Opioid Receipt Research Articles

External validation of a model to predict future chronic opioid use among hospitalized patients.

Previous research demonstrates an association between opioid prescribing at hospital discharge and future chronic opioid use. Various opioid guidelines and policies contributed to changes in opioid prescribing practices. How this affected hospitalized patients remains unknown. Externally validate a prediction model to identify hospitalized patients at the highest risk for future chronic opioid therapy (COT). Retrospective analysis of health record data from 2011 to 2022 using logistic regression. Hospitalized adults with limited to no opioid use 1-year prior to hospitalization. A statewide healthcare system. Used variables associated with progression to COT in a derivation cohort from a different healthcare system to predict expected outcomes in the validation cohort. The derivation cohort included 17,060 patients, of whom 9653 (56.6%) progressed to COT 1 year after discharge. Compared to the derivation cohort, in the validation cohort, patients who received indigent care (odds ratio [OR] = 0.40, 95% confidence interval [CI] = 0.27-0.59, p < .001) were least likely to progress to COT. Among variables assessed, opioid receipt at discharge was most strongly associated with progression to COT (OR = 3.74, 95% CI = 3.06-4.61, p < .001). The receiver operating characteristic curve for the validation set using coefficients from the derivation cohort performed slightly better than chance (AUC = 0.55). Our results highlight the importance of externally validating a prediction model prior to use outside of the derivation population. Periodic updates to models are necessary as policy changes and clinical practice recommendations may affect model performance.

Effect of Pharmacist Email Alerts on Concurrent Prescribing of Opioids and Benzodiazepines by Prescribers and Primary Care Managers

Policy makers have sought to discourage concurrent prescribing of opioids and benzodiazepines (coprescribing) because it is associated with overdose. Email alerts sent by pharmacists may reduce coprescribing, but this intervention lacks randomized evidence. To investigate whether pharmacist emails to practitioners caring for patients who recently received opioids and benzodiazepines reduce coprescribing of these medications. Randomized clinical trial (intention to treat) conducted in 2019-2021 of patients and their practitioners (prescribers and primary care managers) in the National Capital Region of the Military Health System. Participants were 2237 patients who were recently coprescribed opioids and benzodiazepines. These patients had 789 practitioners eligible for emails. Patients were randomized to email alerts to their practitioners or as-usual care. Clinical pharmacists sent the email alert. Messages were standardized and designed to facilitate coordination between practitioners, increase awareness of guidelines, and provide action steps and resources. The primary outcomes were patients' days received of opioids, benzodiazepines, and concurrent opioids and benzodiazepines during the 90 days following enrollment evaluated using 1-sided hypothesis tests. Secondary outcomes included total prescribing of opioids and benzodiazepines by patients' practitioners, including to patients outside the study, to test for broader outcomes on their prescribing. Of 2237 patients, 1187 were assigned to treatment and 1050 to control; 1275 (57%) were women. Patients received a mean (SD) of 31 (44) days of opioids and 33 (34) days of benzodiazepines in the 90 days before enrollment. There were no detected differences in the primary end points, including patients' receipt of opioids (adjusted difference, 1.1 days; 95% CI, -∞ to 3.0; P = .81), benzodiazepines (adjusted difference, -0.6 days; 95% CI, -∞ to 1.4; P = .30), and opioids and benzodiazepines together (adjusted difference, -0.1 days; 95% CI, -∞ to 0.7; P = .41). Of 789 practitioners, 429 were considered the treatment group, 325 were considered controls, and 35 were excluded. There were no detected differences in practitioners' total prescribing of opioids, benzodiazepines, or both drug classes together. In this randomized clinical trial of pharmacist emails to practitioners, email alerts failed to detectably reduce coprescribing, highlighting the value of alternative approaches. Combining randomization with quality improvement activities may help stakeholders seeking evidence-based interventions to encourage guideline-concordant care. ClinicalTrials.gov Identifier: NCT03887247.

Association between prescribed opioid dose and risk of motor vehicle crashes.

Opioid-involved motor vehicle traffic fatalities have increased over the past 2 decades. However, the extent to which prescribed opioids increase the risk of motor vehicle crashes remains uncertain. This study used real-world healthcare claims data to examine the association between prescription opioid dose and motor vehicle crash risk. Using nationwide US commercial insurance claims data for 2010 to 2018, we identified 772,404 adults who received incident, noncancer opioid therapy. We examined associations between daily prescription opioid dose, calculated in morphine milligram equivalents (MME) from filled prescription claims, and risk of motor vehicle crashes, assessed as diagnoses of motor vehicle injuries in claims for emergency visits, inpatient hospitalizations, and ambulance transportation. We estimated associations using a within-individual design, which ruled out all time-stable confounding. We complemented the design with time-varying statistical adjustment for other pharmacotherapies and a negative control pain pharmacotherapy analysis (with incident cyclic antidepressant prescriptions). During 2,150,009 person-years of follow-up, there were 12,123 motor vehicle crashes (5.64 crashes per 1000 person-years). In within-individual comparisons, crash risk was greater during opioid prescription periods involving doses ≤60 MME/day (odds ratio [OR], 3.86; 95% confidence interval [CI], 3.54, 4.21), >60 to 120 MME/day (OR, 5.46; 95% CI, 4.44, 6.73), and >120 MME/day (OR, 3.45; 95% CI, 2.31, 5.15) than during off-treatment periods. The negative control analysis supported the specificity of the results to opioids rather than to other processes associated with pharmacologic pain management. These findings suggest that the receipt of prescription opioids, even at doses ≤60 MME/day, is associated with an increased risk of motor vehicle crashes.

Trajectories and correlates of opioid prescription receipt among patients experiencing interpersonal violence.

Interpersonal violence increases vulnerability to the deleterious effects of opioid use. Increased opioid prescription receipt is a major contributor to the opioid crisis; however, our understanding of prescription patterns and risk factors among those with a history of interpersonal violence remains elusive. This study sought to identify 5-year longitudinal patterns of opioid prescription receipt among patients experiencing interpersonal violence within a large healthcare system and sociodemographic and clinical characteristics associated with prescription patterns. This secondary analysis examined electronic health record data from January 2004-August 2019 for a cohort of patients (N = 1,587) referred for interpersonal violence services. Latent class growth analysis was used to estimate trajectories of opioid prescription receipt over a 5-year period. Standardized differences were calculated to assess variation in sociodemographic and clinical characteristics between classes. Our cohort had a high prevalence of prescription opioid receipt (73.3%) and underlying co-morbidities, including chronic pain (54.6%), substance use disorders (39.0%), and mental health diagnoses (76.9%). Six prescription opioid receipt classes emerged, characterized by probability of any prescription opioid receipt at the start and end of the study period (high, medium, low, never) and change in probability over time (increasing, decreasing, stable). Classes with the highest probability of prescription opioids also had the highest proportions of males, chronic pain diagnoses, substance use disorders, and mental health diagnoses. Black, non-Hispanic and Hispanic patients were more likely to be in low or no prescription opioid receipt classes. These findings highlight the importance of monitoring for synergistic co-morbidities when providing pain management and offering treatment that is trauma-informed, destigmatizing, and integrated into routine care.

Inpatient opioid receipt and care experiences for vaginal delivery.

To examine the relationship between care experiences and inpatient opioid receipt during and after delivery for women hospitalized for vaginal delivery (VD). We used a pooled cross-sectional design with inverse probability weighting to examine the association between inpatient opioid receipt and care experiences of women hospitalized for VD at a single health care system in a Midwestern state. We used 4 Hospital Consumer Assessment of Healthcare Providers and Systems scores (2 pain care items and 2 global items) as measures of care experiences of women hospitalized for VD. We used 4 inverse probability-weighted logit regressions to estimate the relationship between inpatient opioid receipt and each patient care experience measure. In supplementary analyses, we used the same inverse probability-weighted methods to estimate the relationship between receipt of opioids and patient care experience measures in 3 patient subgroups based on mean patient-reported pain score during hospitalization (no pain, mild pain, moderate pain). We found no relationship between inpatient opioid receipt and inpatient pain care experiences. As an exception, we found that women hospitalized for VD were 5 (95% CI, 2-8) percentage points more likely to rate the hospital as 10 ("the best hospital possible") during hospitalizations in which an opioid was received. We also found higher overall ratings of the hospital among hospitalized women who reported mild pain if they received an opioid (marginal effects = 0.05; 95% CI, 2-8 percentage points). Receipt of opioids may not be a significant determinant of the pain-specific patient care experiences of women hospitalized for VD.

The association of prescription opioid use with suicide attempts: An analysis of statewide medical claims data.

BackgroundSuicides and opioid overdose deaths are among the most pressing public health concerns in the US. However direct evidence for the association between opioid use and suicidal behavior is limited. The objective of this article is to examine the association between frequency and dose of prescription opioid use and subsequent suicide attempts.Methods and findingsThis retrospective cohort study analyzed 4 years of statewide medical claims data from the Connecticut All-Payer Claims Database. Commercially insured adult patients in Connecticut (n = 842,773) who had any medical claims beginning in January 2012 were followed through December 2015. The primary outcome was suicide attempt identified using International Classification of Diseases (ICD 9) diagnosis codes. Primary predictor variables included frequency of opioid use, which was defined as the number of months with claims for prescription opioids per year, and strength of opioid dose, which was standardized using morphine milligram equivalent (MME) units. We also controlled for psychiatric and medical comorbidities using ICD 9 codes. We used Cox proportional hazards regression to examine the association between frequency, dose, and suicide attempts, adjusting for medical and psychiatric comorbid conditions. Interactions among measures of opioid use and comorbid conditions were analyzed.In this cohort study with follow-up time up to 4 years (range = 2–48 months, median = 46 months), the hazard ratios (HR) from the time-to-event analysis indicated that patients prescribed opioid medications for at least 6 months during the past year and at 20–50 MME levels or higher had 4.44 (95% CI: [3.71, 5.32]) to 7.23 (95% CI: [6.22, 8.41]) times the risk of attempted suicide compared to those not prescribed opioids. Risk of suicide attempt was sharply elevated among patients with psychiatric conditions other than anxiety who were prescribed more frequent and higher opioid doses. In contrast, more frequent and higher doses of prescription opioids were associated with lower risk of suicide attempts among patients with medical conditions necessitating pain management.This study is limited by its exclusive focus on commercially insured patients and does not include patients covered by public insurance. It is also limited to patients’ receipt of prescription opioids and does not take into account opioids obtained through other means, nor does it include measures of actual patient opioid use.ConclusionsThis analysis provides evidence of a complex relationship among prescription opioids, mental health, pain and other medical comorbidities, and suicide risk. Findings indicate the need for proactive suicide surveillance among individuals diagnosed with affective or psychotic disorders who are receiving frequent and high doses of opioids. However, appropriate opioid treatment may have significant value in reducing suicide risk for those without psychiatric comorbidities.

What is driving declines in oncology-prescribed opioids?

6583 Background: Patients with cancer have experienced sharp declines in opioid prescribing during the past decade, raising concerns about insufficient pain management in a population with high rates of undertreated pain. It is unclear whether these declines are driven by certain oncology subspecialties, payors, or clinical guidelines regarding opioid prescribing released in/after March 2016. Methods: We conducted time series analyses using 2006-2019 IQVIA Longitudinal Prescription Data, which represents up to 92% of all U.S. prescription fills. Using log-linear regression stratified by group, we estimated annual percent change in opioid receipt by: subspecialty (medical oncology MO, radiation oncology RO, and surgical oncology SO); payor (third-party; Medicare, including Medicare Part D; Medicaid; cash/out-of-pocket); and pre- versus post-March 2016. Opioid receipt outcomes included: monthly fills of any opioid; monthly fills of extended-release/long-acting (ER/LA) opioids; and monthly number of patients receiving long-term opioid therapy (LTOT). Outcomes were per 1,000 survivors to account for temporal changes in cancer prevalence. Results: Between 2006 and 2019, 14,301,900 opioid fills were prescribed by oncologists to 3,476,354 distinct patients. Across all outcomes, MO had the highest levels of dispensing, followed by RO, then SO; for example, in 2006 MO dispensed 6.2 fills per 1,000 survivors (compared to 1.9 fills among RO, and 0.5 among SO). We observed substantial declines in all opioid outcomes. Per 1,000 survivors, there was an annual decline of: 5.7% (95CI: 5.1-6.3; total unadjusted decline 2006-2019=70.2%) in the rate of all opioid fills; 4.9% (95CI: 4.1-5.6; total unadjusted decline=66.8%) in ER/LA fills; 3.2% (95CI: 1.5-5.0; total unadjusted decline=56.2%) in LTOT fills, and 1.9% in average daily dose (95CI: 1.9-2.0; total unadjusted decline=29.8%). The annual decline in opioid fills prescribed by MO (7.1%, 95CI: 6.6-7.7) was sharper than for RO (5.9%, 95CI: 5.4-6.4) and SO (5.2%, 95CI: 4.7-5.7). Annual declines were steepest among fills paid out-of-pocket (14.5%, 95CI: 13.9-15.0), followed by those paid by Medicaid (13.1%, 95CI: 12.5-13.6), third-party payors (9.3%, 95CI: 8.7-9.9), and Medicare (2.4%, 95CI: 1.8-3.1). Declines in every outcome accelerated following clinical guidelines released in/after 2016. Conclusions: Opioids prescribed by oncologists declined dramatically across groups and outcomes. Medical oncologists were responsible for a disproportionate share of opioid fills in 2006, and for the sharpest declines. Out-of-pocket fills declined more sharply than fills covered by insurance and clinical guidelines may have contributed to accelerating declines. While de-escalation of opioid therapy may reduce risk of opioid-related harms to cancer survivors, care is needed to ensure cancer-related pain is appropriately treated.

Patterns and Trends in Receipt of Opioids Among Patients Receiving Treatment for Cancer in a Large Health System.

Given limited evidence on opioid prescribing among patients receiving treatment for cancer during the ongoing opioid epidemic, our objective was to assess predictors of and trends in opioid receipt during cancer treatment, including how patterns differ by type of cancer. Using cancer registry data, we identified patients with a first lifetime primary diagnosis of breast, colorectal, or lung cancer from 2013 to 2017 who underwent treatment within a large cancer center network. Cancer registry data were linked to electronic health record information on opioid prescriptions. We examined predictors of and trends in receipt of any opioid prescription within 12 months of cancer diagnosis. The percentage of patients receiving opioids varied by cancer type: breast cancer, 35% (1,996/5,649); colorectal, 37% (776/2,083); lung, 47% (1,259/2,654). In multivariable analysis, opioid use in the year before cancer diagnosis was the factor most strongly associated with receipt of opioids after cancer diagnosis, with 4.90 (95% CI, 4.10-5.86), 5.09 (95% CI, 3.88-6.69), and 3.31 (95% CI, 2.68-4.10) higher odds for breast, colorectal, and lung cancers, respectively. We did not observe a consistent decline in opioid prescribing over time, and trends differed by cancer type. Our findings suggest that prescription of opioids to patients with cancer varies by cancer type and other factors. In particular, patients are more likely to receive opioids after cancer diagnosis if they were previously exposed before diagnosis, suggesting that pain among patients with cancer may commonly include non-cancer-related pain. Heterogeneity and complexity among patients with cancer must be accounted for in developing policies and guidelines aimed at addressing pain management while minimizing the risk of opioid misuse.

The Impact of a PDMP-EHR Data Integration Combined With Clinical Decision Support on Opioid and Benzodiazepine Prescribing Across Clinicians in a Metropolitan Area.

Despite inconclusive evidence that prescription drug monitoring programs (PDMP) reduce opioid-related mortality, guidelines recommend PDMP review with opioid prescribing. Some reported barriers to use include time-consuming processes to obtain data and workflow disruptions. We provided access to a PMDP-electronic health record (EHR) integrated program to 123 clinicians in one healthcare system. Remaining clinicians within the healthcare system and metropolitan area did not receive PDMP-EHR integration program access. We identified changes in opioid prescribing by linking prescription data available in the state PMDP database to individual clinicians. The primary outcome was change in receipt of high dose opioid prescriptions (>90 mg morphine equivalents) by Colorado residents before and after program integration. Secondary outcomes included changes in long-acting opioid receipt and overlapping opioid and benzodiazepine prescription days. Next, we surveyed clinicians to assess their perspectives on PDMP data acquisition before and after PDMP-EHR integration program access. High-dose opioid receipt decreased significantly across all 3 clinician groups [PDMP-EHR integration program access (27.6%, to 6.9%, P < 0.001); no program access in the same healthcare system (4.8% to 2.9%, P < 0.001), and no program access across the metropolitan area (13.5% to 6.1%, P < 0.001)]. Clinicians reported improved access to PDMP data using the PDMP-EHR integrated program compared to the state PDMP website (98.6%). Further study of PDMP-EHR integration programs on patient and clinician outcomes may illuminate the role of this technology in public health and in clinical practice.

Embedded emergency department physical therapy versus usual care for acute low back pain: a protocol for the NEED-PT randomised trial

IntroductionLow back pain is a common problem and a substantial source of morbidity and disability worldwide. Patients frequently visit the emergency department (ED) for low back pain, but many experience...

Long-term Opioid Therapy and Overdose in Patients with and without Cancer

Pain is experienced by most patients with cancer and opioids are a cornerstone of cancer pain management. Our objectives were (1) to identify patterns or trajectories of long-term opioid therapy (LTOT) and their correlates among patients with and without cancer and (2) to assess the association between trajectories and risk for opioid overdose, considering the potential moderating role of cancer. We conducted a retrospective cohort study among Veterans in the Veterans Health Administration (VHA) electronic health record database with incident LTOT with and without cancer (N=44,351; N=285,772, respectively) between 2010-2017. Using latent growth mixture modeling and Cox Proportional Hazards modeling, we investigated the relationship between trajectory of LTOT and all ICD-9 and 10-defined accidental and intentional opioid-related overdose events. Trajectories of opioid receipt observed in patients without cancer and replicated in patients with cancer were: low-dose, low-dose/de-escalating trend, moderate-dose, moderate-dose/escalating trend, and high-dose/escalating trend. Time to first overdose was significantly predicted by higher-dose and escalating trajectories; the two low-dose trajectories conferred similar, lower risk. Conditional hazard ratios (99% CI) for the moderate-dose and moderate-dose/escalating and high-dose/escalating trends were 1.84 (1.19, 2.85), 2.65 (1.63, 4.32), and 2.25 (1.27, 3.96), respectively. Effects of trajectories on time to overdose did not differ presence of cancer. Inferences were replicated when restricting the cancer sample to patients with stage 3 or 4 cancer at cohort entry. Patients with cancer face opioid overdose risks like patients without cancer. Clinicians and researchers alike should consider this when counseling patients and developing inclusion criteria for studies of LTOT. Future studies should seek to expand our knowledge about opioid risk in patients with cancer, and how to address it. Grant support from Department of Veterans Affairs (VA) Service Directed Research project SDR 15-461. Pain is experienced by most patients with cancer and opioids are a cornerstone of cancer pain management. Our objectives were (1) to identify patterns or trajectories of long-term opioid therapy (LTOT) and their correlates among patients with and without cancer and (2) to assess the association between trajectories and risk for opioid overdose, considering the potential moderating role of cancer. We conducted a retrospective cohort study among Veterans in the Veterans Health Administration (VHA) electronic health record database with incident LTOT with and without cancer (N=44,351; N=285,772, respectively) between 2010-2017. Using latent growth mixture modeling and Cox Proportional Hazards modeling, we investigated the relationship between trajectory of LTOT and all ICD-9 and 10-defined accidental and intentional opioid-related overdose events. Trajectories of opioid receipt observed in patients without cancer and replicated in patients with cancer were: low-dose, low-dose/de-escalating trend, moderate-dose, moderate-dose/escalating trend, and high-dose/escalating trend. Time to first overdose was significantly predicted by higher-dose and escalating trajectories; the two low-dose trajectories conferred similar, lower risk. Conditional hazard ratios (99% CI) for the moderate-dose and moderate-dose/escalating and high-dose/escalating trends were 1.84 (1.19, 2.85), 2.65 (1.63, 4.32), and 2.25 (1.27, 3.96), respectively. Effects of trajectories on time to overdose did not differ presence of cancer. Inferences were replicated when restricting the cancer sample to patients with stage 3 or 4 cancer at cohort entry. Patients with cancer face opioid overdose risks like patients without cancer. Clinicians and researchers alike should consider this when counseling patients and developing inclusion criteria for studies of LTOT. Future studies should seek to expand our knowledge about opioid risk in patients with cancer, and how to address it. Grant support from Department of Veterans Affairs (VA) Service Directed Research project SDR 15-461.

Comparing Outpatient Opioids, High-Risk Prescribing, and Opioid Poisoning Between Transgender and Cisgender Veterans: A Cross-sectional Analysis

Transgender veterans have a high prevalence of substance use disorder and physical and mental-health comorbidities, which are associated with prescription opioid use and overdose risk. This study compares receipt of outpatient opioids, high-risk opioid prescribing, and opioid poisoning between transgender and cisgender (i.e., nontransgender) veterans. A secondary analysis of Veterans Health Administration health record data from January 1, 2018 to December 31, 2018 was conducted in 2021. Transgender veterans (n=9,686) were randomly matched to 3 cisgender veterans (n=29,058) on the basis of age and county. Using the same matching criteria, a second cohort was created of all transgender veterans and a matched sample of cisgender veterans who were prescribed an outpatient opioid (n=7,576). Stratified Cox proportional hazard regression measured the RR of each prescription outcome and opioid poisoning. Transgender veterans had a 20% higher risk of being prescribed any outpatient opioid than cisgender veterans (adjusted RR=1.20, 95% CI=1.13, 1.27). Transgender and cisgender veterans who were prescribed an opioid did not have different risks of high-risk prescribing: overlapping opioid prescriptions (adjusted RR=0.93, 95% CI=0.85, 1.02), daily dose >120 morphine milligram equivalents (adjusted RR=0.86, 95% CI=0.66, 1.10), or overlapping opioid and benzodiazepine prescriptions (adjusted RR=1.05, 95% CI=0.96, 1.14). Overall, transgender veterans had more than twice the risk of opioid poisoning than cisgender veterans (RR=2.76, 95% CI=1.57, 4.86). The risk of opioid poisoning did not differ between transgender and cisgender veterans who were prescribed an opioid (RR=1.09, 95% CI=0.56, 2.11). Transgender veterans had a greater risk of being prescribed an outpatient opioid than cisgender veterans but did not have different risks of high-risk opioid prescribing.

Opioid Prescriptions and Pain-Related Patient-Initiated Communication After Mohs Micrographic Surgery: A Retrospective Cohort Study.

There is a wide variety in utilization of opioids during Mohs Micrographic Surgery (MMS) despite evidence that a multimodality approach may be more beneficial. To evaluate prescription opioid use at our institution and subsequent pain-related patient communication following MMS. This was a retrospective cohort study involving 2360 patients who underwent MMS. Patient and operative characteristics in relation to opioid use in the peri-operative period were compared using univariate and bivariate statistical measures. A total of 306 patients (13%) were prescribed opioids postoperatively. However, receipt of opioids is associated with greater odds of pain-related patient communication (OR=6.2; 95% CI:3.3&ndash;11.4). Opioid type was not significantly associated with reported pain (OR=0.7; 95% CI:0.3&ndash;1.8). Consistent with existing guidelines, certain patient and operative characteristics such as age, number of Mohs stages, repair type, and anatomic site were associated with greater odds of receiving opioids. While certain patients may require opioids for adequate pain control, in our cohort, opioid use was associated with increased odds of pain-related patient communication post MMS. J Drugs Dermatol. 2022;21(5):551-554. doi:10.36849/JDD.5742.

Racial, Gender, and Neighborhood-Level Disparities in Pediatric Trauma Care.

Disparities in trauma outcomes and care are well established for adults, but the extent to which similar disparities are observed in pediatric trauma patients requires further investigation. The objective of this study was to evaluate the unique contributions of social determinants (race, gender, insurance status, community distress, rurality/urbanicity) on trauma outcomes after controlling for specific injury-related risk factors. All pediatric (age < 18) trauma patients admitted to a single level 1 trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed (n = 14,398). Primary outcomes were receipt of opioids in the emergency department, post-discharge rehabilitation referrals, and mortality. Multivariate logistic regressions evaluated demographic, socioeconomic, and injury characteristics. Multilevel logistic regressions evaluated area-level indicators, which were derived from abstracted home addresses. Analyses adjusting for demographic and injury characteristics revealed that Black children (n = 6255) had significantly lower odds (OR = 0.87) of being prescribed opioid medications in the emergency department compared to White children (n = 5883). Children living in more distressed and rural communities had greater odds of receiving opioid medications. Girls had significantly lower odds (OR = 0.61) of being referred for rehabilitation services than boys. Post hoc analyses revealed that Black girls had the lowest odds of receiving rehabilitation referrals compared to Black boys and White children. Results highlight the need to examine both main and interactive effects of social determinants on trauma care and outcomes. Findings reinforce and expand into the pediatric population the growing notion that traumatic injury care is not immune to disparities.

Did prescribing laws disproportionately affect opioid dispensing to Black patients?

To evaluate whether pain management clinic laws and prescription drug monitoring program (PDMP) prescriber check mandates, two state opioid policies with relatively rapid adoption across states, reduced opioid dispensing more or less in Black versus White patients. Pharmacy claims data, US sample of commercially insured adults, 2007-2018. Stratifying by race, we used generalized estimating equations with an event-study specification to estimate time-varying effects of each policy on opioid dispensing, comparing to the four pre-policy quarters and states without the policy. Outcomes included high-dosage opioids, overlapping opioid prescriptions, concurrent opioid/benzodiazepines, opioids from >3 prescribers, opioids from >3 pharmacies. We identified all prescription opioid dispensing to Black and White adults aged 18-64 without a palliative care or cancer diagnosis code. Exactly 7,096,592 White and 1,167,310 Black individuals met inclusion criteria. Pain management clinic laws were associated with reductions in two outcomes; their association with high-dosage receipt was larger among White patients. In contrast, reductions due to PDMP mandates appeared limited to, or larger in, Black patients compared with White patients in four of five outcomes. For example, PDMP mandates reduced high-dosage receipt in Black patients by 0.7 percentage points (95% CI: 0.36-1.08 ppt.) over 4 years: an 8.4% decrease from baseline; there was no apparent effect in White patients. Similarly, while there was limited evidence that mandates reduced overlapping opioid receipt in White patients, they appeared to reduce overlapping opioid receipt in Black patients by 1.3ppt. (95% CI: -1.66--1.01 ppt.) across post-policy years-a 14.4% decrease from baseline. PDMP prescriber check mandates but not pain management clinic laws appeared to reduce opioid dispensing more in Black patients than White patients. Future research should discern the mechanisms underlying these disparities and their consequences for pain management.

Switching of opioid agonist treatment modality during imprisonment: A novel marker for increased support need during and following release from prison.

The endocannabinoid system has been implicated in physiological processes fundamental to pain, giving plausibility to the hypothesis that cannabis may be used as a substitute or complement to prescription opioids in the management of chronic pain. We examined the association of medical cannabis licensure with likelihood of prescription opioid receipt using administrative records.This study linked registry information for medical cannabis licensure with records from the prescription drug monitoring program from April 1, 2016 to March 31, 2019 to create a population-based, retrospective cohort in Rhode Island. We examined within-person changes in receipt of any opioid prescription and receipt of an opioid prescription with a morphine equivalent dose of 50 mg or more, and of 90 mg or more.The sample included 5,296 participants with medical cannabis license. Medical cannabis licensure was not associated with the odds of filling any opioid prescription (OR: 0.99; 95% CI: 0.94–0.1.05) or the odds of filling a prescription with a morphine equivalent dose of 50 mg or more (OR: 0.93; 95% CI: 0.84–1.04) and 90 mg or more (OR: 0.99; 95% CI: 0.86–1.15).Medical cannabis licensure was not associated with subsequent cessation and reduction in prescription opioid use. Re-scheduling of cannabis will allow for the conduct of randomized controlled trials to determine the efficacy of medical cannabis as an alternative to prescription opioid use or a complement to the use of lower doses of prescription opioids in patients with chronic pain.

Association of medical cannabis licensure with prescription opioid receipt: A population-based, individual-level retrospective cohort study.

The endocannabinoid system has been implicated in physiological processes fundamental to pain, giving plausibility to the hypothesis that cannabis may be used as a substitute or complement to prescription opioids in the management of chronic pain. We examined the association of medical cannabis licensure with likelihood of prescription opioid receipt using administrative records. This study linked registry information for medical cannabis licensure with records from the prescription drug monitoring program from April 1, 2016 to March 31, 2019 to create a population-based, retrospective cohort in Rhode Island. We examined within-person changes in receipt of any opioid prescription and receipt of an opioid prescription with a morphine equivalent dose of 50 mg or more, and of 90 mg or more. The sample included 5,296 participants with medical cannabis license. Medical cannabis licensure was not associated with the odds of filling any opioid prescription (OR: 0.99; 95% CI: 0.94-0.1.05) or the odds of filling a prescription with a morphine equivalent dose of 50 mg or more (OR: 0.93; 95% CI: 0.84-1.04) and 90 mg or more (OR: 0.99; 95% CI: 0.86-1.15). Medical cannabis licensure was not associated with subsequent cessation and reduction in prescription opioid use. Re-scheduling of cannabis will allow for the conduct of randomized controlled trials to determine the efficacy of medical cannabis as an alternative to prescription opioid use or a complement to the use of lower doses of prescription opioids in patients with chronic pain.

Opioid Prescription Is Associated With Increased Survival in Older Adult Patients With Pancreatic Cancer in the United States: A Propensity Score Analysis.

Few studies have assessed the interaction between pain treatment and mortality in pancreatic cancer. The aim of this study was to investigate the association between receipt of opioid prescriptions and survival in adults with pancreatic cancer. The SEER-Medicare linked database was used to identify patients diagnosed with late-stage pancreatic cancer between 2007 and 2015. Kaplan-Meier models were used to assess the association between opioid prescriptions in the year after cancer diagnosis and survival. Cox proportional hazard models were used to determine the association between opioid receipt and survival, adjusting for propensity score and other relevant confounders including cancer-directed therapies and palliative care referral. A total of 5,770 older adults with pancreatic cancer were identified; 1,678 (29.1%) were prescribed opioids for at least 60 days. Median survival was increased in those with opioid prescriptions (6.0 months) compared with those without (4.0 months, P < .0001). After adjustment for confounders, opioid prescriptions were still associated with improved survival (hazard ratio 0.80; 95% CI, 0.75 to 0.86). On multivariable analysis, opioid prescriptions were associated with older age, female sex, residing in nonmetro areas, and treatment with celiac plexus neurolysis, chemotherapy, and radiation. Receipt of opioid prescriptions is associated with longer survival in patients with pancreatic cancer. This may be due to the impact of cancer-related pain, although further studies are needed to better understand the interaction between pain management, cancer-directed therapies, and systemic factors, such as palliative care, availability of opioids, and clinical practice culture.

Social determinants of trauma care: Associations of race, insurance status, and place on opioid prescriptions, postdischarge referrals, and mortality.

Racial disparities in trauma care have been reported for a range of outcomes, but the extent to which these remain after accounting for socioeconomic and environmental factors remains unclear. The objective of this study was to evaluate the unique contributions of race, health insurance, community distress, and rurality/urbanicity on trauma outcomes after carefully controlling for specific injury-related risk factors. All adult (age, ≥18 years) trauma patients admitted to a single Level I trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed. Primary outcomes were mortality, rehabilitation referral, and receipt of opioids in the emergency department. Demographic, socioeconomic, and injury characteristics as well as indicators of community distress and rurality based on home address were abstracted from a trauma registry database. Analyses revealed that Black patients (n = 13,073) were younger, more likely to be male, more likely to suffer penetrating injuries, and more likely to suffer assault-based injuries compared with White patients (n = 10,946; all p < 0.001). In adjusted analysis, insured patients had a 28% lower risk of mortality (odds ratio, 0.72; p = 0.005) and were 92% more likely to be referred for postdischarge rehabilitation than uninsured patients (odds ratio, 1.92; p = 0.005). Neither race- nor place-based factors were associated with mortality. However, post hoc analyses revealed a significant race by age interaction, with Black patients exhibiting more pronounced increases in mortality risk with increasing age. The present findings help disentangle the social determinants of trauma disparities by adjusting for place and person characteristics. Uninsured patients were more likely to die and those who survived were less likely to receive referrals for rehabilitation services. The expected racial disparity in mortality risk favoring White patients emerged in middle age and was more pronounced for older patients. Prognostic and epidemiological, Level III.

Substance use history is associated with lower opioid use for emergency department pain management.

In the current national opioid crisis, where 10% of the US population has or has had a substance use disorder (SUD), emergency department (ED) clinicians are challenged when treating pain in the ED and when prescribing pain medications to these patients on discharge as there is concern for contributing to the cycle of addiction. The objective of this study was to examine whether acute pain is treated differently in patients with and without current or past SUD by quantifying the amount of opioid analgesia given in the ED and prescribed on discharge. Retrospective cohort study of patients presenting to a 60,000-visit tertiary referral ED with acute fracture between January 1, 2016 and June 30, 2019. The primary exposure was indication of SUD (SUD+) versus those without SUD (SUD-). The primary outcome was receipt of opioids in the ED, and the secondary outcome was opioids prescribed at discharge. 117 matched pairs (n = 234) were included in the sample. Overall, 53.4% and 62.4% of patients received opioids in the ED or a prescription for opioids, respectively. Opioid receipt in the ED was lower among SUD+ patients compared to SUD- patients (48.7% and 58.1%, respectively; aOR: 0.33; 95%CI: 0.14, 0.77). Similarly, receipt of a prescription for opioids was lower among SUD+ patients compared to SUD- patients (56.4% and 68.4%, respectively; aOR: 0.50; 95%CI: 0.26, 0.95). Overall, ED clinicians gave opioids less frequently to SUD+ patients in the ED and on discharge from the ED compared to SUD- patients with acute pain secondary to acute fracture.