First Opioid Prescription and Subsequent High-Risk Opioid Use: a National Study of Privately Insured and Medicare Advantage Adults

187 Background: While opioids represent a cornerstone of cancer pain management, the timing and patterns of persistent and high-risk opioid use in the context of the ongoing opioid epidemic are not well studied. This study sought to explore longitudinal trends in short-term, long-term, and high-risk opioid use among older cancer patients. Methods: Within a cohort of 84,994 Medicare beneficiaries ≥ 65 years old diagnosed with cancer between 2007 and 2013, we determined the likelihood of being prescribed an opioid after cancer diagnosis (0-6 months, 6-12 months, and 1-2 years post-diagnosis) and of receiving a daily morphine equivalent dose (MED) ≥ 200 mg, a dose associated with higher opioid-related mortality. Multivariable logistic regression models were used to identify patient and cancer risk factors associated with outcomes. Results: The rates of opioid prescription at 0 to 6 months, 6 to 12 months, and 1 to 2 years after diagnosis were 60.7%, 32.7%, and 38.2% respectively. Among patients who were prescribed an opioid, 4.0% received a MED ≥ 200 mg within 2 years of diagnosis. The likelihood of opioid prescription 0 to 6 months after diagnosis increased over the study period (OR = 1.05 per year, CI = 1.04 to 1.06), while the likelihood of opioid prescription 6 to 12 months (OR = 0.98 per year, CI = 0.97 to 0.99) and 1 to 2 years (OR = 0.98 per year, CI = 0.97 to 0.99) after diagnosis decreased over the study period. The probability of receiving a MED ≥ 200 mg decreased over the study period (OR = 0.98 per year, CI = 0.96 to 0.99). On multivariable analysis, Black (OR = 1.14, CI = 1.06 to 1.23) and American Indian/Native Alaskan (OR = 1.46, CI = 1.06 to 2.02) patients were more likely to receive opioids 1 to 2 years after diagnosis. Patients living in areas with higher rates of poverty (OR = 1.40, CI = 1.32 to 1.48) were also more likely to receive an opioid 1 to 2 years after diagnosis. Black (OR = 1.72, CI = 1.59 to 1.86), Asian (OR = 1.46, CI = 1.19 to 1.80), and Hispanic (OR = 1.36, CI = 1.23 to 1.51) patients were more likely to receive a MED ≥ 200 mg. Conclusions: While the rate of short-term opioid use is rising, rates of persistent and high-risk opioid use are declining among cancer patients. This may reflect growing awareness of the dangers of opioid misuse among clinicians treating patients with cancer. Nevertheless, racial and socioeconomic disparities in patterns of opioid use are persistent in the cancer population.

Download Full-text

O18 National variation and factors associated with long-term opioid use for non-cancer pain in the first year of use

Rheumatology ◽

10.1093/rheumatology/keaa110.017 ◽

2020 ◽

Vol 59 (Supplement_2) ◽

Author(s):

Meghna Jani ◽

Belay Birlie-Yimer ◽

Therese Sheppard ◽

Mark Lunt ◽

William G Dixon

Keyword(s):

High Risk ◽

Case Mix ◽

First Year ◽

Opioid Use ◽

Opioid Prescription ◽

Factors Associated ◽

Opioid Prescribing ◽

Population Average ◽

Opioid Users

Abstract Background Physician prescribing behaviour has been described as a key driver of rising opioid prescriptions and long-term opioid use. However, the effect of prescribers requires interpretation within context. No studies have investigated the extent to which regions, practices, prescribers, vary in opioid prescribing by considering this hierarchy together, whilst accounting for case-mix. Objectives: (i)quantify and identify risk factors for the transition from new-users to long-term opioid users (ii) quantify variation of long-term use attributed to region, practice, prescriber, accounting for patient mix and chance variation. Methods We conducted a retrospective observational study between 2006-2017 using Clinical Practice Research Datalink. New users of opioids, ≥18 years, without cancer were identified. Long-term opioid use was defined as ≥ 3 opioid prescriptions within a 90-day period from index date, or ≥ 1 opioid prescription lasting at least 90-days in the first year. A multi-level random-effects logistic regression model was used to examine the association of patient characteristics with the odds of becoming a long-term opioid-user. To examine variation in opioid use among prescribers, GP-practices and region after adjusting for case-mix, we used a nested random-effect structure. A ‘high-risk’ region, prescriber or practice was defined as those where the entire adjusted 95% CI lay above population average. Results 1,968,742 new opioid users were included; 14.6% transitioned to long-term use. In the fully-adjusted model, factors associated with higher-odds of long-term use included high morphine-milligram equivalents (MME)/day at first prescription, older-age, deprivation, fibromyalgia, rheumatological conditions and prior surgery (Table 1). After adjustment for case-mix, the North-West, Yorkshire and South-West were found to be high-risk regions for long-term use. 103 practices (25.6%) and 540 prescribers (3.5%) were associated with a significantly higher risk of long-term use. The odds of becoming a long-term user for patients belonging to these prescribers reached up to > 3.5 times than the population average. Conclusion Prescribing factors, age, deprivation and conditions including fibromyalgia and rheumatological conditions were associated with higher odds of long-term opioid use. In the first UK study evaluating long-term opioid prescribing with patient-level characteristics adjustment, variation in regions, especially practices and prescribers were observed. Our findings support greater calls for action to reduce practice/prescriber variation by promoting safe practice in opioid-prescribing. Disclosures M. Jani: None. B. Birlie-Yimer: None. T. Sheppard: None. M. Lunt: None. W.G. Dixon: None.

Download Full-text

The association of multimodal analgesia and high-risk opioid discharge prescriptions in opioid-naive surgical patients

Perioperative Medicine ◽

10.1186/s13741-021-00230-3 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Erica Langnas ◽

Rosa Rodriguez-Monguio ◽

Yanting Luo ◽

Rhiannon Croci ◽

R. Adams Dudley ◽

...

Keyword(s):

High Risk ◽

Hospital Discharge ◽

Medical Center ◽

Academic Medical Center ◽

Multimodal Analgesia ◽

Surgical Patients ◽

Surgical Patient ◽

Opioid Use ◽

Opioid Prescription ◽

Analgesic Agents

Abstract Background Opioids and multimodal analgesia are widely administered to manage postoperative pain. However, little is known on how improvements in inpatient pain control are correlated with high-risk (> 90 daily OME) discharge opioid prescriptions for opioid naïve surgical patients. Methods We conducted a retrospective observational study of adult opioid-naïve patients undergoing surgery from June 2012 through December 2018 at a large academic medical center. We used multivariate logistic regression to assess whether multimodal analgesic drugs consumed in the 24 h prior to discharge was associated with a reduction in high-risk opioid discharge prescriptions. We identified other risk factors for receiving a high-risk discharge opioid prescription. Results Among the 32,511 patients, 83% of patients were discharged with an opioid prescription. In 2013, 34.1% of patients with a discharge opioid prescription received a high-risk prescription and this declined to 17.7% by 2018. Use of multimodal analgesic agents during the final 24 h of hospitalization increased each year, with over 80% receiving at least one multimodal analgesic agent by 2018. The median OME consumed in the 24 h prior to discharge peaked in 2013 at 31 and steadily decreased to 19.8 by 2018. There was a significant association between the use of acetaminophen in the 24 h prior to discharge and a high-risk prescription at discharge (p < 0.01). OMEs consumed in the 24 h prior to discharge was a significant predictor of receiving a high-risk discharge prescription, even at low doses. Other factors associated with receipt of a high-risk discharge opioid prescription included male gender, race, history of anxiety disorder, and discharge service. Discussion Use of multimodal analgesia regimens in hospitalized surgical patients in the 24 h prior to hospital discharge increased between 2012 and 2018. Simultaneously, opioid use prior to hospital discharge decreased. Despite these gains, approximately one in five discharge prescriptions was high-risk (> 90 daily OME). In addition, we found that prescribing of discharge opioids above inpatient opioid requirements remains common in opioid naive surgical patients. Conclusion Providers should account for pre-discharge opioid consumption and use of multimodal analgesia when considering the total and daily OME’s that may be appropriate for an individual surgical patient on the discharge opioid prescription.

Download Full-text

Impact of Preoperative Opioid Use on 2-Year Patient-Reported Outcomes in Knee Surgery Patients

The Journal of Knee Surgery ◽

10.1055/s-0040-1716358 ◽

2020 ◽

Author(s):

Ali Aneizi ◽

Patrick M. J. Sajak ◽

Aymen Alqazzaz ◽

Tristan Weir ◽

Cameran I. Burt ◽

...

Keyword(s):

Physical Function ◽

Patient Reported Outcomes ◽

Knee Surgery ◽

The Body ◽

Pain Interference ◽

Opioid Use ◽

Opioid Prescription ◽

Social Satisfaction ◽

Patient Reported ◽

Met Expectations

AbstractThe objectives of this study are to assess perioperative opioid use in patients undergoing knee surgery and to examine the relationship between preoperative opioid use and 2-year postoperative patient-reported outcomes (PROs). We hypothesized that preoperative opioid use and, more specifically, higher quantities of preoperative opioid use would be associated with worse PROs in knee surgery patients. We studied 192 patients undergoing knee surgery at a single urban institution. Patients completed multiple PRO measures preoperatively and 2-year postoperatively, including six patient-reported outcomes measurement information system (PROMIS) domains; the International Knee Documentation Committee (IKDC) questionnaire, numeric pain scale (NPS) scores for the operative knee and the rest of the body, Marx's knee activity rating scale, Tegner's activity scale, International Physical Activity Questionnaire, as well as measures of met expectations, overall improvement, and overall satisfaction. Total morphine equivalents (TMEs) were calculated from a regional prescription monitoring program. Eighty patients (41.7%) filled an opioid prescription preoperatively, and refill TMEs were significantly higher in this subpopulation. Opioid use was associated with unemployment, government insurance, smoking, depression, history of prior surgery, higher body mass index, greater comorbidities, and lower treatment expectations. Preoperative opioid use was associated with significantly worse 2-year scores on most PROs, including PROMIS physical function, pain interference, fatigue, social satisfaction, IKDC, NPS for the knee and rest of the body, and Marx's and Tegner's scales. There was a significant dose-dependent association between greater preoperative TMEs and worse scores for PROMIS physical function, pain interference, fatigue, social satisfaction, NPS body, and Marx's and Tegner's scales. Multivariable analysis confirmed that any preoperative opioid use, but not quantity of TMEs, was an independent predictor of worse 2-year scores for function, activity, and knee pain. Preoperative opioid use and TMEs were neither independent predictors of met expectations, satisfaction, patient-perceived improvement, nor improvement on any PROs. Our findings demonstrate that preoperative opioid use is associated with clinically relevant worse patient-reported knee function and pain after knee surgery.

Download Full-text

Opioid availability statistics from the International Narcotics Control Board do not reflect the medical use of opioids: comparison with sales data from Scandinavia

Scandinavian Journal of Pain ◽

10.1515/sjpain-2021-0023 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Emmanuel Bäckryd ◽

Markus Heilig ◽

Mikael Hoffmann

Keyword(s):

Opioid Analgesics ◽

Warning Signal ◽

Control Board ◽

Opioid Use ◽

Opioid Prescription ◽

Sales Data ◽

Narcotics Control ◽

Addiction Risk ◽

The Usa ◽

Prescription Rates

Abstract Objectives Opioid analgesics are essential in clinical practice, but their excessive use is associated with addiction risk. Increases in opioid prescription rates have fuelled an epidemic of opioid addiction in the USA, making statistics on medical opioid use a critical warning signal. A dramatic 150% increase in Swedish opioid access 2001–2013 was recently reported based on data from the International Narcotics Control Board (INCB; Berterame et al. 2016) in conflict with other studies of opioid use in the Nordic countries. This article aims to analyse to what degree published INCB statistics on opioids in Scandinavia (Denmark, Norway and Sweden) reflect actual medical use and study the methodological reasons for putative discrepancies. Methods Data on aggregated total national sales of opioids for the whole population, including hospitals, were collected from the Swedish e-Health Authority. Total sales data for Denmark and drugs dispensed at pharmacies in Norway are publicly available through the relevant authorities’ websites. Results INCB opioid statistics during the period 2001–2013 were markedly inconsistent with sales data from Scandinavia, calling the reliability of INCB data into question. INCB-data were flawed by (a) over-representing the volume of fentanyl, (b) under-reporting of codeine, and (c) by not including tramadol. Conclusions Opioid availability, as expressed by INCB statistics, does not reflect medical opioid use. It is crucial to underline that INCB statistics are based on the manual compilation of national production, import and export data from manufacturers and drug companies. This is not the same amount that is prescribed and consumed within the health care system. Moreover, there are methodological problems in the INCB reports, in particular concerning fentanyl, codeine and tramadol. We suggest that INCB should carefully review the quality of their data on medical opioids.

Download Full-text

Treatment approaches and outcome trajectories for youth with high‐risk opioid use: A narrative review

Early Intervention in Psychiatry ◽

10.1111/eip.13155 ◽

2021 ◽

Author(s):

Jean Nicolas Westenberg ◽

Andy M. Y. Tai ◽

Julie Elsner ◽

Mostafa M. Kamel ◽

James S. H. Wong ◽

...

Keyword(s):

High Risk ◽

Narrative Review ◽

Opioid Use ◽

Treatment Approaches

Download Full-text

Association Between Mental Health Conditions and Care Fragmentation: A National Study of High-Risk Older Veterans

Innovation in Aging ◽

10.1093/geroni/igaa057.1202 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 373-373

Author(s):

Ranak Trivedi ◽

Fernanda Rossi ◽

Sarah Javier ◽

Liberty Greene ◽

Sara Singer ◽

...

Keyword(s):

Mental Health ◽

High Risk ◽

Health Conditions ◽

Mental Health Provider ◽

National Study ◽

Mental Health Conditions ◽

Resource Center ◽

Physical Conditions ◽

Risk Patients ◽

Care Fragmentation

Abstract Fragmented healthcare causes information loss, duplicative tests, and unwieldy self-care regimens. These challenges may be amplified among older, high-risk patients with co-occurring mental health conditions (MHC). We compared healthcare fragmentation for chronic physical conditions among Veterans with and without MHC (depression, PTSD, schizophrenia, bipolar disorder, anxiety, personality disorder, or psychosis based on ICD-9 codes). Sample included Veterans who were □65y, at high risk for 1-year hospitalization, and had □4 non-MHC visits during FY14. Visits were covered by Veterans Affairs (VA), VA-purchased care (both from VA Corporate Data Warehouse), or Medicare Parts A/B (claims data from VA Information Resource Center). Outcomes were two fragmentation measures calculated in FY15: 1) non-mental health provider count, where a higher number indicates more fragmentation, and 2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen provider, where a higher number indicates less fragmentation. We used Poisson regression and GLM with binomial distribution and logit link to test the association between MHC status and fragmentation, controlling for sociodemographic characteristics (e.g., age), medical comorbidity, and driving distance to VA. Of the 125,481 Veterans included, 47.3% had 1+ MHC. Compared to older, high-risk Veterans without MHC, those with MHC saw fewer providers (pseudo R2 = 0.02) and had a higher UPC (more concentrated care; OR = 1.07). Within the VA, older, high-risk Veterans with MHC do not experience greater healthcare fragmentation. Further research is needed to determine if this is due to different needs, underuse, or appropriate use of healthcare across the groups.

Download Full-text

Opioid use disorder and overdose among youth following an initial opioid prescription

Addiction ◽

10.1111/add.15487 ◽

2021 ◽

Author(s):

Scott E. Hadland ◽

Sarah M. Bagley ◽

Mam Jarra Gai ◽

Joel J. Earlywine ◽

Samantha F. Schoenberger ◽

...

Keyword(s):

Opioid Use Disorder ◽

Opioid Use ◽

Opioid Prescription

Download Full-text

Long-term postoperative opioid prescription after cholecystectomy or gastric by-pass surgery: a retrospective observational study

Scandinavian Journal of Pain ◽

10.1515/sjpain-2020-0150 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Viktoria Larsson ◽

Cecilia Nordenson ◽

Pontus Karling

Keyword(s):

Observational Study ◽

Postoperative Period ◽

Medical Records ◽

Early Postoperative Period ◽

Retrospective Observational Study ◽

Opioid Use ◽

Opioid Prescription ◽

Post Surgery ◽

Gastric By Pass

Abstract Objectives Opioids are commonly prescribed post-surgery. We investigated the proportion of patients who were prescribed any opioids 6–12 months after two common surgeries – laparoscopic cholecystectomy and gastric by-pass (GBP) surgery. A secondary aim was to examine risk factors prior to surgery associated with the prescription of any opioids after surgery. Methods We performed a retrospective observational study on data from medical records from patients who underwent cholecystectomy (n=297) or GBP (n=93) in 2018 in the Region of Västerbotten, Sweden. Data on prescriptions for opioids and other drugs were collected from the patients` medical records. Results There were 109 patients (28%) who were prescribed opioids after discharge from surgery but only 20 patients (5%) who still received opioid prescriptions 6–12 months after surgery. All 20 of these patients had also been prescribed opioids within three months before surgery, most commonly for back and joint pain. Only 1 out of 56 patients who were prescribed opioids preoperatively due to gallbladder pain still received prescriptions for opioids 6–12 months after surgery. Although opioid use in the early postoperative period was more common among patients who underwent cholecystectomy, the patients who underwent GBP were more prone to be “long-term” users of opioids. In the patients who were prescribed opioids within three months prior to surgery, 8 out of 13 patients who underwent GBP and 12 of the 96 patients who underwent cholecystectomy were still prescribed opioids 6–12 months after surgery (OR 11.2; 95% CI 3.1–39.9, p=0,0002). Affective disorders were common among “long-term” users of opioids and prior benzodiazepine and amitriptyline use were significantly associated with “long-term” opioid use. Conclusions The proportion of patients that used opioids 6–12 months after cholecystectomy or GBP was low. Patients with preoperative opioid-use experienced a significantly higher risk of “long-term” opioid use when undergoing GBP compared to cholecystectomy. The indication for being prescribed opioids in the “long-term” were mostly unrelated to surgery. No patient who was naïve to opioids prior surgery was prescribed opioids 6–12 months after surgery. Although opioids are commonly prescribed in the preoperative and in the early postoperative period to patients with gallbladder disease, there is a low risk that these prescriptions will lead to long-term opioid use. The reasons for being prescribed opioids in the long-term are often due to causes not related to surgery.

Download Full-text

The association between initial opioid type and long-term opioid use after hip fracture surgery in elderly opioid-naïve patients

Scandinavian Journal of Pain ◽

10.1515/sjpain-2019-0170 ◽

2020 ◽

Vol 20 (4) ◽

pp. 755-764

Author(s):

Amalie H. Simoni ◽

Lone Nikolajsen ◽

Anne E. Olesen ◽

Christian F. Christiansen ◽

Søren P. Johnsen ◽

...

Keyword(s):

Hip Fracture ◽

Pain Treatment ◽

Population Based ◽

Opioid Use ◽

Calendar Time ◽

Opioid Prescription ◽

Hip Fracture Surgery ◽

Opioid Users ◽

Fracture Surgery

AbstractObjectivesLong-term opioid use after hip fracture surgery has been demonstrated in previously opioid-naïve elderly patients. It is unknown if the opioid type redeemed after hip surgery is associated with long-term opioid use. The aim of this study was to examine the association between the opioid type redeemed within the first three months after hip fracture surgery and opioid use 3–12 months after the surgery.MethodsA nationwide population-based cohort study was conducted using data from Danish health registries (2005–2015). Previously opioid-naïve patients registered in the Danish Multidisciplinary Hip Fracture Registry, aged ≥65 years, who redeemed ≥1 opioid prescription within three months after the surgery, were included. Long-term opioid use was defined as ≥1 redeemed prescription within each of three three-month periods within the year after hip fracture surgery. The proportion with long-term opioid use after surgery, conditioned on nine-month survival, was calculated according to opioid types within three months after surgery. Adjusted odds ratios (aOR) for different opioid types were computed by logistic regression analyses with 95% confidence intervals (CI) using morphine as reference. Subgroup analyses were performed according to age, comorbidity and calendar time before and after 2010.ResultsThe study included 26,790 elderly, opioid-naïve patients with opioid use within three months after hip fracture surgery. Of these patients, 21% died within nine months after the surgery. Among the 21,255 patients alive nine months after surgery, 15% became long-term opioid users. Certain opioid types used within the first three months after surgery were associated with long-term opioid use compared to morphine (9%), including oxycodone (14%, aOR; 1.76, 95% CI 1.52–2.03), fentanyl (29%, aOR; 4.37, 95% CI 3.12–6.12), codeine (13%, aOR; 1.55, 95% CI 1.14–2.09), tramadol (13%, aOR; 1.56, 95% CI 1.35–1.80), buprenorphine (33%, aOR; 5.37, 95% CI 4.14–6.94), and >1 opioid type (27%, aOR; 3.83, 95% CI 3.31–4.44). The proportion of long-term opioid users decreased from 18% before 2010 to 13% after 2010.ConclusionsThe findings suggest that use of certain opioid types after hip fracture surgery is more associated with long-term opioid use than morphine and the proportion initiating long-term opioid use decreased after 2010. The findings suggest that some elderly, opioid-naïve patients appear to be presented with untreated pain conditions when seen in the hospital for a hip fracture surgery. Decisions regarding the opioid type prescribed after hospitalization for hip fracture surgery may be linked to different indication for pain treatment, emphasizing the likelihood of careful and conscientious opioid prescribing behavior.

Download Full-text