Objectives: Identifying factors associated with opioid use in middle-aged and older adults is a fundamental step in the mitigation of potentially unnecessary opioid consumption and opioid-related harms.
Methods: Using longitudinal data on a community-based cohort of adults aged 50-90 years residing in Johnston County, North Carolina, we examined sociodemographic and clinical factors in non-opioid users (n = 786) at baseline (2006-2010) as predictors of opioid use at follow-up (2013-2015). Variables included age, sex, race, obesity, educational attainment, employment status, household poverty rate, marital status, depressive symptoms, social support, pain catastrophizing, pain sensitivity, insurance status, polypharmacy, and smoking status.
Results: At follow-up, 13% of participants were using prescription opioids. In the multivariable model, high pain catastrophizing (adjusted odds ratio; 95% confidence interval = 2.14; 1.33-3.46), polypharmacy (2.08; 1.23-3.53), and history of depressive symptoms (2.00; 1.19-3.38) were independent markers of opioid use.
Discussion: Findings support the assessment of these modifiable factors during clinical encounters in patients ≥ 50 years old with chronic pain.
Resource type:
Article
Affiliation Label Tesim:
Department of Epidemiology, Injury Prevention Research Center, and University of North Carolina at Chapel Hill
Considerations for observational study design: Comparing the evidence of opioid use between electronic health records and insurance claims
Creator:
Stürmer, Til, Dasgupta, Nabarun, Funk, Michele, Young, Jessica, and Pate, Virginia
Date of publication:
August 31, 2022
Abstract Tesim:
Purpose: Pharmacoepidemiology studies often use insurance claims and/or electronic health records (EHR) to capture information about medication exposure. The choice between these data sources has important implications.
Methods: We linked EHR from a large academic health system (2015-2017) to Medicare insurance claims for patients undergoing surgery. Drug utilization was characterized based on medication order dates in the EHR, and prescription fill dates in Medicare claims. We compared opioid use documented in EHR orders to prescription claims in four time periods: 1) Baseline (182 days before surgery); 2) Perioperative period; 3) Discharge date; 4) Follow-up (90 days after surgery).
Results: We identified 11 128 patients undergoing surgery. During baseline, 34.4% (EHR) versus 44.1% (claims) had evidence of opioid use, and 56.9% of all baseline use was reflected only in one data source. During the perioperative period, 78.8% (EHR) versus 47.6% (claims) had evidence of use. On the day of discharge, 59.6% (EHR) versus 45.5% (claims) had evidence of use, and 51.8% of all discharge use was reflected only in one data source. During follow-up, 4.3% (EHR) versus 10.4% (claims) were identified with prolonged opioid use following surgery with 81.4% of all prolonged use reflected only in one data source.
Conclusions: When characterizing opioid exposure, we found substantial discrepancies between EHR medication orders and prescription claims data. In all time periods assessed, most patients' use was reflected only in the EHR, or only in the claims, not both. The potential for misclassification of drug utilization must be evaluated carefully, and choice of data source may have large impacts on key study design elements.
Resource type:
Article
Affiliation Label Tesim:
Department of Epidemiology, Injury Prevention Research Center, and Cecil G. Sheps Center for Health Services Research
Type:
http://purl.org/dc/dcmitype/Text
DOI:
https://doi.org/10.17615/98rh-vx42
Language Label:
English
ORCID:
Other Affiliation:
Person:
Stürmer, Til, Dasgupta, Nabarun, Funk, Michele, Young, Jessica, and Pate, Virginia
Association of Opioid Dose Reduction With Opioid Overdose and Opioid Use Disorder Among Patients Receiving High-Dose, Long-term Opioid Therapy in North Carolina
Importance: Rapid reduction or discontinuation of long-term opioid therapy may increase risk of opioid overdose or opioid use disorder (OUD). Current guidelines for chronic pain management caution against rapid dose reduction but are based on limited evidence.
Objective: To characterize the association between rapid reduction or abrupt discontinuation of opioid therapy (vs maintained or gradual reduction) and incidence of opioid overdose and OUD among patients prescribed high-dose, long-term opioid therapy (HDLTOT).
Design, setting, and participants: This retrospective cohort study was conducted among patients aged 18 to 64 years who were prescribed HDLTOT (≥90 daily morphine milligram equivalents for ≥90% of 90 days) from January 2006 to September 2018, with follow-up up to 4 years after cohort entry. Claims data were drawn from a large private health insurer in North Carolina and analyzed from March 1, 2006, to September 30, 2018.
Exposures: Time-varying exposure of rapid dose reduction or discontinuation (>10% dose reduction/week) vs maintenance, increase, or gradual reduction or discontinuation.
Main outcomes and measures: The main outcome was incident opioid overdose (fatal or nonfatal) or diagnosed OUD. Inverse probability-weighted cumulative incidence of outcomes were estimated using the cumulative incidence function and hazard ratios (HRs) using marginal structural Fine-Gray models as a function of rapid dose tapering or discontinuation (vs gradual reduction or discontinuation or maintained or increased), accounting for competing risks.
Results: A total of 19 443 patients (median [IQR] age, 49 [41-55] years; 10 073 [51.8%] men) who received HDLTOT were identified. Rapid reduction or discontinuation was associated with higher risk of fatal and nonfatal overdoses compared with gradual reduction after the first year (year 1: HR, 1.43; 95% CI, 0.94-2.18; years 2-4: HR, 1.95; 95% CI, 1.31-2.90). There was no association between rapid reduction or discontinuation and diagnosed OUD through 2 years of follow-up; however, the hazard of incident OUD among patients exposed to rapid tapering or discontinuation was greater 25 to 48 months after the start of follow-up (HR, 1.28; 95% CI, 1.01-1.63).
Conclusions and relevance: In this cohort study, rapid dose reduction or discontinuation was associated with increased risk of opioid overdose and OUD during long-term follow-up. These findings reinforce prior concerns about safety of rapid dose reductions for patients receiving HDLTOT and highlight the need for caution when reducing opioid doses.
Resource type:
Article
Affiliation Label Tesim:
Injury Prevention Research Center, School of Medicine, Department of Epidemiology, and Gillings School of Global Public Health
Changing Trends in Drug Overdose Mortality in Kentucky: An Examination of Race and Ethnicity, Age, and Contributing Drugs, 2016-2020
Creator:
Rock, Peter, Liford, Madison, Walsh, Sharon, Quesinberry, Dana, Hargrove, Sarah, Brancato, Candace, Freeman, Patricia, and Slavova, Svetla
Date of publication:
February 21, 2022
Abstract Tesim:
Objectives: Increased drug overdose mortality among non-Hispanic Black people in the United States in the past 5 years highlights the need for better tailored programs and services. We evaluated (1) changes in drug overdose mortality for various racial and ethnic groups and (2) drug involvement to inform drug overdose prevention efforts in Kentucky.
Methods: We used Kentucky death certificates and postmortem toxicology reports from 2016-2020 (provisional data) to estimate changes in age-adjusted drug overdose death rates per 100 000 standard population.
Results: The age-adjusted drug overdose death rate per 100 000 standard population among non-Hispanic Black residents doubled from 2016 (21.2) to 2020 (46.0), reaching the rate among non-Hispanic White residents in 2020 (48.7; P = .48). From 2016 to 2020, about 80% of these drug overdose deaths involved opioids; heroin involvement declined about 20 percentage points; fentanyl involvement increased about 30 percentage points. The number of psychostimulant-involved drug overdose deaths increased 513% among non-Hispanic Black residents and 191% among non-Hispanic White residents. Cocaine-involved drug overdose deaths increased among non-Hispanic Black residents but declined among non-Hispanic White residents. Drug overdose death rates were significantly lower among Hispanic residents than among non-Hispanic White residents.
Conclusions: Increased opioid-involved overdose deaths among non-Hispanic Black residents in Kentucky in combination with rapidly expanding concomitant psychostimulant involvement require increased understanding of the social, cultural, and illicit market circumstances driving these rapid trend changes. Our findings underscore the urgent need to expand treatment and harm reduction services to non-Hispanic Black residents with substance use disorder.
Resource type:
Article
Type:
http://purl.org/dc/dcmitype/Text
DOI:
https://doi.org/10.17615/awe0-v146
Language Label:
English
ORCID:
Other Affiliation:
University of Kentucky
Person:
Rock, Peter, Liford, Madison, Walsh, Sharon, Quesinberry, Dana, Hargrove, Sarah, Brancato, Candace, Freeman, Patricia, and Slavova, Svetla
Invited Commentary: Drug Checking for Novel Insights Into the Unregulated Drug Supply
Creator:
Figgatt, Mary and Dasgupta, Nabarun
Date of publication:
January 24, 2022
Abstract Tesim:
Tobias et al. (Am J Epidemiol. 2022;191 (2):241-247) present a novel analysis of time trends in fentanyl concentrations in the unregulated drug supply in British Columbia, Canada. The preexisting knowledge about unregulated drugs had come from law-enforcement seizures and postmortem toxicology. As both of these data sources are subject to selection bias, large-scale drug-checking programs are poised to be a crucial component of the public health response to the unrelenting increase in overdose in North America. As programs expand, we offer 2 guiding principles. First, the primary purpose of these programs is to deliver timely results to people who use drugs to mitigate health risks. Second, innovation is needed to go beyond criminal justice paradigms in laboratory analysis for a more nuanced understanding of health concerns. We provide examples of the role adulterants play in our understanding of drug harms. We also describe the applications and limitations of common laboratory assays, with implications for epidemiologic surveillance. While the research and direct service teams in British Columbia have taken groundbreaking steps, there is still a need to establish best practices for communicating results to sample donors in an approachable yet nonalarmist tone.
Resource type:
Article
Affiliation Label Tesim:
Department of Epidemiology and Injury Prevention Research Center
Impacts of Initial Prescription Length and Prescribing Limits on Risk of Prolonged Postsurgical Opioid Use
Creator:
Hudgens, Michael, Stürmer, Til, Funk, Michele, Dasgupta, Nabarun, Pate, Virginia, Chidgey, Brooke, and Young, Jessica
Date of publication:
January 1, 2022
Abstract Tesim:
Background: In response to concerns about opioid addiction following surgery, many states have implemented laws capping the days supplied for initial postoperative prescriptions. However, few studies have examined changes in the risk of prolonged opioid use associated with the initial amount prescribed.
Objective: The objective of this study was to estimate the risk of prolonged opioid use associated with the length of initial opioid prescribed and the potential impact of prescribing limits.
Research design: Using Medicare insurance claims (2007-2017), we identified opioid-naive adults undergoing surgery. Using G-computation methods with logistic regression models, we estimated the risk of prolonged opioid use (≥1 opioid prescription dispensed in 3 consecutive 30-d windows following surgery) associated with the varying initial number of days supplied. We then estimate the potential reduction in cases of prolonged opioid use associated with varying prescribing limits.
Results: We identified 1,060,596 opioid-naive surgical patients. Among the 70.0% who received an opioid for postoperative pain, 1.9% had prolonged opioid use. The risk of prolonged use increased from 0.7% (1 d supply) to 4.4% (15+ d). We estimated that a prescribing limit of 4 days would be associated with a risk reduction of 4.84 (3.59, 6.09)/1000 patients and would be associated with 2255 cases of prolonged use potentially avoided. The commonly used day supply limit of 7 would be associated with a smaller reduction in risk [absolute risk difference=2.04 (-0.17, 4.25)/1000].
Conclusions: The risk of prolonged opioid use following surgery increased monotonically with increasing prescription duration. Common prescribing maximums based on days supplied may impact many patients but are associated with relatively low numbers of reduced cases of prolonged use. Any prescribing limits need to be weighed against the need for adequate pain management.
Resource type:
Article
Affiliation Label Tesim:
Department of Biostatistics, Department of Epidemiology, Injury Prevention Research Center, and Department of Anesthesiology
Type:
http://purl.org/dc/dcmitype/Text
DOI:
https://doi.org/10.17615/f3gz-ff20
Language Label:
English
ORCID:
Other Affiliation:
Person:
Hudgens, Michael, Stürmer, Til, Funk, Michele, Dasgupta, Nabarun, Pate, Virginia, Chidgey, Brooke, and Young, Jessica
Objective: Evaluate beliefs and behaviors pertaining to abuse-deterrent opioids (ADFs).
Design: Survey in 2019 by invitation to all licensed physicians.
Setting: Commonwealth of Kentucky.
Participants: 374 physicians.
Methods: Descriptive statistics, and hypothesis test that early adopter prescribers would have greater endorsement of opioid risk management.
Results: Of all prescribers, 55% believed all opioid analgesics should have ADF requirements (15% were unsure); 74% supported mandating insurance coverage. Only one-third considered whether an opioid was ADF when prescribing, motivated by patient family diversion (94%) and societal supply reduction (88%). About half believed ADFs were equally effective in preventing abuse by intact swallowing, injection, chewing, snorting, smoking routes. Only 4% of OxyContin prescribers chose it primarily because of ADF properties. Instead, the most common reason (33%) was being started by another prescriber. A quarter of physicians chose not to prescribe ADFs because of heroin switching potential. Early adopters strongly believed ADFs were effective in reducing abuse (PR 3.2; 95% CI 1.5, 6.6) compared to mainstream physicians. Early-adopter risk-management practices more often included tools increasing agency and measurement: urine drug screens (PR 2.0; 1.3, 3.1), risk screening (PR 1.3; 0.94, 1.9). While nearly all respondents (96%) felt that opioid abuse was a problem in the community, only 57% believed it was a problem among patients in their practice. Attribution theory revealed an externalization of opioid abuse problems that deflected blame from patients on to family members.
Conclusions: The primary motivator for prescribing ADFs was preventing diversion by family members, not patient-level abuse concerns.
Resource type:
Article
Affiliation Label Tesim:
Hussman School of Journalism and Media and Injury Prevention Research Center
Type:
http://purl.org/dc/dcmitype/Text
DOI:
https://doi.org/10.17615/0q7v-xd43
Language Label:
English
ORCID:
Other Affiliation:
, University of Kentucky, and Kentucky Injury Prevention and Research Center
Kentucky pharmacists’ experiences in dispensing abuse-deterrent opioid analgesics
Creator:
Dasgupta, Nabarun, Oyler, Douglas, Brown, John, Freeman, Patricia, and Slavova, Svetla
Date of publication:
August 4, 2022
Abstract Tesim:
Background: Despite pharmaceutical industry promise and enthusiasm, abuse-deterrent formulation (ADF) opioid use is relatively low. While some barriers to use have been addressed through state laws and policy, pharmacists' experiences with and opinions of ADF opioids are unclear.
Objectives: The objective of this study was to evaluate pharmacists' perceptions of dispensing ADFs.
Methods: This was a cross-sectional survey of community pharmacists licensed and practicing in Kentucky conducted in late 2019. The survey asked about perception, experience dispensing, and insurance coverage of 5 ADF opioids available at the time.
Results: Most respondents (421/629, 67.9%) were familiar or very familiar with ADFs, and 63.1% agreed that all opioids should meet U.S. Food and Drug Administration standards for abuse deterrence. Aside from OxyContin, most ADF opioid formations were not stocked (range: 46.7%-73.6%). Third-party payer claims were occasionally or almost always rejected for most ADFs (range: 56.3%-75.4%). Contrary to intended mechanism of deterrence, ADFs were rated as the least effective strategy to reduce opioid misuse/abuse, with over half (51.2%) of respondents believing ADFs were not effective or somewhat effective. ADFs were rated as effective or very effective at reducing opioid abuse by swallowing intact by 37.4% of respondents.
Conclusion: Pharmacists are familiar with ADFs but do not dispense them frequently. Pharmacists appear skeptical about the effectiveness of ADFs but support policies that could increase ADF uptake.
Resource type:
Article
Affiliation Label Tesim:
Injury Prevention Research Center
Type:
http://purl.org/dc/dcmitype/Text
DOI:
https://doi.org/10.17615/74vt-bc05
Language Label:
English
ORCID:
Other Affiliation:
, University of Kentucky, and Kentucky Injury Prevention and Research Center
Person:
Dasgupta, Nabarun, Oyler, Douglas, Brown, John, Freeman, Patricia, and Slavova, Svetla
Purpose: The primary objective of this study was to estimate the percentage of opioid analgesic (OA) prescriptions dispensed by Kentucky independent pharmacies with correctly entered days' supply in the state prescription drug monitoring program (PDMP) system in 2019.
Methods: Using a two-stage cluster design, pharmacies were sampled with probabilities proportional to the volume of dispensed OAs; 100 random OA prescriptions were sampled from PDMP records submitted by each pharmacy. Following recruitment, demographic information and hard-copy prescription data for sampled records were abstracted on-site. Days' supply was independently calculated by two pharmacists using a standard formula with disagreements adjudicated blindly by a third pharmacist. Adjudicated days' supply was compared with that submitted to the PDMP and classified as accurate/inaccurate. Descriptive statistics were used to characterize the sample and a multivariable logistic regression model was used to assess the relationship between accuracy and prescription/practice-related factors.
Results: A total of 1281 OA prescriptions were reviewed at 13 participating pharmacies. Accuracy of reported OA days' supply was 89.85%, (95% CI: 86.90, 92.80). Factors associated with accuracy were presence of special instructions from the prescriber (OR 3.13 [95% CI: 1.43, 6.82]), presence of 'as-needed' directions (OR 0.29 [95% CI: 0.18, 0.47]), and billing to a third-party payer (OR 1.43 [95% CI: 1.01, 2.02]).
Conclusions: Accuracy of OA days' supply reported to the state PDMP was found to be moderately high. Certain prescription-related factors influence accuracy and should be accounted for in future studies. Patterns, including opioid 'split-billing' were identified and may impact validity of PDMP and administrative claims studies.
Resource type:
Article
Affiliation Label Tesim:
Injury Prevention Research Center
Type:
http://purl.org/dc/dcmitype/Text
DOI:
https://doi.org/10.17615/ha9d-cr86
Language Label:
English
ORCID:
Other Affiliation:
, University of Kentucky, and Kentucky Injury Prevention and Research Center
Day-of-Surgery Gabapentinoids and Prolonged Opioid Use: A Retrospective Cohort Study of Medicare Patients Using Electronic Health Records
Creator:
Funk, Michele, Pate, Virginia, Hudgens, Michael, Dasgupta, Nabarun, Stürmer, Til, Young, Jessica, and Chidgey, Brooke
Date of publication:
November 1, 2021
Abstract Tesim:
BACKGROUND: While preoperative gabapentinoids are commonly used in surgical multimodal analgesia protocols, little is known regarding the effects this therapy has on prolonged postsurgical opioid use. In this observational study, we used data from a large integrated health care system to estimate the association between preoperative day-of-surgery gabapentinoids and the risk of prolonged postsurgical opioid use.
METHODS: We identified adults age ≥65 years undergoing major therapeutic surgical procedures from a large integrated health care system from 2016 to 2019. Exposure to preoperative gabapentinoids on the day of surgery was measured using inpatient medication administration records, and the outcome of prolonged opioid use was measured using outpatient medication orders. We used stabilized inverse probability of treatment-weighted log-binomial regression to estimate risk ratios and 95% confidence intervals (CIs) of prolonged opioid use, comparing patients who received preoperative gabapentinoids to those who did not and adjusting for relevant clinical factors. The main analysis was conducted in the overall surgical population, and a secondary analysis was conducted among procedures where at least 30% of all patients received a preoperative gabapentinoid.
RESULTS: Overall, 13,958 surgical patients met inclusion criteria, of whom 21.0% received preoperative gabapentinoids. The observed 90-day risk of prolonged opioid use following surgery was 0.91% (95% CI, 0.77–1.08). Preoperative gabapentinoid administration was not associated with a reduced risk of prolonged opioid use in the main analysis conducted in a broad surgical population (adjusted risk ratio [adjRR], 1.19 [95% CI, 0.67–2.12]) or in the secondary analysis conducted in patients undergoing colorectal resection, hip arthroplasty, knee arthroplasty, or hysterectomy (adjRR, 1.01 [95% CI, 0.30–3.33]).
CONCLUSIONS: In a large integrated health system, we did not find evidence that preoperative gabapentinoids were associated with reduced risk of prolonged opioid use in patients undergoing a broad range of surgeries.
Resource type:
Article
Affiliation Label Tesim:
Department of Epidemiology, Department of Biostatistics, Injury Prevention Research Center, and Department of Anesthesiology
Type:
http://purl.org/dc/dcmitype/Text
DOI:
https://doi.org/10.17615/t8ka-5m43
Language Label:
English
ORCID:
Other Affiliation:
Person:
Funk, Michele, Pate, Virginia, Hudgens, Michael, Dasgupta, Nabarun, Stürmer, Til, Young, Jessica, and Chidgey, Brooke