A Disparity beneath a Paradox: Cancer Mortality among Young Hispanic Americans in the US-Mexico Border Region.

The age-adjusted mortality rate for cancer in the US Hispanic population is two thirds that of the non-Hispanic white population, probably because of differences in smoking rates. We aimed to determine whether Hispanic white (HW) cancer mortality in the US-Mexico Border Region was also lower than that of the non-Hispanic white (NHW) border population, particularly in the younger population less likely to develop smoking-related cancer. We obtained age-adjusted cancer mortality rates from 1999 to 2017 for the 44 border counties, the four US-Mexico border states, and the rest of the US. We obtained cancer incidence rates for 1999-2016 from state registries. We stratified rates by age group, ethnicity, border state, urbanization, and cancer site. Age-adjusted border cancer mortality rates were 139.1/100,000 in the HW and 171.4 in the NHW populations, a ratio of 0.8. HW mortality rates were higher than NHW rates only for the 0-34 age group. State-specific HW cancer incidence rates for people 0-34 years old were 77%-80% of NHW rates. We also calculated mortality-incidence ratios (MIR) for the 0-34 population. Border mortality-incidence ratios were higher in the HW population. HW rates exceeded NHW rates for all cancer sites except skin cancer. The HW cancer disparity is due to poorer survival in the HW population, which might be due to limited access to prevention and treatment in a medically underserved area. Mortality among young border Hispanic residents might be reduced through efforts to improve insurance coverage and increase access to medical providers .

Opioid Prescribing Behaviors - Prescription Behavior Surveillance System, 11 States, 2010-2016.

PROBLEM/CONDITION: In 2017, a total of 70,237 persons in the United States died from a drug overdose, and 67.8% of these deaths involved an opioid. Historically, the opioid overdose epidemic in the United States has been closely associated with a parallel increase in opioid prescribing and with widespread misuse of these medications. National and state policy makers have introduced multiple measures to attempt to assess and control the opioid overdose epidemic since 2010, including improvements in surveillance systems. PERIOD COVERED: 2010-2016 DESCRIPTION OF SYSTEM: The Prescription Behavior Surveillance System (PBSS) was created in 2011. Its goal was to track rates of prescribing of controlled substances and possible misuse of such drugs using data from selected state prescription drug monitoring programs (PDMP). PBSS data measure prescribing behaviors for prescription opioids using multiple measures calculated from PDMP data including 1) opioid prescribing, 2) average daily opioid dosage, 3) proportion of patients with daily opioid dosages ≥90 morphine milligram equivalents, 4) overlapping opioid prescriptions, 5) overlapping opioid and benzodiazepine prescriptions, and 6) multiple-provider episodes. For this analysis, PBSS data were available for 2010-2016 from 11 states representing approximately 38.0% of the U.S. POPULATION: Average quarterly percent changes (AQPC) in the rates of opioid prescribing and possible opioid misuse measures were calculated for each state. RESULTS AND INTERPRETATION: Opioid prescribing rates declined in all 11 states during 2010-2016 (range: 14.9% to 33.0%). Daily dosage declined least (AQPC: -0.4%) in Idaho and Maine, and most (AQPC: -1.6%) in Florida. The percentage of patients with high daily dosage had AQPCs ranging from -0.4% in Idaho to -2.3% in Louisiana. Multiple-provider episode rates declined by at least 62% in the seven states with available data. Variations in trends across the 11 states might reflect differences in state policies and possible differential effects of similar policies. PUBLIC HEALTH ACTIONS: Use of PDMP data from individual states enables a more detailed examination of trends in opioid prescribing behaviors and indicators of possible misuse than is feasible with national commercially available prescription data. Comparison of opioid prescribing trends among states can be used to monitor the temporal association of national or state policy interventions and might help public health policymakers recognize changes in the use or possible misuse of controlled prescription drugs over time and allow for prompt intervention through amended or new opioid-related policies.

Parsing the Paradox: Hispanic Mortality in the US by Detailed Cause of Death.

US Hispanics are a disadvantaged population that paradoxically has lower mortality rates than non-Hispanic whites. We conducted a descriptive analysis of age-adjusted mortality rates for 113 causes of death for US Hispanics (USH) and US non-Hispanic whites (USNHW) during 1999-2015. All-cause, age-adjusted mortality rates per 100,000 were: 581.1 USH and 788.8 USNHW. Lower Hispanic mortality from cancer, heart disease, and respiratory disease accounted for almost all the all-cause mortality gap. USH rates were higher than USNHW rates for cancers of the stomach, liver, and cervix; diabetes mellitus; liver disease; and homicide. Behavioural factors such as less smoking among USH probably drive their lower rates for the major chronic diseases. Social disadvantages contribute to elevated risk for certain cancers, diabetes, and homicide. Efforts to improve Hispanic well-being in the US should remedy the social disadvantages while preserving the health advantages the population enjoys.

Mortality, Ethnicity, and Urbanization Among Children Aged 1-4 Years on the US-Mexico Border.

OBJECTIVES: Little is known about the mortality of children along the US-Mexico border. The objective of our study was to determine whether mortality rates among Hispanic children along the border ("border Hispanic children") exceeded mortality rates among non-Hispanic white children along the border. METHODS: We examined mortality rates from 2001-2015 for children aged 1-4 years in US-Mexico border counties and in the United States overall. We compared mortality rates among Hispanic and non-Hispanic white children by county urbanization level (large central, medium, and small metropolitan; micropolitan nonmetropolitan; and noncore nonmetropolitan). RESULTS: During 2001-2015, 1811 children aged 1-4 years died in the border region. The mortality rate per 100 000 children among border Hispanic children (28.3; 95% confidence interval [CI], 26.8-29.9) exceeded the mortality rate of US Hispanic children (24.7; 95% CI, 24.3-25.1) and border non-Hispanic white children (23.2; 95% CI, 20.8-25.6). When stratified by county urbanization level, however, mortality rates of border Hispanic children were not significantly different from mortality rates of US Hispanic or border non-Hispanic white children. Mortality rates in noncore nonmetropolitan counties were twice those in large central metropolitan counties, with injury mortality accounting for most of the excess. Mortality rates increased in nonmetropolitan border counties after 2010. CONCLUSIONS: Increased risk for injury and disease in noncore nonmetropolitan counties might be related to poverty, reduced access to care, or poorer quality of care. Future research should identify the remediable risk factors in such communities as the next step in preventing deaths among children aged 1-4 years.

A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits.

BACKGROUND: Increasing prescription overdose deaths have demonstrated the need for safer emergency department (ED) prescribing practices for patients who are frequent ED users. OBJECTIVES: We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients. METHODS: We conducted a multisite randomized controlled trial (RCT) across all EDs in a metropolitan area; 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual. RESULTS: The intervention arm experienced a 34% decrease (incident rate ratios = 0.66, p < 0.001; 95% confidence interval 0.57-0.78) in ED visits and an 80% decrease (odds ratio = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers, respectively. CONCLUSION: This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing.

Recognition and response to opioid overdose deaths-New Mexico, 2012.

PURPOSE: Drug overdose deaths are epidemic in the U.S. Prescription opioid pain relievers (OPR) and heroin account for the majority of drug overdoses. Preventing death after an opioid overdose by naloxone administration requires the rapid identification of the overdose by witnesses. This study used a state medical examiner database to characterize fatal overdoses, evaluate witness-reported signs of overdose, and identify opportunities for intervention. METHODS: We reviewed all unintentional drug overdose deaths that occurred in New Mexico during 2012. Data were abstracted from medical examiner records at the New Mexico Office of the Medical Investigator. We compared mutually exclusive groups of OPR and heroin-related deaths. RESULTS: Of the 489 overdose deaths reviewed, 49.3% involved OPR, 21.7% involved heroin, 4.7% involved a mixture of OPR and heroin, and 24.3% involved only non-opioid substances. The majority of OPR-related deaths occurred in non-Hispanic whites (57.3%), men (58.5%), persons aged 40-59 years (55.2%), and those with chronic medical conditions (89.2%). Most overdose deaths occurred in the home (68.7%) and in the presence of bystanders (67.7%). OPR and heroin deaths did not differ with respect to paramedic dispatch and CPR delivery, however, heroin overdoses received naloxone twice as often (20.8% heroin vs. 10.0% OPR; p<0.01). CONCLUSION: OPR overdose deaths differed by age, health status, and the presence of bystanders, yet received naloxone less often when compared to heroin overdose deaths. These findings suggest that naloxone education and distribution should be targeted in future prevention efforts.

Changes in the medical management of patients on opioid analgesics following a diagnosis of substance abuse.

PURPOSE: When providers recognize that patients are abusing prescription drugs, review of the drugs they are prescribed and attempts to treat the substance use disorder are warranted. However, little is known about whether prescribing patterns change following such a diagnosis. METHODS: We used national longitudinal health claims data from the Market Scan® commercial claims database for January 2010-June 2011. We used a cohort of 1.85 million adults 18-64 years old prescribed opioid analgesics but without abuse diagnoses during a 6-month "preabuse" period. We identified a subset of 9009 patients receiving diagnoses of abuse of non-illicit drugs (abuse group) during a 6-month "abuse" period and compared them with patients without such a diagnosis (nonabuse group) during both the abuse period and a subsequent 6-month "postabuse" period. RESULTS: During the abuse period 5.78% of the abuse group and 0.14% of the nonabuse group overdosed. Overdose rates declined to 2.12% in the abuse group in the postabuse period. Opioid prescribing rates declined 13.5%, and benzodiazepine rates declined 12.3% in the abuse group in the post-abuse period. Antidepressants and gabapentin were prescribed to roughly one half and one quarter of the abuse group, respectively, during all three periods. Daily opioid dosage did not decline in the abuse group following diagnosis. CONCLUSIONS: Prescribing to people who abuse drugs changes little after their abuse is documented. Actions such as tapering opioid and benzodiazepine prescriptions, maximizing alternative treatments for pain, and greater use of medication-assisted treatment such as buprenorphine could help reduce risk in this population. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

Use of Naloxone by Emergency Medical Services during Opioid Drug Overdose Resuscitation Efforts.

Naloxone administration is an important component of resuscitation attempts by emergency medical services (EMS) for opioid drug overdoses. However, EMS providers must first recognize the possibility of opioid overdose in clinical encounters. As part of a public health response to an outbreak of opioid overdoses in Rhode Island, we examined missed opportunities for naloxone administration and factors potentially influencing EMS providers' decision to administer naloxone. We reviewed medical examiner files on all individuals who died of an opioid-related drug overdose in Rhode Island from January 1, 2012 through March 31, 2014, underwent attempted resuscitation by EMS providers, and had records available to assess for naloxone administration. We evaluated whether these individuals received naloxone as part of their resuscitation efforts and compared patient and scene characteristics of those who received naloxone to those who did not receive naloxone via chi-square, t-test, and logistic regression analyses. One hundred and twenty-four individuals who underwent attempted EMS resuscitation died due to opioid overdose. Naloxone was administered during EMS resuscitation attempts in 82 (66.1%) of cases. Females were nearly three-fold as likely not to receive naloxone as males (OR 2.9; 95% CI 1.2-7.0; p-value 0.02). Additionally, patients without signs of potential drug abuse also had a greater than three-fold odds of not receiving naloxone (OR 3.3; 95% CI 1.2-9.2; p-value 0.02). Older individuals, particularly those over age 50, were more likely not to receive naloxone than victims younger than age 30 (OR 4.8; 95% CI 1.3-17.4; p-value 0.02). Women, older individuals, and those patients without clear signs of illicit drug abuse, were less likely to receive naloxone in EMS resuscitation attempts. Heightened clinical suspicion for opioid overdose is important given the recent increase in overdoses among patients due to prescription opioids.

Controlled Substance Prescribing Patterns--Prescription Behavior Surveillance System, Eight States, 2013.

PROBLEM/CONDITION: Drug overdose is the leading cause of injury death in the United States. The death rate from drug overdose in the United States more than doubled during 1999-2013, from 6.0 per 100,000 population in 1999 to 13.8 in 2013. The increase in drug overdoses is attributable primarily to the misuse and abuse of prescription drugs, especially opioid analgesics, sedatives/tranquilizers, and stimulants. Such drugs are prescribed widely in the United States, with substantial variation by state. Certain patients obtain drugs for nonmedical use or resale by obtaining overlapping prescriptions from multiple prescribers. The risk for overdose is directly associated with the use of multiple prescribers and daily dosages of >100 morphine milligram equivalents (MMEs) per day. PERIOD COVERED: 2013. DESCRIPTION OF SYSTEM: The Prescription Behavior Surveillance System (PBSS) is a public health surveillance system that allows public health authorities to characterize and quantify the use and misuse of prescribed controlled substances. PBSS began collecting data in 2012 and is funded by CDC and the Food and Drug Administration. PBSS uses standard metrics to measure prescribing rates per 1,000 state residents by demographic variables, drug type, daily dose, and source of payment. Data from the system can be used to calculate rates of misuse by certain behavioral measures such as use of multiple prescribers and pharmacies within specified time periods. This report is based on 2013 de-identified data (most recent available) that represent approximately one fourth of the U.S. POPULATION: Data were submitted quarterly by prescription drug monitoring programs (PDMPs) in eight states (California, Delaware, Florida, Idaho, Louisiana, Maine, Ohio, and West Virginia) that routinely collect data on every prescription for a controlled substance to help law enforcement and health care providers identify misuse or abuse of such drugs. RESULTS: In all eight states, opioid analgesics were prescribed approximately twice as often as stimulants or benzodiazepines. Prescribing rates by drug class varied widely by state: twofold for opioids, fourfold for stimulants, almost twofold for benzodiazepines, and eightfold for carisoprodol, a muscle relaxant. Rates for opioids and benzodiazepines were substantially higher for females than for males in all states. In most states, opioid prescribing rates peaked in either the 45-54 years or the 55-64 years age group. Benzodiazepine prescribing rates increased with age. Louisiana ranked first in opioid prescribing, and Delaware and Maine had relatively high rates of use of long-acting (LA) or extended-release (ER) opioids. Delaware and Maine ranked highest in both mean daily opioid dosage and in the percentage of opioid prescriptions written for >100 MMEs per day. The top 1% of prescribers wrote one in four opioid prescriptions in Delaware, compared with one in eight in Maine. For the five states whose PDMPs collected the method of payment, the percentage of controlled substance prescriptions paid for in cash varied almost threefold, and the percentage paid by Medicaid varied sixfold. In West Virginia, for 1 of every 5 days of treatment with an opioid, the patient also was taking a benzodiazepine. Multiple-provider episode rates were highest in Ohio and lowest in Louisiana. INTERPRETATION: This report presents rates of population-based prescribing and behavioral measures of drug misuse in the general population that have not been available previously for comparison among demographic groups and states. The higher prescribing rates for opioids among women compared with men are consistent with a higher self-reported prevalence of certain common types of pain, such as lower back pain among women. The trend in opioid prescribing rates with age is consistent with an increase in the prevalence of chronic pain with age, but the increasing prescribing rates of benzodiazepines with age is not consistent with the fact that anxiety is most common among persons aged 30-44 years. The variation among states in the type of opioid or benzodiazepine of choice is unexplained. Most opioid prescribing occurs among a small minority of prescribers. Most of the prescriptions by top-decile prescribers probably are written by general, family medicine, internal medicine, and midlevel practitioners. The source of payment varied by state, for reasons that are unclear. Persons who are prescribed opioids also are commonly prescribed benzodiazepine sedatives despite the risk for additive depressant effects. PUBLIC HEALTH ACTIONS: States can use their prescription drug monitoring programs to generate population-based measures for the prescribing of controlled substances and for behaviors that suggest their misuse. Comparing data with other states and tracking changes in these measures over time can be useful in measuring the effect of policies designed to reduce prescription drug misuse.

Trends and characteristics of heroin overdoses in Wisconsin, 2003-2012.

BACKGROUND: Heroin abuse has increased substantially during the past decade in the United States. This study describes trends and demographic shifts of heroin overdoses and heroin-related fatalities in Wisconsin and contrasts these with prescription opioid overdoses. METHODS: This study was cross-sectional using databases of emergency department (ED) visits, hospital admissions, and death certificates in Wisconsin, United States, during 2003-2012. Cases were Wisconsin residents treated for heroin or prescription opioid overdose, and residents who died of heroin-related drug poisoning. Primary measurements were rates over time and by geographic region, and rates and rate ratios for selected demographic characteristics. RESULTS: During 2003-2012, age-adjusted rates of heroin overdoses treated in EDs increased from 1.0 to 7.9/100,000 persons; hospitalized heroin overdoses increased from 0.7 to 3.5/100,000. Whites accounted for 68% of hospitalized heroin overdoses during 2003-2007 but 80% during 2008-2012. Heroin-related deaths were predominantly among urban residents; however, rural fatalities accounted for zero deaths in 2003 but 31 (17%) deaths in 2012. Among patients aged 18-34 years, those hospitalized with heroin overdose were more often men (73.0% versus 54.9%), uninsured (44.2% versus 29.9%), and urban (84.3% versus 73.2%) than those with prescription opioid overdose. Rates of ED visits for heroin overdose in this age group exceeded rates for prescription opioid overdose in 2012 (26.1/100,000 versus 12.6/100,000 persons, respectively). CONCLUSIONS: An epidemic of heroin abuse is characterized by demographic shifts toward whites and rural residents. Rates of heroin overdose in younger persons now exceed rates of prescription opioid overdose.

Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012.

INTRODUCTION: Opioid analgesic prescriptions are driving trends in drug overdoses, but little is known about prescribing patterns among medical specialties. We conducted this study to examine the opioid-prescribing patterns of the medical specialties over time. METHODS: IMS Health's National Prescription Audit (NPA) estimated the annual counts of pharmaceutical prescriptions dispensed in the U.S. during 2007-2012. We grouped NPA prescriber specialty data by practice type for ease of analysis, and measured the distribution of total prescriptions and opioid prescriptions by specialty. We calculated the percentage of all prescriptions dispensed that were opioids, and evaluated changes in that rate by specialty during 2007-2012. The analysis was conducted in 2013. RESULTS: In 2012, U.S. pharmacies and long-term care facilities dispensed 4.2 billion prescriptions, 289 million (6.8%) of which were opioids. Primary care specialties accounted for nearly half of all dispensed opioid prescriptions. The rate of opioid prescribing was highest for specialists in pain medicine (48.6%); surgery (36.5%); and physical medicine/rehabilitation (35.5%). The rate of opioid prescribing rose during 2007-2010 but leveled thereafter as most specialties reduced opioid use. The greatest percentage increase in opioid-prescribing rates during 2007-2012 occurred among physical medicine/rehabilitation specialists (+12.0%). The largest percentage drops in opioid-prescribing rates occurred in emergency medicine (-8.9%) and dentistry (-5.7%). CONCLUSIONS: The data indicate diverging trends in opioid prescribing among medical specialties in the U.S. during 2007-2012. Engaging the medical specialties individually is critical for continued improvement in the safe and effective treatment of pain.

Prescription practices involving opioid analgesics among Americans with Medicaid, 2010.

Recent state-based studies have shown an increased risk of opioid overdose death in Medicaid populations. To explore one side of risk, this study examines indicators of potential opioid inappropriate use or prescribing among Medicaid enrollees. We examined claims from enrollees aged 18-64 years in the 2010 Truven Health MarketScan® Multi-State Medicaid database, which consisted of weighted and nationally representative data from 12 states. Pharmaceutical claims were used to identify enrollees (n=359,368) with opioid prescriptions. Indicators of potential inappropriate use or prescribing included overlapping opioid prescriptions, overlapping opioid and benzodiazepine prescriptions, long acting/extended release opioids for acute pain, and high daily doses. In 2010, Medicaid enrollees with opioid prescriptions obtained an average 6.3 opioid prescriptions, and 40% had at least one indicator of potential inappropriate use or prescribing. These indicators have been linked to opioid-related adverse health outcomes, and methods exist to detect and deter inappropriate use and prescribing of opioids.

Prescription opioid analgesic use among adults: United States, 1999-2012.

Prescription opioid analgesics are used to treat pain from surgery, injury, and health conditions such as cancer. Opioid dependence and opioid-related deaths are growing public health problems. Opioid analgesic sales (in kilograms per 10,000) quadrupled from 1999 to 2010 (1), and from 1999 to 2012, opioid-related deaths (per 100,000) more than tripled (2). During 1999­2002, 4.2% of persons aged 18 and over used a prescription opioid analgesic in the past 30 days (3). This report provides updated estimates and trends in prescription opioid analgesic use among adults aged 20 and over, overall and by selected subgroups.

Vital signs: alcohol poisoning deaths - United States, 2010-2012.

BACKGROUND: Alcohol poisoning is typically caused by binge drinking at high intensity (i.e., consuming a very large amount of alcohol during an episode of binge drinking). Approximately 38 million U.S. adults report binge drinking an average of four times per month and consuming an average of eight drinks per episode. METHODS: CDC analyzed data for 2010­2012 from the National Vital Statistics System to assess average annual alcohol poisoning deaths and death rates (ICD-10 codes X45 and Y15; underlying cause of death) in the United States among persons aged ≥15 years, by sex, age group, race/ethnicity, and state. RESULTS: During 2010­2012, an annual average of 2,221 alcohol poisoning deaths (8.8 deaths per 1 million population) occurred among persons aged ≥15 years in the United States. Of those deaths, 1,681 (75.7%) involved adults aged 35­64 years, and 1,696 (76.4%) involved men. Although non-Hispanic whites accounted for the majority of alcohol poisoning deaths (67.5%; 1,500 deaths), the highest age-adjusted death rate was among American Indians/Alaska Natives (49.1 per 1 million). The age-adjusted rate of alcohol poisoning deaths in states ranged from 5.3 per 1 million in Alabama to 46.5 per 1 million in Alaska. CONCLUSIONS: On average, six persons, mostly adult men, die from alcohol poisoning each day in the United States. Alcohol poisoning death rates vary substantially by state. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Evidence-based strategies for preventing excessive drinking (e.g., regulating alcohol outlet density and preventing illegal alcohol sales in retail settings) could reduce alcohol poisoning deaths by reducing the prevalence, frequency, and intensity of binge drinking.

Variation among states in prescribing of opioid pain relievers and benzodiazepines--United States, 2012.

INTRODUCTION: Overprescribing of opioid pain relievers (OPR) can result in multiple adverse health outcomes, including fatal overdoses. Interstate variation in rates of prescribing OPR and other prescription drugs prone to abuse, such as benzodiazepines, might indicate areas where prescribing patterns need further evaluation. METHODS: CDC analyzed a commercial database (IMS Health) to assess the potential for improved prescribing of OPR and other drugs. CDC calculated state rates and measures of variation for OPR, long-acting/extended-release (LA/ER) OPR, high-dose OPR, and benzodiazepines. RESULTS: In 2012, prescribers wrote 82.5 OPR and 37.6 benzodiazepine prescriptions per 100 persons in the United States. State rates varied 2.7-fold for OPR and 3.7-fold for benzodiazepines. For both OPR and benzodiazepines, rates were higher in the South census region, and three Southern states were two or more standard deviations above the mean. Rates for LA/ER and high-dose OPR were highest in the Northeast. Rates varied 22-fold for one type of OPR, oxymorphone. CONCLUSIONS: Factors accounting for the regional variation are unknown. Such wide variations are unlikely to be attributable to underlying differences in the health status of the population. High rates indicate the need to identify prescribing practices that might not appropriately balance pain relief and patient safety. IMPLICATIONS FOR PUBLIC HEALTH: State policy makers might reduce the harms associated with the abuse of prescription drugs by implementing changes that will make the prescribing of these drugs more cautious and more consistent with clinical recommendations.

What we know, and don't know, about the impact of state policy and systems-level interventions on prescription drug overdose.

BACKGROUND: Drug overdose deaths have been rising since the early 1990s and is the leading cause of injury death in the United States. Overdose from prescription opioids constitutes a large proportion of this burden. State policy and systems-level interventions have the potential to impact prescription drug misuse and overdose. METHODS: We searched the literature to identify evaluations of state policy or systems-level interventions using non-comparative, cross-sectional, before-after, time series, cohort, or comparison group designs or randomized/non-randomized trials. Eligible studies examined intervention effects on provider behavior, patient behavior, and health outcomes. RESULTS: Overall study quality is low, with a limited number of time-series or experimental designs. Knowledge and prescribing practices were measured more often than health outcomes (e.g., overdoses). Limitations include lack of baseline data and comparison groups, inadequate statistical testing, small sample sizes, self-reported outcomes, and short-term follow-up. Strategies that reduce inappropriate prescribing and use of multiple providers and focus on overdose response, such as prescription drug monitoring programs, insurer strategies, pain clinic legislation, clinical guidelines, and naloxone distribution programs, are promising. Evidence of improved health outcomes, particularly from safe storage and disposal strategies and patient education, is weak. CONCLUSIONS: While important efforts are underway to affect prescriber and patient behavior, data on state policy and systems-level interventions are limited and inconsistent. Improving the evidence base is a critical need so states, regulatory agencies, and organizations can make informed choices about policies and practices that will improve prescribing and use, while protecting patient health.

Alcohol involvement in opioid pain reliever and benzodiazepine drug abuse-related emergency department visits and drug-related deaths - United States, 2010.

The abuse of prescription drugs has led to a significant increase in emergency department (ED) visits and drug-related deaths over the past decade. Opioid pain relievers (OPRs) and benzodiazepines are the prescription drugs most commonly involved in these events. Excessive alcohol consumption also accounts for a significant health burden and is common among groups that report high rates of prescription drug abuse. When taken with OPRs or benzodiazepines, alcohol increases central nervous system depression and the risk for overdose. Data describing alcohol involvement in OPR or benzodiazepine abuse are limited. To quantify alcohol involvement in OPR and benzodiazepine abuse and drug-related deaths and to inform prevention efforts, the Food and Drug Administration (FDA) and CDC analyzed 2010 data for drug abuse-related ED visits in the United States and drug-related deaths that involved OPRs and alcohol or benzodiazepines and alcohol in 13 states. The analyses showed alcohol was involved in 18.5% of OPR and 27.2% of benzodiazepine drug abuse-related ED visits and 22.1% of OPR and 21.4% of benzodiazepine drug-related deaths. These findings indicate that alcohol plays a significant role in OPR and benzodiazepine abuse. Interventions to reduce the abuse of alcohol and these drugs alone and in combination are needed.

Vital signs: variation among States in prescribing of opioid pain relievers and benzodiazepines - United States, 2012.

BACKGROUND: Overprescribing of opioid pain relievers (OPR) can result in multiple adverse health outcomes, including fatal overdoses. Interstate variation in rates of prescribing OPR and other prescription drugs prone to abuse, such as benzodiazepines, might indicate areas where prescribing patterns need further evaluation. METHODS: CDC analyzed a commercial database (IMS Health) to assess the potential for improved prescribing of OPR and other drugs. CDC calculated state rates and measures of variation for OPR, long-acting/extended-release (LA/ER) OPR, high-dose OPR, and benzodiazepines. RESULTS: In 2012, prescribers wrote 82.5 OPR and 37.6 benzodiazepine prescriptions per 100 persons in the United States. State rates varied 2.7-fold for OPR and 3.7-fold for benzodiazepines. For both OPR and benzodiazepines, rates were higher in the South census region, and three Southern states were two or more standard deviations above the mean. Rates for LA/ER and high-dose OPR were highest in the Northeast. Rates varied 22-fold for one type of OPR, oxymorphone. CONCLUSIONS: Factors accounting for the regional variation are unknown. Such wide variations are unlikely to be attributable to underlying differences in the health status of the population. High rates indicate the need to identify prescribing practices that might not appropriately balance pain relief and patient safety. IMPLICATIONS FOR PUBLIC HEALTH: State policy makers might reduce the harms associated with abuse of prescription drugs by implementing changes that will make the prescribing of these drugs more cautious and more consistent with clinical recommendations.

Decline in drug overdose deaths after state policy changes - Florida, 2010-2012.

During 2003-2009, the number of deaths caused by drug overdose in Florida increased 61.0%, from 1,804 to 2,905, with especially large increases in deaths caused by the opioid pain reliever oxycodone and the benzodiazepine alprazolam. In response, Florida implemented various laws and enforcement actions as part of a comprehensive effort to reverse the trend. This report describes changes in overdose deaths for prescription and illicit drugs and changes in the prescribing of drugs frequently associated with these deaths in Florida after these policy changes. During 2010-2012, the number of drug overdose deaths decreased 16.7%, from 3,201 to 2,666, and the deaths per 100,000 persons decreased 17.7%, from 17.0 to 14.0. Death rates for prescription drugs overall decreased 23.2%, from 14.5 to 11.1 per 100,000 persons. The decline in the overdose deaths from oxycodone (52.1%) exceeded the decline for other opioid pain relievers, and the decline in deaths for alprazolam (35.6%) exceeded the decline for other benzodiazepines. Similar declines occurred in prescribing rates for these drugs during this period. The temporal association between the legislative and enforcement actions and the substantial declines in prescribing and overdose deaths, especially for drugs favored by pain clinics, suggests that the initiatives in Florida reduced prescription drug overdose fatalities.

Risk of adverse health outcomes with increasing duration and regularity of opioid therapy.

PURPOSE: The purpose of this study was to examine trends in frequency and daily dosage of opioid use and related adverse health outcomes in a commercially insured population. METHODS: We examined medical claims from the Truven Health MarketScan commercial claims database for 789,457 continuously enrolled patients ages 18 to 64 years to whom opioids were dispensed during the first half of 2008. We tracked them every 6 months until either opioid use was discontinued or the end of 2010. We compared outcomes among all opioid users with those for patients who used opioids with only limited interruptions during the index period, referred to as "daily users." We contrasted the experience of daily users, other users, and nonusers for various outcomes. RESULTS: Of all claimants, 10.7% had at least one opioid prescription during the first 6 months of 2008. Of these, 39.9% continued through a second 6-month period, and 18.0% continued through the end of 2010. Only 9.0% of all users qualified as daily users, but 87.1% of them continued some use of opioids through the end of 2010. Only 43.8% of all users who continued use through 2010 initially qualified as daily users. Among all users who continued use through 2010, days of use and daily dosage increased with duration of use. Among daily users, only dosage increased, rising from 101 to 114 morphine milligram equivalents/day over the 3 years. The prevalence of benzodiazepine use was greater for daily than all users, exceeding 40% among daily users who continued opioid use for 3 years. Drug abuse and overdose rates increased with longer use. Daily users accounted for 25.0%, other users for 43.6%, and nonusers for 31.4% of opioid analgesic overdoses. CONCLUSIONS: Adverse health outcomes can increase with accumulating opioid use and increasing dosage. Existing guidelines developed by specialty societies for managing patients using opioids daily or nearly daily do not address the larger number of patients who use opioids intermittently over periods of years. Practitioners should consider applying such guidelines to patients who use opioids less frequently.