Multiple Opioid Prescriptions Research Articles

All-Cause Opioid Prescriptions Dispensed: The Outsized Role of Adults With Arthritis

Limited estimates of prescribed opioid use among adults with arthritis exist. All-cause (i.e., for any condition) prescribed opioid dispensed (referred to as opioid prescription in the remainder of this abstract) in the past 12 months among U.S. adults aged ≥18 years (n=35,427) were studied, focusing on adults with arthritis (n=12,875). In 2018-2019, estimates were generated using Medical Expenditure Panel Survey data: (1) 2015 prevalence of 1 or more opioid prescriptions to U.S. adults overall and by arthritis status and (2) in 2014-2015, among adults with arthritis, multivariable-adjusted associations between 1 or more opioid prescriptions and sociodemographic characteristics, health status, and healthcare utilization characteristics. In 2015, the age-standardized prevalence of 1 or more opioid prescriptions among adults with arthritis (29.6%) was almost double of that for all adults (15.4%). Adults with arthritis represented more than half of all adults (55.3%) with at least 1 opioid prescription; among those with 1 or more prescriptions, 43.2% adults had 4 or more prescriptions. The strongest multivariable-adjusted associations with 1 or more opioid prescriptions were ambulatory care visits (1-4: prevalence ratios=1.9-2.0, 5-8: prevalence ratios=2.5-2.7, 9 or more: prevalence ratios=3.4-3.7) and emergency room visits (1: prevalence ratios=1.6, 2-3: prevalence ratios=1.9-2.0, 4 or more: prevalence ratios=2.4); Ref for both: no visits. Adults with arthritis are a high-need target group for improving pain management, representing more than half of all U.S. adults with 1 or more opioid prescriptions. The association with ambulatory care visits suggests that providers have routine opportunities to discuss comprehensive and integrative pain management strategies, including low-cost evidence-based self-management approaches (e.g., physical activity, self-management education programs, cognitive behavioral therapy). Those with multiple opioid prescriptions may need extra support if transitioning to nonopioid and nonpharmacologic pain management strategies.

Receipt of multiple outpatient opioid prescriptions is associated with increased risk of adverse outcomes in youth: opioid prescribing trends, individual characteristics, and outcomes from 2005 to 2016.

Data on all outpatient opioid prescriptions (N = 71,647) to youth below age 21 (N = 42,020) from 2005 to 2016 were extracted from electronic medical records within a university hospital system in New Mexico (NM) as were demographic details and markers of morbidity/mortality. Relative risk was calculated for markers of morbidity/mortality based on sociodemographic characteristics. The sample was primarily male (55.0%), Hispanic/Latinx (50.1%), English-speaking (88.9%), and publicly insured (50.1%). Mean age was 13.54 (SD = 6.50). From 2005 to 2016, overall frequency of opioid prescriptions increased by 86.6% (from 2470 to 4610) with the largest increase (206.2%) observed from 2005 to 2008 (2470-7562). Patients who were older, white, and non-Hispanic were more likely to receive multiple opioid prescriptions. Large relative increases in morbidity and mortality were documented, although base rates remained low. The percentage of individuals within the sample who experienced an overdose increased steadily from 0 in 2005 to 1.09% in 2016. Incidence of mortality increased from 0.12% of the sample to 1.39% in 2016. The proportion of individuals who received a medication for the treatment of opioid dependence increased from 0.06% in 2005 to 0.44% in 2016. Significantly increased risk of adverse outcomes was observed in patients receiving multiple opioid prescriptions, and in patients who were older, of minority race, received their first prescription in an outpatient clinic, and publicly insured or uninsured. Results add to the growing literature concerning opioid prescription rates over time. They also provide important information on potential additive risks of adverse outcomes when pediatric patients receive multiple opioid prescriptions.

Patterns of Prescription Opioid Use in Women With Endometriosis: Evaluating Prolonged Use, Daily Dose, and Concomitant Use With Benzodiazepines.

To examine opioid use, opioid prescribing patterns, and timing of the first opioid prescription in endometriosis patients compared with matched women in the control group without endometriosis. We conducted a retrospective analysis of the Clinformatics Datamart database. Women diagnosed with endometriosis from January 2006 through December 2016 and aged 18-49 years were compared with women in the control group matched on age, region, race, insurance payer, and plan type. Key outcomes included: filled prescription for an opioid, multiple opioid prescriptions, number of days' supply, daily dose (morphine milligram equivalents), and concomitant opioid and benzodiazepine prescriptions. Cohorts were descriptively analyzed using t- and χ statistics and multivariable regression analyses yielded adjusted relative risk (RR) ratios and 95% CI. The study sample included 53,847 endometriosis patients and 107,694 patients in the control group. The mean age was 38 years, 62.4% of patients were white, and 51.6% lived in the South. Women in the endometriosis case group, compared with women in the control group, were more likely to fill an opioid prescription (42,705 [79.3%] women in the case group vs 26,106 [24.2%] women in the control group; adjusted RR ratio 2.91; 2.87-2.94), had higher likelihood of filling prescriptions with a dose of 50 morphine milligram equivalents or more (24,544 [45.6%] vs 10,463 [9.7%]; adjusted RR ratio 4.07; 3.98-4.16) or 100 morphine milligram equivalents or more (8,013 [14.9%] vs 3,582 [3.3%]; adjusted RR ratio 3.56; 3.43-3.70). Women in the case group were more likely to have concomitant opioid and benzodiazepine prescriptions (5,453 [10.1%] vs 3,711 [3.5%]; adjusted RR ratio 1.95; 1.88-2.03) and to have used these drugs concurrently for at least 30 days (1,596 [3.0%] vs 1,265 [1.2%]; adjusted RR ratio 1.43; 1.34-1.52) or at least 90 days (875 [1.6%] vs 777 [0.7%]; adjusted RR ratio 1.27; 1.17-1.37). Similar results were obtained after excluding opioid prescriptions received during a 30-day postsurgery window. Women with endometriosis had higher probabilities of prolonged use of opioids and concomitant use with benzodiazepines compared with women without this condition. This study was funded by AbbVie, Inc.

Assessing Prior Pain Visits and Medical History Risk Factors for Opioid Overdose

Objective: Identifying text features of emergency department visits associated with risk of future drug overdose.Introduction: Opioid overdoses are a growing cause of mortality in the United States.1 Medical prescriptions for opioids are a risk factor for overdose2. This observation raises concerns that patients may seek multiple opioid prescriptions, possibly increasing their overdose risk. One route for obtaining those prescriptions is visiting the emergency department (ED) for pain-related complaints. Here, two hypotheses related to prescription seeking and overdoses are tested. (1) Overdose patients have a larger number of prior ED visits than matched controls. (2) Overdose patients have distinct patterns of pain-related complaints compared to matched controls.Methods: ED registrations were collected via the EpiCenter syndromic surveillance system. Regular expression searches on chief complaints identified overdose visits. Overdose visits were matched with control visits from the same facility with maximal similarity of gender, age, home location and arrival time.A year of prior ED visits for cases and controls were matched using facility-specific patient identifiers or birthdate, gender and home location.Patient history chief complaints were sanitized to standardize spelling, expand abbreviations and consolidate phrases. Word frequency comparisons between groups identified candidate terms for modeling.Odds ratios of patient history terms were calculated with univariate logistic regression. Multivariate lasso logistic regression selected covariates for prediction. These models were fit to data from one quarter and cutoffs for covariate inclusion were validated on the following quarter’s data. Model predictions were validated on a 1% sample of ED registrations from the next quarter.Results: Quarter three of 2016 yielded 23,769 overdose ED visits and matching controls; quarter four yielded 21,957 pairs; and 15,824 ED visits were sampled from the first quarter of 2017 including 130 overdose visits.Contrary to expectations, patients in the control group averaged 0.7 additional ED visits in the prior year relative to controls; this pattern was consistent across quarters and regardless of how prior visits were matched (Fig 1).Prior visits for various pain categories were also more common among control patients than overdose patients (e.g. odds ratio for “back pain”: 0.78). Terms associated with drug use (e.g. “detox” odds ratio: 2.66) and mental health concerns (e.g. “psychological” odds ratio: 4.28) were most consistently overrepresented in the history of overdose patients (Table 1). Terms associated with chronic disease were most overrepresented in the history of control patients (Table 2).The best predictive model achieved a sensitivity of 57% and a specificity of 86% on test data (Fig 2).Conclusions: While a history of more overall ED visits and more ED visits related to pain were not associated with overdose ED visits, vocabulary of prior ED visits did predict future overdose ED visits. Performance of predictive models exceeded expectations, given the relative scarcity of overdoses among ED visits and the simplicity of chief complaints used for prediction. The correlation between past and future overdose visits highlights the need for targeted intervention to break addiction cycles.

Multiple opioid prescriptions among privately insured dental patients in the United States: Evidence from claims data

BackgroundMultiple or high dosage opioid prescriptions increase the risk of experiencing drug misuse and overdose. The authors examine index (first) and follow-up opioid prescriptions for 1 year among privately insured dental patients in the United States from 2010 through 2015. MethodsThe authors used the 2010 through 2015 Truven Health MarketScan Research databases and the Prescription Drug Monitoring Program Training Technical Assistance Center conversion data set. The authors analyzed index prescriptions, repeat prescriptions over 1 year, same-day multiple prescriptions, and concurrent prescriptions among dental patients. Descriptive analyses were conducted for days’ supply, quantity of opioids, daily morphine milligram equivalent (MME) dose, and total MME dose. ResultsApproximately 17.27% of all index prescriptions were dental related. The percentage of dental-related index prescriptions for age groups 11 through 18 years and 19 through 25 years was 23.51% and 23.41%, respectively. Approximately 80.87% of repeat prescriptions within 30 days of dental-related index prescriptions were dental related. In 39.07% of dental-related same-day multiple prescription incidents, the daily dose was greater than or equal to 50 MME. Approximately 58.28% of dental-related concurrent prescriptions were dispensed when an existing dental-related opioid prescription was available. ConclusionsDental-related index prescriptions were highest for the age groups 11 through 18 years and 19 through 25 years. The frequency of dental-related repeat prescriptions was the highest within 30 days of a dental-related index prescription. Practical ImplicationsLow dosages of opioids and the use of prescription drug monitoring programs before prescribing opioids may reduce the potential for drug misuse or overdose.

Dental opioid prescribing and multiple opioid prescriptions among dental patients: Administrative data from the South Carolina prescription drug monitoring program

BackgroundDespite increased attention to dentists’ roles in curbing opioid misuse, abuse, and diversion, information regarding prescribing practices and the frequency of multiple concurrent opioid prescriptions among dental patients is limited. MethodsThe authors reviewed South Carolina prescription drug monitoring program data representing dispensed medication for patients prescribed at least 1 opioid by a dentist during the most recently available 2-year time frame (2012-2013). The authors used descriptive analyses to examine the types and frequency of dental opioid prescriptions and the frequency of existing multiple concurrent opioid prescriptions among dental patients. ResultsNearly all dispensed dental opioid prescriptions (99.9%; n = 653,650) were for immediate-release opioids and were initial prescription fills (96.2%). Hydrocodone (76.1%) and oxycodone (12.2%) combination products were the most frequently dispensed opioids prescribed by dentists. People younger than 21 years received 11.2% of dentist-prescribed opioids dispensed. Patients with multiple concurrent opioid prescriptions were identified within 30-day (n = 113,818), 90-day (n = 166,124), and 180-day (n = 205,576) time frames. ConclusionsDentists prescribed a high volume of the immediate-release opioids dispensed in South Carolina. A notable minority of dental patients had incidents of multiple preexisting opioid prescriptions, a factor implicated in patient misuse, abuse, overdose, and diversion. Practical ImplicationsUse of a prescription drug monitoring program before prescribing provides a record of controlled substances dispensed to a patient and may inform prescribing, coordination of care, and addiction screening or referral. Patients should receive information regarding misuse behaviors and their risks, as well as the importance of secure storage and disposal of leftover opioid medications.

Risk for Opioid Misuse Among Emergency Department Cancer Patients

One of the most challenging areas of emergency medicine practice is the management and treatment of severe and persistent pain, including cancer-related pain. Emergency departments (EDs) in the United States frequently provide care for patients with cancer and an increasing concern is the potential for opioid misuse in this patient group. The authors determined the risk for opioid misuse among ED cancer patients with pain and assessed demographic and clinical factors associated with increased misuse risk. The Texas state prescription monitoring program was also queried for evidence of multiple opioid prescriptions for comparing low- and high-risk groups. The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) was administered to assess risk for opioid misuse among cancer patients presenting to the ED of a comprehensive cancer center in the United States. Eligibility criteria included: 1) presentation for treatment of chronic cancer-related pain while taking a prescribed schedule II opioid for analgesia, 2) age of 18 years or older, 3) ability to speak English, and 4) ability to understand the study and give written informed consent. Of 934 ED patients screened for the study, 290 were eligible and 209 participated (72% response rate). On the basis of the recommended SOAPP-R cutoff score of 18, a total of 71 of the 209 patients (34%) were categorized as having a high risk of misuse. Of note, 15% and 4% of all patients reported past or current use of illicit substances, respectively. The total number of annual opioid prescriptions (17.8 vs. 12.6; p = 0.023) differed between the high- versus low-risk groups. Multivariable analyses showed that depression (odds ratio [OR] = 3.06, 95% confidence interval [CI] = 1.45 to 6.48; p = 0.003), poor coping (OR = 1.08, 95% CI = 1.03 to 1.13; p = 0.001), and illicit substance use (OR = 28.30, 95% CI = 2.97 to 269.24; p = 0.029) were significantly associated with high risk of opioid misuse. The risk of opioid misuse among cancer patients is substantial. Screening for opioid misuse in the ED is feasible.

Estimating the prevalence of opioid diversion by "doctor shoppers" in the United States.

BackgroundAbuse of prescription opioid analgesics is a serious threat to public health, resulting in rising numbers of overdose deaths and admissions to emergency departments and treatment facilities. Absent adequate patient information systems, “doctor shopping” patients can obtain multiple opioid prescriptions for nonmedical use from different unknowing physicians. Our study estimates the prevalence of doctor shopping in the US and the amounts and types of opioids involved.Methods and FindingsThe sample included records for 146.1 million opioid prescriptions dispensed during 2008 by 76% of US retail pharmacies. Prescriptions were linked to unique patients and weighted to estimate all prescriptions and patients in the nation. Finite mixture models were used to estimate different latent patient populations having different patterns of using prescribers. On average, patients in the extreme outlying population (0.7% of purchasers), presumed to be doctor shoppers, obtained 32 opioid prescriptions from 10 different prescribers. They bought 1.9% of all opioid prescriptions, constituting 4% of weighed amounts dispensed.ConclusionsOur data did not provide information to make a clinical diagnosis of individuals. Very few of these patients can be classified with certainty as diverting drugs for nonmedical purposes. However, even patients with legitimate medical need for opioids who use large numbers of prescribers may signal dangerously uncoordinated care. To close the information gap that makes doctor shopping and uncoordinated care possible, states have created prescription drug monitoring programs to collect records of scheduled drugs dispensed, but the majority of physicians do not access this information. To facilitate use by busy practitioners, most monitoring programs should improve access and response time, scan prescription data to flag suspicious purchasing patterns and alert physicians and pharmacists. Physicians could also prevent doctor shopping by adopting procedures to screen new patients for their risk of abuse and to monitor patients' adherence to prescribed treatments.

Sex Differences in Long-term Opioid Use

Sex Differences in Long-term Opioid Use

New Item on Pediatric Menu: Food Allergy

at the University of California-Davis and a former president of the academy, said that otherwise physicians may simply choose to prescribe short-acting opioids instead of long-acting or extendedrelease versions, even if a short-acting formulation is not the best option for the patient. That is exactly what happened, he said, when the state of California instituted a prescription monitoring program in which physicians were required to obtain triplicate prescription pads from law enforcement agencies to prescribe Schedule II (longacting or sustained-release) opioids. He explained that many physicians substituted short-acting opioids rather than participate in the program. In turn, while abuse of Schedule II drugs decreased, abuse of the short-acting drug hydrocodone increased. “We need to level the field for all these drugs, so all are equal when physicians are choosing one in the best interest of the patient,” said Fishman. Jenkins said during the briefing that the FDA has chosen to focus on the long-acting products because the agency has detected a strong safety signal for these products, particularly methadone. However, he agreed that immediate-release products also pose safety concerns, and that the agency had not yet decided whether the scope of the safety plan should be extended to include them. The American Academy of Pain Medicine has also proposed the creation of a national program or a linked state prescription monitoring program to allow physicians and pharmacists to access up-to-date information on their patients’ prescriptions. Such a program could help prevent individuals from obtaining multiple opioid prescriptions from different clinicians. Whilehebelievesthatillegaluseofprescription opioid drugs is largely driving the increase in opioid-associated deaths andinjuries,Fishman,whoalsowrotethe federation’sopioidprescribingguide,said that a lack of physician education on proper use is contributing. He said such training should begin in medical school and extend to all licensed physicians, to ensure that patients have access to good painmanagement.Onewaytoaccomplish thismightbetohavestatemedicalboards make such training a requirement for license renewal. “Pain is the most common reason patients visit a doctor,” Fishman said. “It’s an essential part of what we do. At some point, we must say if you are going to be a doctor, you must treat pain.”