Correction: High-Dose Opioid Prescribing and Opioid-Related Hospitalization: A Population-Based Study.
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ABSTRACT:
SUBMITTER: PLOS ONE Staff
PROVIDER: S-EPMC5249127 | biostudies-literature | 2017
REPOSITORIES: biostudies-literature
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Correction: High-Dose Opioid Prescribing and Opioid-Related Hospitalization: A Population-Based Study.
PloS one 20170120 1
[This corrects the article DOI: 10.1371/journal.pone.0167479.]. ...[more]
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Project description:AimsTo examine the impact of national clinical practice guidelines and provincial drug policy interventions on prevalence of high-dose opioid prescribing and rates of hospitalization for opioid toxicity.DesignInterventional time-series analysis.SettingOntario, Canada, from 2003 to 2014.ParticipantsOntario Drug Benefit (ODB) beneficiaries aged 15 to 64 years from 2003 to 2014.InterventionsPublication of Canadian clinical practice guidelines for use of opioids in chronic non-cancer pain (May 2010) and implementation of Ontario's Narcotics Safety and Awareness Act (NSAA; November 2011).MeasurementsThree outcomes were explored: the rate of opioid use among ODB beneficiaries, the prevalence of opioid prescriptions exceeding 200 mg and 400 mg morphine equivalents per day, and rates of opioid-related emergency department visits and hospital admissions.FindingsOver the 12 year study period, the rate of opioid use declined 15.2%, from 2764 to 2342 users per 10,000 ODB eligible persons. The rate of opioid use was significantly impacted by the Canadian clinical practice guidelines (p-value = .03) which led to a decline in use, but no impact was observed by the enactment of the NSAA (p-value = .43). Among opioid users, the prevalence of high-dose prescribing doubled (from 4.2% to 8.7%) over the study period. By 2014, 40.9% of recipients of long-acting opioids exceeded daily doses of 200 mg morphine or equivalent, including 55.8% of long-acting oxycodone users and 76.3% of transdermal fentanyl users. Moreover, in the last period, 18.7% of long-acting opioid users exceeded daily doses of 400 mg morphine or equivalent. Rates of opioid-related emergency department visits and hospital admissions increased 55.0% over the study period from 9.0 to 14.0 per 10,000 ODB beneficiaries from 2003 to 2013. This rate was not significantly impacted by the Canadian clinical practice guidelines (p-value = .68) or enactment of the NSAA (p-value = .59).ConclusionsAlthough the Canadian clinical practice guidelines for use of opioids in chronic non-cancer pain led to a decline in opioid prescribing rates among ODB beneficiaries these guidelines and subsequent Ontario legislation did not result in a significant change in rates of opioid-related hospitalizations. Given the prevalence of high dose opioid prescribing in this population, this suggests that improved strategies and programs for the safe prescribing of long-acting opioids are needed.
| S-EPMC5156349 | biostudies-literature
Project description:ObjectiveTo describe current state-level policies in the United States, January 1, 2007-June 1, 2017, limiting high morphine equivalent daily dose (MEDD) prescribing.MethodsState-level MEDD threshold policies were reviewed using LexisNexis and Westlaw Next for legislative acts and using Google for nonlegislative state-level policies. The websites of each state's Medicaid agency, health department, prescription drug monitoring program, workers' compensation board, medical board, and pharmacy board were reviewed to identify additional policies. The final policy list was checked against existing policy compilations and academic literature and through contact with state health agency representatives. Policies were independently double-coded on the categories: state, agency/organization, policy type, effective date, threshold level, and policy exceptions.ResultsCurrently, 22 states have at least one type of MEDD policy, most commonly guidelines (14 states), followed by prior authorizations (four states), rules/regulations (four states), legislative acts (three states), claim denials (two states), and alert systems/automatic patient reports (two states). Thresholds range widely (30-300 mg MEDD), with higher thresholds generally corresponding to more restrictive policies (e.g., claim denial) and lower thresholds corresponding to less restrictive policies (e.g., guidelines). The majority of policies exclude some groups of opioid users, most commonly patients with terminal illnesses or acute pain.ConclusionsMEDD policies have gained popularity in recent years, but considerable variation in threshold levels and policy structure point to a lack of consensus. This work provides a foundation for future evaluation of MEDD policies and may inform states considering adopting such policies.
| S-EPMC8607298 | biostudies-literature
Project description:BackgroundRising opioid-related death rates have prompted reductions of opioid prescribing, yet limited data exist on population-level associations between opioid prescribing and opioid-related deaths.ObjectiveTo evaluate population-level associations between five opioid prescribing measures and opioid-related deaths.DesignAn ecological panel analysis was performed using linear regression models with year and commuting zone fixed effects.ParticipantsPeople ≥10 years aggregated into 886 commuting zones, which are geographic regions collectively comprising the entire USA.Main measuresAnnual opioid prescriptions were measured with IQVIA Real World Longitudinal Prescription Data including 76.5% (2009) to 90.0% (2017) of US prescriptions. Prescription measures included opioid prescriptions per capita, percent of population with ≥1 opioid prescription, percent with high-dose prescription, percent with long-term prescription, and percent with opioid prescriptions from ≥3 prescribers. Outcomes were age- and sex-standardized associations of change in opioid prescriptions with change in deaths involving any opioids, synthetics other than methadone, heroin but not synthetics or methadone, and prescription opioids, but not other opioids.Key resultsChange in total regional opioid-related deaths was positively correlated with change in regional opioid prescriptions per capita (β=.110, p<.001), percent with ≥1 opioid prescription (β=.100, p=.001), and percent with high-dose prescription (β=.081, p<.001). Change in total regional deaths involving prescription opioids was positively correlated with change in all five opioid prescribing measures. Conversely, change in total regional deaths involving synthetic opioids was negatively correlated with change in percent with long-term opioid prescriptions and percent with ≥3 prescribers, but not for persons ≥45 years. Change in total regional deaths in heroin was not associated with change in any prescription measure.ConclusionsRegional decreases in opioid prescriptions were associated with declines in overdose deaths involving prescription opioids, but were also associated with increases in deaths involving synthetic opioids (primarily fentanyl). Individual-level inferences are limited by the ecological nature of the analysis.
| S-EPMC9905341 | biostudies-literature
Project description:BackgroundAny opioid-related hospitalization is an indicator of opioid-related harm and should ideally trigger carefully monitored decreases in opioid prescribing after inpatient stays in many, if not most, cases. However, past studies on opioid prescribing after hospitalizations have largely been limited to overdose related visits. It is unclear whether prescribing is different for other opioid-related indications such as opioid dependence and abuse and how that may compare with hospitalizations for overdose.ObjectiveTo examine opioid-prescribing patterns before and after opioid-related hospitalizations for all opioid-related indications, not limited to overdose.Research designRetrospective cohort analysis of Veterans Health Administration (VHA) administrative claims from 2011 to 2014.SubjectsVHA patients who were hospitalized between fiscal years 2011 and 2014 and had at least 1 prescription opioid medication filled through the VHA pharmacy before their hospitalization.MeasuresOpioid dispensing trajectories after hospitalization by opioid-related indication (ie, opioid dependence and/or abuse vs. overdose) compared with prescribing patterns for non-opioid-related hospitalizations.ResultsOverall, opioid dosage dropped significantly (66% for dependence/abuse, 42% for overdose, and 3% for nonopioid diagnoses; P<0.001) across all 3 categories when comparing dose 57-63 days after admission to 57-63 days before hospitalization. However, 47% of the patients remained on the same dose or increased their opioid dose at 60 days after an opioid-related hospitalization. After adjusting for covariates, patients with a primary diagnosis of dependence/abuse had higher odds of having their dose discontinued compared with those with overdose: odds ratio (OR) 2.17 (1.19-3.96). Patients with admissions for opioid dependence and/or abuse had a statistically significant higher prevalence of depression, posttraumatic stress disorder, anxiety, and substance use disorders compared with those with an opioid overdose hospitalization.ConclusionsOpioid prescribing and patient risk factors before and after opioid-related hospitalizations vary by indication for hospitalization. To reduce costs and morbidity associated with opioid-related hospitalizations, opioid deintensification efforts need to be tailored to indication for hospitalization.
| S-EPMC6742521 | biostudies-literature
Project description:BACKGROUND:Oregon's Medicaid program is delivered through 16 Coordinated Care Organizations (CCOs) participating in a statewide performance improvement program to reduce high-dose opioid prescribing. CCOs were allowed flexibility to develop their own dose targets and any policies, trainings, guidelines, and/or materials to meet these targets. In this study, we characterize CCO strategies to reduce high-dose opioid prescribing across the 16 CCOs. METHODS:We reviewed relevant CCO documents and conducted semi-structured interviews with CCO administrators to acquire opioid-related policies, practices, timelines and contextual factors. We applied a systematic coding procedure to develop a comprehensive description of each CCO's strategy. We used administrative data from the state to summarize contextual utilization data for each CCO. RESULTS:Most CCOs selected a target daily morphine milligram equivalent (MME) dose of 90?mg. Sixteen issued quantity limits related to dose, eight restricted specific drug formulations (short-acting or long-acting), and 11 allowed for time-limited taper plan periods for patients over threshold. Many CCOs also employed provider trainings, feedback reports, and/or onsite technical assistance. Other innovations included incentive measures, electronic health record alerts, and toolkits with materials on local alternative therapy resources and strategies for patient communication. CCOs leveraging collaborations with regional partners appeared to mount a greater intensity of interventions than independently operating CCOs. CONCLUSIONS:CCOs developed a diversity of interventions to confront high-risk opioid prescribing within their organization. As healthcare systems mount interventions to reduce risky opioid prescribing, it is critical to carefully describe these activities and examine their impact on process and health outcomes.
| S-EPMC6078786 | biostudies-literature
Project description:BackgroundThe duration of an opioid prescribed at hospital discharge does not intrinsically account for opioid needs during a hospitalization. This discrepancy may lead to patients receiving much larger supplies of opioids on discharge than they truly require.ObjectiveAssess a novel discharge opioid supply metric that adjusts for opioid use during hospitalization, compared to the conventional discharge prescription signature.Design, setting, & participantsRetrospective study using electronic health record data from June 2012 to November 2018 of adults who received opioids while hospitalized and after discharge from a single academic medical center.Measures & analysisWe ascertained inpatient opioids received and milligrams of opioids supplied after discharge, then determined days of opioids supplied after discharge by the conventional prescription signature opioid-days ("conventional days") and novel hospital-adjusted opioid-days ("adjusted days") metrics. We calculated descriptive statistics, within-subject difference between measurements, and fold difference between measures. We used multiple linear regression to determine patient-level predictors associated with high difference in days prescribed between measures.ResultsThe adjusted days metric demonstrates a 2.4 day median increase in prescription duration as compared to the conventional days metric (9.4 vs. 7.0 days; P<0.001). 95% of all adjusted days measurements fall within a 0.19 to 6.90-fold difference as compared to conventional days measurements, with a maximum absolute difference of 640 days. Receiving a liquid opioid prescription accounted for an increased prescription duration of 135.6% by the adjusted days metric (95% CI 39.1-299.0%; P = 0.001). Of patients who were not on opioids prior to admission and required opioids during hospitalization but not in the last 24 hours, 325 (8.6%) were discharged with an opioid prescription.ConclusionsThe adjusted days metric, based on inpatient opioid use, demonstrates that patients are often prescribed a supply lasting longer than the prescription signature suggests, though with marked variability for some patients that suggests potential under-prescribing as well. Adjusted days is more patient-centered, reflecting the reality of how patients will take their prescription rather than providers' intended prescription duration.
| S-EPMC7774844 | biostudies-literature
Project description:BackgroundAntimicrobial resistance and opioid misuse both present major public health challenges, and identifying high prescribers of both of these agents can help provide a common target for intervention. We sought to determine the association between being a high prescriber of antibiotics and being a high prescriber of opioids in the primary care setting.MethodsWe performed a cross-sectional study of the antibiotic- and opioid-prescribing habits of primary care physicians in Ontario, Canada between Mar. 1, 2017, and Feb. 28, 2018, using administrative databases. We defined high prescribers as the top quartile of antibiotic or opioid prescribers using 3 antibiotic-prescribing metrics (prescriptions per patient visit, proportion of prescriptions that were broad spectrum and proportion of prescriptions > 8 d) and 3 opioid-prescribing metrics (prescriptions per patients seen, proportion of prescriptions > 90 mg of morphine equivalents and proportion of prescriptions > 28 d). We tabulated agreement between prescribing metrics using the κ statistic.ResultsWe included 9994 physicians. We observed minimal overlap between high antibiotic initiation and high opioid initiation (618 physicians [6.2%]) (κ = 0.00, 95% confidence interval -0.02 to 0.02). There was slight agreement between the antibiotic-prescribing indices and between the opioid-prescribing indices (within-class, range of κ 0.05 to 0.18). There was slight disagreement to slight agreement across antibiotic- and opioid-prescribing metrics (between-class, range of κ -0.09 to 0.16).InterpretationAmong primary care physicians, there was a lack of association between high antibiotic prescribing and high opioid prescribing. Our findings suggest that separate tailored approaches to antibiotic and opioid stewardship strategies are needed.
| S-EPMC8034295 | biostudies-literature
Project description:BACKGROUND:Emergency physicians provide primary care to patients and often prescribe opioids for acutely painful self-limiting conditions. The objective of this study was to describe patterns of opioid prescribing by emergency physicians and family physicians and to explore the relation between setting of initiation of opioid treatment and adverse events over the subsequent 2 years. METHODS:This was a population-based cohort study using administrative data from Ontario. Opioid-naive patients aged 15-64 years who received an opioid prescription for noncancer pain from an emergency or family physician between Apr. 1, 2008, and Mar. 31, 2012 were eligible for inclusion. RESULTS:A total of 34?713 and 45?952 patients were initiated on an opioid by an emergency physicians and family physicians, respectively. Both emergency and family physicians most commonly prescribed codeine-containing products (58.9% and 79.6% of prescriptions, respectively); however, emergency physicians were twice as likely as family physicians to prescribe higher-potency opioids (morphine, oxycodone, hydromorphone, fentanyl, meperidine) (both combination and single-agent preparations) (40.6% v. 19.9%, ? = 20.7, 95% confidence interval [CI] 20.0-21.3). Compared to patients in the family physician group, those in the emergency physician group received significantly higher daily dosages, a higher proportion were initiated on a daily dosage of 100 mg of morphine equivalents (MEQs) or more, and had a hospital admission for opioid toxicity within 2 years (0.5% v. 0.3%, ? = 0.2%, 95% CI 0.1%-0.3%). A higher proportion of patients in the family physician group than in the emergency physician group had dosage escalation beyond 199 mg MEQs within 2 years (0.7% v. 0.1%, ? = 0.6%, 95% CI 0.5%-0.7%). INTERPRETATION:Codeine was the most common opioid prescribed by emergency and family physicians. Compared to patients prescribed opioids by family physicians, those prescribed opioids by emergency physicians received higher initial daily dosages and had an increased likelihood of opioid toxicity.
| S-EPMC5878958 | biostudies-literature
Project description:BackgroundOpioid use during pregnancy has been associated with adverse maternal and infant health outcomes. Prescription drug monitoring programs (PDMP) provide a population-based source of prescription data. We linked statewide PDMP and birth certificate data in Tennessee (TN) to determine patterns of prescription opioid and benzodiazepine use during pregnancy.MethodsWe constructed a cohort of 311,217 live singleton births from 2013 to 2016 with prescription history from 90 days before pregnancy to birth. Descriptive statistics were used to describe opioid prescription patterns during pregnancy overall, by maternal characteristics and by year. Multivariable logistic regression models estimated adjusted odds ratios and 95% confidence intervals for factors associated with prescription use.ResultsThe prevalence of prescription use during pregnancy was 14.1% for opioid analgesics, 1.6% buprenorphine for medication-assisted treatment, and 2.6% for benzodiazepines. The prevalence of opioid analgesic use decreased from 16.6% (2013) to 11.8% (2016) (ptrend< 0.001). About 25% used for > 7 and 9.7% for > 30 days' supply. The most common types were hydrocodone (9.3%), codeine (3.4%), and oxycodone (2.9%). In adjusted models, lower education, lower income, pre-pregnancy obesity and smoking during pregnancy were associated with increased odds of any opioid and opioid analgesic use.Conclusion(s)Despite the encouraging trend of decreasing use of prescription opioid analgesics, the overall prevalence remained close to 12% with many women using for long durations. Use was associated with lower socioeconomic status, obesity, and prenatal smoking. Findings highlight the need for maternal education and resources, and provider support for implementation of evidence-based care.
| S-EPMC10838571 | biostudies-literature
Project description:As the opioid crisis has escalated, states have enacted numerous policies targeting opioid access and monitoring possible misuse. Recently, the majority of states have passed electronic prescribing mandates for controlled substances. These mandates require that controlled substances be prescribed electronically directly to the pharmacy. The electronic system maintains a rich patient history that prescribers will observe when issuing a prescription while also reducing opportunities for fraud. The first enforced mandate was implemented in New York in March 2016; thus empirical evidence about the effects of such mandates is limited. We study how adoption of the New York e-prescribing mandate affected opioid supply and opioid-related overdoses. We estimate that the mandate reduced the rate of overdoses involving natural and semi-synthetic opioids by 22 %. We find little evidence of any corresponding changes in overdose rates involving illicit opioids.
| S-EPMC8222172 | biostudies-literature