepine use. Descriptive statistics were performed to describe benzodiazepine use among new users. The analysis was stratified by COPD severity defined by COPD exacerbation frequency (less severe COPD: 0 exacerbations in the year prior; more severe COPD: 1 or more exacerbations in the year prior). Among 111,445 older adults with COPD, 35,311 (31.7%) received a new benzodiazepine. New benzodiazepine receipt was higher among individuals with more severe COPD (adjusted odds ratio 1.43, 95% CI 1.38-1.48). Among new benzodiazepine users, there was a relatively high frequency of receipt of long-acting agents (14.6%), dispensations for greater than 30days (32.6%), second dispensations (22.0% or 30.6% for occurrence within 120% or 200% days of the index prescription, respectively), early refills (11.6%), and benzodiazepine receipt during COPD exacerbations (9.0%). Among individuals with more severe COPD, 35.4% of incident use occurred during a COPD exacerbation. Almost one-third of older individuals with COPD received a new benzodiazepine, and rates were higher among those with more severe COPD. Important safety and quality of care issues are potentially raised by the degree and pattern of benzodiazepine use in this older and respiratory-vulnerable population.

Main challenges facing the pharmaceutical sector in Buchanan County, Virginia: a pilot study

Little is known about the challenges facing the pharmaceutical sector in rural counties in the USA. The aim of this pilot study is to determine the main challenges facing the pharmaceutical sector and suggestions for improving the sector in Buchanan County, a poor and marginalized county in Central Appalachia, Virginia. This cross-sectional study used the drop-by survey based on the first step of the modified Delphi Interview Technique. A convenience sample of healthcare professionals in Buchanan County were asked to complete a self-administered survey instrument between May and August 2011. A total of 16 healthcare professionals including six pharmacists completed the survey. The respondents had worked for an average of 13.4 (SD=10.7) years in the County (range: 1-33 years). The main challenges facing the pharmaceutical sector were drug abuse (n=11), doctor shopping by patients (n=9), early refills (n=7) and drug shortage (n=6). Respondents suggested increased patient education by pharmacists (n=6) and better coordination and communication between pharmacy and doctor (n=6) to improve the pharmaceutical sector in the County. Drug abuse, doctor shopping, early refills and drug shortage are the main challenges facing the pharmaceutical sector in Buchanan County. Concerted efforts are required to solve these problems. More research is required to confirm these findings.

Aberrant Drug-Related Behaviors: Unsystematic Documentation Does Not Identify Prescription Drug Use Disorder

No evidence-based methods exist to identify prescription drug use disorder (PDUD) in primary care (PC) patients prescribed controlled substances. Aberrant drug-related behaviors (ADRBs) are suggested as a proxy. Our objective was to determine whether ADRBs documented in electronic medical records (EMRs) of patients prescribed opioids and benzodiazepines could serve as a proxy for identifying PDUD. A cross-sectional study of PC patients at an urban, academic medical center. Two hundred sixty-four English-speaking patients (ages 18-60) with chronic pain (≥3 months), receiving ≥1 opioid analgesic or benzodiazepine prescription in the past year, were recruited during outpatient PC visits. Composite International Diagnostic Interview defined Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of past year PDUD and no disorder. EMRs were reviewed for 15 prespecified ADRBs (e.g., early refill, stolen medications) in the year before and after study entry. Fisher's exact test compared frequencies of each ADRB between participants with and without PDUD. Sixty-one participants (23%) met DSM-IV PDUD criteria and 203 (77%) had no disorder; 85% had one or more ADRB documented. Few differences in frequencies of individual behaviors were noted between groups, with only "appearing intoxicated or high" documented more frequently among participants with PDUD (N = 10, 16%) vs no disorder (N = 8, 4%), P = 0.002. The only common ADRB, "emergency visit for pain," did not discriminate between those with and without the disorder (82% PDUD vs 78% no disorder, P = 0.6). EMR documentation of ADRBs is common among PC patients prescribed opioids or benzodiazepines, but unsystematic clinician documentation does not identify PDUDs. Evidence-based approaches are needed.

Prescription Opioid Deaths: A Preventable Epidemic

Prescription Opioid Deaths: A Preventable Epidemic

Prescription drug mayhem and rural America

Rural areas have a number of characteristics that facilitate greater awareness of health problem areas, such as drug abuse. In a forthcoming Rural and Remote Health publication, rural pharmacists and practitioners acting at the local level identified drug abuse, doctor shopping, early refills, and drug shortages as major problems. Living in a rural location can magnify the impact of these problems.

Association of Mental Health Disorders With Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan

Record numbers of Iraq and Afghanistan veterans survive their war injuries and yet continue to experience pain and mental health problems, particularly posttraumatic stress disorder (PTSD). Little is known about the association of mental health disorders and prescription opioid use. To investigate the effect of mental health disorders, particularly PTSD, on risks and adverse clinical outcomes associated with prescription opioid use. Retrospective cohort study involving 141,029 Iraq and Afghanistan veterans who received at least 1 non-cancer-related pain diagnosis within 1 year of entering the Department of Veterans Affairs (VA) health care system from October 1, 2005, through December 31, 2010. Independent association of mental health disorders and the prescription of opioids, higher risk opioid use, and adverse clinical outcomes (eg, accidents and overdose) within 1 year of receiving a pain-related diagnosis. A total of 15,676 veterans were prescribed opioids within 1 year of their initial pain diagnosis. Compared with 6.5% of veterans without mental health disorders, 17.8% (adjusted relative risk [RR], 2.58; 95% CI, 2.49-2.67) of veterans with PTSD and 11.7% (adjusted RR, 1.74; 95% CI, 1.67-1.82) with other mental health diagnoses but without PTSD were significantly more likely to receive opioids for pain diagnoses. Of those who were prescribed pain medication, veterans with PTSD were more likely than those without mental health disorders to receive higher-dose opioids (22.7% vs 15.9%, adjusted RR, 1.42; 95% CI, 1.31-1.54), receive 2 or more opioids concurrently (19.8% vs 10.7%, adjusted RR, 1.87; 95% CI, 1.70-2.06), receive sedative hypnotics concurrently (40.7% vs 7.6%, adjusted RR, 5.46; 95% CI, 4.91-6.07), or obtain early opioid refills (33.8% vs 20.4%; adjusted RR, 1.64; 95% CI, 1.53-1.75). Receiving prescription opioids (vs not) was associated with an increased risk of adverse clinical outcomes for all veterans (9.5% vs 4.1%; RR, 2.33; 95% CI, 2.20-2.46), which was most pronounced in veterans with PTSD. Among US veterans of Iraq and Afghanistan, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids for pain, high-risk opioid use, and adverse clinical outcomes.

Shoshin béribéri: réémergence d’une pathologie ancienne ? À propos d’une série de 11 cas à Mayotte

In the French island of Mayotte in the Indian Ocean, the health and food situation remains contrasted. For a very long time dry beriberi women in postpartum had been suspected and treated. But in 2004 the first infantile epidemic of beriberi was scientifically authenticated and a program of thiaminic supplementation for the pregnant women and infants was set up. In this context, we describe an epidemic of 11 cases of shoshin beriberi among adults between January 2008 and Februar 2009. Over 11 cases of shoshin beriberi, 5 cases were confirmed biologically and 6 were probable. The sex ratio M/W was 0.37. The median age was 34 years. The clinic picture was typical: severe acute dyspnea, an agitation/drowsiness, right cardiac failure: polynevritis of the lower limbs was noted in 9 cases over 11. Biologically it was characterized by a lactic acidosis (average pH: 7.08, lactates: 12.08 mmol/l). The evolution was favorable in the 8 cases which could benefit from early thiaminic refill. The outbreak of an epidemic of shoshin beriberi among adults mainly in groups not having benefited from supplementation shows the effectiveness of the program but also its limits. We compare our series with others: the period from April to June when the food is less diversified, is confirmed as a higher risk period. The programs of nutritional education must be increased and a B1 vitamin supplementation for broader people during the rain season might be discussed.