Patients' willingness to pay for naloxone: A national cross-sectional survey of prescription opioid users with chronic pain in the United States.

BACKGROUND: Millions of U.S. people have been heavily affected by opioids. In March 2023, the Food and Drug Administration approved naloxone as an over-the-counter medication. This has allowed more access to patients at high risk of opioid overdose. However, the patient's willingness to pay for naloxone at the pharmacy counter has not been assessed. OBJECTIVES: This study aimed to characterize factors associated with the willingness to pay for naloxone among the patient group. METHODS: A cross-sectional Qualtrics online panel survey instrument was developed. This survey was distributed to patients in the United States, aged ≥ 18 years, with any chronic pain and taking opioids. The survey included demographics, and clinical characteristics (pain assessment, opioid use, and knowledge of naloxone). In addition, willingness to pay was assessed using a 7-point Likert scale ranging from strongly disagree to strongly agree. An ordinal logistic regression model was used to examine demographic and clinical characteristics. RESULTS: A total of 549 subjects completed the survey (women [53.01%], white or Caucasian (83.61%), age mean [SD] 44 [13]). Women were associated with less willingness to pay (adjusted odds ratio [aOR] 0.685 [95% CI 0.478-0.983], P = 0.0403). Compared with the high household income group (≥ $150,000), low household income ≤ $25,000 (aOR 0.326 [95% CI 0.160-0.662], P = 0.0020) or income between $25,000 and 74,999 (aOR 0.369 [95% CI 0.207-0.657], P = 0.0007) was associated with less likelihood of willing to pay. Patients with a previous diagnosis of obstructive sleep apnea were associated with a higher likelihood of willingness to pay (aOR 1.685 [95% CI 1.138-2.496], P = 0.0092). Each unit increase in pain was also associated with a higher likelihood of willingness to pay (aOR 1.247 [95% CI 1.139-1.365], P < 0.0001). CONCLUSIONS: Demographics and clinical factors were associated with willingness to pay for naloxone. This study's findings are useful in the development of interventions to address pharmacy-based naloxone distribution programs.

Opioid and Non-Opioid Pharmacotherapy Use for Pain Management Among Privately Insured Pediatric Patients With Cancer in the United States.

BACKGROUND: This study examined the trends and patterns of opioid and non-opioid pharmacotherapy use among a large national sample of privately insured pediatric patients with cancer in the United States. MATERIALS AND METHODS: We identified pediatric (aged < 21) patients diagnosed with central nervous system (CNS), lymphoma, gonadal, leukemia, or bone cancer from MarketScan data 2005-2019. We examined the proportion of patients who filled a prescription for the following 5 types of pharmacotherapy: opioid, anticonvulsant, non-steroidal anti-inflammatory drug (NSAID), antidepressant, and muscle relaxant during active cancer treatment. We assessed the trends and patterns in pharmacotherapy using multivariable logistic regressions. RESULTS: Among 4174 patients included, 2979 (71%) had an opioid prescription; 746 (18%), 384 (9%), 202 (5%), and 169 (4%) had anticonvulsant, NSAID, antidepressant and muscle relaxant prescriptions, respectively. Multivariable logistic regression showed a nonlinear trend in the use of opioids among pediatric patients with cancer over time such that use slightly increased until 2012 (OR of 1.40 [95% CI, 1.12-1.73] for 2012 vs. 2006) but then decreased thereafter (OR of 0.51 [0.37-0.68] for 2018 vs. 2012). The use of anticonvulsants, NSAIDs, and muscle relaxants increased significantly linearly over time (all P < .005). CONCLUSION: There has been a downward trend in the use of opioids in recent years among pediatric patients with cancer and an upward trend in the use of non-opioid pharmacotherapy for pain management potentially as an alternative to opioids.

Productivity Loss Among Opioid and Benzodiazepine Users in the United States: A Medical Expenditure Panel Survey From 2010 to 2019.

OBJECTIVE: The aim of the study is to estimate the association between productivity losses and the use of prescription opioids and benzodiazepines among employed US adults with painful conditions. METHODS: Using Medical Expenditures Panel Survey (2010-2019), we used two-part (logistic regression and generalized linear model with zero-truncated negative binomial link) model to compare missed workdays due to illness or injury among employed adults with a painful condition. RESULTS: Of the eligible sample of 57,413 working US individuals, 14.65% were prescription opioid users, 2.95% were benzodiazepine users, and 1.59% were both opioid and benzodiazepine users. The predicted missed workdays were 5.75 (95% Confidence Limit [CL]: 5.58-5.92) days for benzodiazepine users, 13.06 (95% CL: 12.88-13.23) days among opioid users, and 15.18 (95% CL: 14.46-15.90) days for opioid and benzodiazepine concomitant users. CONCLUSIONS: Concomitant use of prescription opioids and benzodiazepines was significantly associated with having more missed workdays among employed adults with documented painful conditions.

Physician perspective on the implementation of risk mitigation strategies when prescribing opioid medications: a qualitative analysis.

OBJECTIVE: To understand the physician perspective on the barriers and facilitators of implementing nine different opioid risk mitigation strategies (RMS) when prescribing opioid medications. METHODS: We created and dispersed a cross-sectional online survey through the Qualtrics© data collection platform among a nationwide sample of physicians licensed to practice medicine in the United States who have prescribed an opioid medication within the past year. The responses were analyzed using a deductive thematic analysis approach based on the Consolidated Framework for Implementation Research (CFIR) to ensure a holistic approach to identifying the barriers and facilitators for each RMS assessed. In concordance with this method, the themes and codes for the thematic analysis were defined prior to the analysis. The five domains within the CFIR were used as themes and the 39 nested constructs were treated as the codes. Two members of the research team independently coded the transcripts and discussed points of disagreement until consensus was reached. All analyses were conducted in ATLAS.ti© V7. RESULTS: The completion rate for this survey was 85.1% with 273 participant responses eligible for analysis. Intercoder reliability was calculated to be 82%. Deductive thematic analysis yielded 2,077 descriptions of factors affecting implementation of the nine RMS. The most salient code across all RMS was Knowledge and Beliefs about the Intervention, which refers to individuals' attitudes towards and value placed on the intervention. Patient Needs and Resources, a code referring to the extent to which patient needs are known and prioritized by the organization, also emerged as a salient code. The physicians agreed that the patient perspective on the issue is vital to the uptake of each of the RMS. CONCLUSIONS: This deductive thematic analysis identified key points for actionable intervention across the nine RMS assessed and established the importance of patient concordance with physicians when deciding on a course of treatment.

Student-led podcasts to enhance literature evaluation skills.

BACKGROUND AND PURPOSE: Critical evaluation and understanding of primary literature is essential to pharmacy practice. This project evaluated student confidence and learning outcomes in a critical care elective course where podcasts were used as an active learning assignment for literature evaluation. EDUCATIONAL ACTIVITY AND SETTING: Third-year pharmacy students created a 15- to 20-min podcast episode that reviewed a landmark critical care trial. A pre/post survey was used to assess student perceptions of confidence in evaluating primary literature. A standardized rubric was used to assess literature evaluation skills in several domains. FINDINGS: Ninety-two third-year pharmacy students were enrolled in the critical care elective course, and 93% (86 of 92) completed the survey. Student perceptions of their ability to evaluate literature improved for all seven questions, including comfort in interpreting study methodology and applying findings of literature to patient care. Students scored proficient on most components of the standardized rubric, with ability to discuss results and conclusions being the lowest performing domain (78.2% fully proficient). After completing the activity, students felt more confident in interpreting results, applying findings, and orally presenting a journal article to peers. Most students felt the podcast activity helped them strengthen their literature evaluation skills and recommended this activity to a peer. SUMMARY: Third-year pharmacy students reported an improvement in confidence in the interpretation and application of primary literature after creating a podcast episode reviewing a critical care trial. Additional research with creation of podcasts or other audio/visual methods should be studied in the future.

Management of metastatic melanoma in Texas: disparities in the utilization of immunotherapy following the regulatory approval of immune checkpoint inhibitors.

BACKGROUND: The utilization of modern-immunotherapies, notably immune checkpoint inhibitors (ICIs), has increased markedly in patients with metastatic melanoma over the past decade and are recommended as standard treatment. Given their increasing adoption in routine care for melanoma, understanding patient access to immunotherapy and patterns of its use in Texas is crucial as it remains one of the few states without Medicaid expansion and with high rates of the uninsured population. The objectives of this study were to examine the trend in the utilization of immunotherapy and to determine factors associated with immunotherapy utilization among patients with metastatic melanoma in the era of ICIs in Texas. METHODS: A retrospective cohort study was conducted using the Texas Cancer Registry (TCR) database. The cohort comprised of adult (≥ 18 years) patients with metastatic melanoma diagnosed between June 2011 and December 2018. The trend in immunotherapy utilization was assessed by determining the proportion of patients receiving immunotherapy each year. The Average Annual Percent Change (AAPC) in immunotherapy utilization was assessed using joinpoint regression, while multivariable logistic regression was used to determine the association between patient characteristics and immunotherapy receipt. RESULTS: A total of 1,795 adult patients with metastatic melanoma were identified from the TCR. Immunotherapy utilization was higher among younger patients, those with no comorbidities, and patients with private insurance. Multivariable analysis showed that the likelihood of receipt of immunotherapy decreased with older age [(adjusted Odds Ratio (aOR), 0.92; 95% CI, 0.89- 0.93, p = 0.001], living in high poverty neighborhood (aOR, 0.52; 95% CI, 0.44 - 0.66, p < 0.0001), having Medicaid (aOR, 0.58; 95% CI, 0.44 - 0.73, p = 0.02), being uninsured (aOR, 0.49; 95% CI, 0.31 - 0.64, p = 0.01), and having comorbidities (CCI score 1: aOR, 0.48; 95% CI, 0.34 - 0.71, p = 0.003; CCI score ≥ 2: aOR, 0.32; 95% CI, 0.16 - 0.56, p < 0.0001). CONCLUSIONS AND RELEVANCE: This cohort study identified sociodemographic and socioeconomic disparities in access to immunotherapy in Texas, highlighting the need for policies such as Medicaid expansion that would increase equitable access to this innovative therapy.

Differences in Perceived Threat and Efficacy in Managing Opioid Use Disorder versus Alcohol Use Disorder.

Background: Efforts to increase the availability of Medication Assisted Treatment for alcohol use disorder (AUD) and opioid use disorder (OUD) may be futile if patients lack motivation for recovery and are unwilling to seek treatment. Objectives: In this cross-sectional, online survey, we used the Extended Parallel Process Model (EPPM) to assess how participants at risk of AUD or OUD react to their perceived threat and assess their response to pharmacotherapy as a potential treatment. EPPM constructs were assessed using the Risk Based Diagnosis Scale. Descriptive statistics measure the proportion of treated vs untreated participants. Untreated participants were sorted into one of three groups categorizing perceived threat - low threat appraisal, and danger or fear control. Results: Of 411 total responses, most (n = 293[71.29%]) sorted into the AUD cohort and 118(28.71%) into the OUD cohort. Overall, 104(25.30%) had received treatment and 307(74.70%) didn't. Within the OUD cohort, there were 67 untreated participants - 16(23.88%) exhibited low threat appraisal, 13(19.40%) were likely to undergo fear control, and 38(56.72%) were likely to undergo danger control. Within the AUD cohort, there were 240 untreated participants - 75(31.25%) exhibited low threat appraisal, 100(41.67%) were likely to experience fear control, and 65(27.08%) were likely to experience danger control. Participants in the OUD cohort were more likely to undergo danger control than those in the AUD cohort (χ2 = 19.26, p < 0.05). Conclusions: This study identified perceived threat and efficacy when an individual was at risk of a SUD, but more insight into potential early interventions is needed - particularly in those individuals with polysubstance use disorder.

Identifying predictors of generalized anxiety among student pharmacists in response to the COVID-19 pandemic.

INTRODUCTION: To explore the prevalence of generalized anxiety (GA) among doctor of pharmacy (PharmD) students at an academic institution during the COVID-19 pandemic and use Alderfer's existence, relatedness, and growth (ERG) theory to elucidate which unsatisfied needs are predictive of higher levels of GA symptoms. METHODS: This was a cross-sectional, single-site survey administered to first- through fourth-year PharmD students from October 2020 to January 2021. The survey tool included demographic information, the validated Counseling Center Assessment of Psychological Symptoms-62 tool, and nine additional questions developed to assess Alderfer's ERG theory of needs. Predictors of GA symptoms were evaluated using descriptive statistics, multiple linear regression, correlation analysis, and multivariable analysis. RESULTS: A total of 214 of 513 students completed the survey (42%) . Among students, 49.01% had no-clinical, 31.31% had low-clinical, and 19.63% had high-clinical GA symptoms. The relatedness needs, which included feeling disliked, socially disconnected, and misunderstood had the strongest correlation (65%) to GA symptoms and was most associated with GA symptoms (ß = 0.56, P < .001). Students who did not exercise experienced more symptoms of GA (P = .008). CONCLUSIONS: Over 50% of PharmD students met clinical cut-offs for GA symptoms and the relatedness need was most predictive of GA symptoms among students. Future student-centered interventions should aim to create opportunities that increase social connections, build resilience, and provide psychosocial support.

Parents' intention to have their child vaccinated at a community pharmacy: A national cross-sectional survey.

BACKGROUND: During the coronavirus disease 2019 pandemic, pediatric vaccination rates for routine childhood vaccines have been declining. To boost pediatric immunizations, pharmacists in the United States may order and administer age-appropriate vaccines to children of 3 years of age and older without a prescription. OBJECTIVE: The objective of this study was to examine parents' intention to have their young children between 3 and 10 years of age vaccinated in a community pharmacy setting. METHODS: A survey instrument was designed based on the health belief model (HBM). The cross-sectional survey was administered online via Qualtrics Panels to parents in the United States with at least 1 child between the ages of 3 and 10 years. Confirmatory factor analysis was used to estimate the correlation between each of the HBM constructs and a 3-item scale measuring parents' intention to have their children between the ages of 3 and 10 vaccinated in a community pharmacy. RESULTS: There were 416 usable responses collected for an effective response rate of 25.95%. Most participants were white (79.09%) and female (51.44%), and many had a graduate degree (48.32%). More than half of parents (69.7%) indicated they would be willing to have their child vaccinated in a community pharmacy. Intention to have their child vaccinated in a pharmacy was most strongly corrected with health benefit beliefs (ψ 0.79 [95% CI 0.75-0.83]), (ψ 0.86 [95% CI 0.83-0.89])cues to action, and perceived convenience.(ψ 0.71 [95% CI 0.66-0.76]). CONCLUSION: Many parents have high intention to vaccinate their young children in community pharmacies. Parents should be educated and informed about services that community pharmacies offer. Stakeholders need to engage in interventions targeted at promoting health benefits of getting vaccinations at a pharmacy and strong recommendations from health care providers.

Optimization of Opioid Discharge Prescriptions Following Thyroid and Parathyroid Surgery.

OBJECTIVE: To evaluate the impact of a quality improvement bundle on opioid discharge prescribing following thyroidectomy and parathyroidectomy. METHODS: This before-and-after study included patients undergoing thyroidectomy or parathyroidectomy at an academic medical center. The quality improvement bundle included a patient education flyer, electronic health record order sets with multimodal analgesia regimens, and provider education. The preimplementation cohort included patients treated from January 2018 to December 2019. The postimplementation cohort included patients treated from June 2021 to August 2021. The primary outcome was the proportion of patients who received new opioid discharge prescriptions. RESULTS: A total of 160 patients were included in the preimplementation cohort, and the first 80 patients treated after bundle implementation were included in the postimplementation cohort. Patients receiving new opioid discharge prescriptions decreased from 80% (128/160) in the preimplementation cohort to 35% (28/80) in the postimplementation cohort with an unadjusted absolute reduction of 45% (95% CI, 33%-57%; P < .001; number needed to treat = 3) and an adjusted odds ratio (OR) of 0.08 (95% CI, 0.04-0.19; P < .001). The bundle was associated with reductions in opioid discharge prescriptions that exceeded 112.5 oral morphine milligram equivalents (33% pre- vs 10% postimplementation; adjusted OR, 0.20; P = .001) or 5 days of therapy (17% pre- vs 6% postimplementation; adjusted OR, 0.34; P = .049). DISCUSSION: Implementation of a pain management quality improvement bundle reduced opioid discharge prescribing following thyroidectomy and parathyroidectomy. IMPLICATIONS FOR PRACTICE: Unnecessary opioid prescriptions generate unused opioids in patients' homes that can lead to opioid misuse. We believe that this bundle reduced the risk for opioid misuse in our community. REGISTRATION: The study was registered at ClinicalTrials.gov (NCT04955444) before implementation.

Intention to get naloxone among patients prescribed opioids for chronic pain.

BACKGROUND: Prescription opioids have been increasingly prescribed for chronic pain while the opioid-related death rates grow. Naloxone, an opioid antagonist, is increasingly recommended in these patients, yet there is limited research that investigates the intention to get naloxone. This study aimed to investigate intention toward getting naloxone in patients prescribed opioids for chronic pain and to assess the predictive utility of the theory of reasoned action (TRA) constructs in explaining intention to get naloxone. METHODS: This was a cross-sectional study of a panel of U.S. adult patients prescribed opioids for chronic pain using a Qualtrics®XM survey. These patients participated in the study during February to March 2020. The online internet survey assessed the main outcome of intention to get naloxone and constructs of TRA (attitudes and subjective norms); additional measures assessed the characteristics of patients' opioid overdose risk factors, knowledge of naloxone, and their demographics. The relationship between TRA constructs, namely, attitudes and subjective norms, and the intention variable was examined using logistic regression analyses with the intention outcome contrasted as follows: high intention (scores ≥ 5) and non-high intention (scores < 5). RESULTS: A total of 549 participants completed the survey. Most of them were female (53.01%), White or Caucasian (83.61%), non-Hispanic (87.57%) and had a mean age of 44.16 years (SD = 13.37). Of these, 167 (30.42%) had high intention to get naloxone. The TRA construct of subjective norm was significantly associated with increased likelihood of higher intentions to get naloxone (OR 3.04, 95% CI 2.50-3.70, P < 0.0001). CONCLUSIONS: Our study provides empirical support of the TRA in predicting intention to get naloxone among chronic pain patients currently taking opioids. Subjective norms significantly predicted intention to get naloxone in these patients. The interventions targeting important reference groups of these patients would have greater impact on increasing intention to get naloxone in this population. Future studies should test whether theory-based interventions focusing on strengthening subjective norms increase intention to get naloxone in this population.

Comparing Two Databases to Identify Access to Buprenorphine Treatment for Opioid Use Disorder.

OBJECTIVE: The objective of this study is to assess the differences in buprenorphine prescribers from a county level in the state of Texas by comparing the Substance Abuse and Mental Health Services Administration (SAMHSA) Buprenorphine Practitioner Locator to the Drug Enforcement Administration's (DEA) Controlled Substance Act (CSA) database. METHODS: County-level counts of buprenorphine prescribers were calculated from both the publicly available SAMHSA buprenorphine practitioner locator list and the DEA CSA database. These were then used to estimate the number of providers per 100,000 residents in each county. Regional variation in access to buprenorphine was compared descriptively across the state using poverty data from the US Census and county-level demography from the Texas Demographic Center. RESULTS: This study found 68.8% more X-waivered providers on the DEA CSA database (n = 2,622) with at least one provider reported in 125 of 144 counties in the state (49.2%) compared to the SAMHSA Buprenorphine Practitioner Locator (n = 1,553) with at least one provider reported in 103 counties (40.5%). CONCLUSIONS: The lack of a complete public registry of buprenorphine prescribers can inhibit the ability of patients to identify a convenient treatment. More work is needed to quantify the gap between treatment capacity and treatment need.

Association of cash payment with intensity of opioid prescriptions.

BACKGROUND: It is difficult to track use and outcomes in patients who pay cash for their prescriptions at the pharmacy. In Texas, 14% of all opioid prescriptions are paid with cash, often by uninsured patients and pharmacy shoppers. OBJECTIVE: To evaluate the association of cash payment with intensity of opioid prescriptions. METHODS: Using a prescription drug monitoring program and the U.S. Census data for the 2019 calendar year, this cross-sectional descriptive study analyzed more than 4 million opioid prescriptions in Texas residents aged 18-64 years. The payment type was coded as insurance if the prescription was paid in whole or in part by a health plan and as cash otherwise. Daily morphine milligram equivalent (MME) dose was used to compare the intensity of opioid prescriptions. The association of uninsured rates with mean daily MME and the number of opioid prescriptions paid with cash per 100,000 persons were assessed at a county level. RESULTS: Cash payment was associated with 30% higher mean daily MME (59 vs. 45; P < 0.001) than insurance payment. This difference was driven by the prescriptions for patients aged 25-34 years and from the highest decile of prescribers based on the percentage of opioid prescriptions paid by cash. For instance, cash payment was associated with 82% higher mean daily MME (91 vs. 50; P < 0.001) when patients aged 25-34 years obtained their prescriptions from the highest decile of prescribers. At a county level, uninsured rates were not associated with mean daily MMEs or the number of opioid prescriptions paid with cash. CONCLUSION: Cash payment was associated with a higher intensity of opioid prescriptions, mirroring the rates of drug overdose deaths across the patient age groups. Further research and policy actions need to address unmet pain management needs in uninsured patients and potential pharmacy shopping with cash payment and fraudulent identifications.

College Students' Perceptions About Prescription Drug Misuse Among Peers.

BACKGROUND: Prescription drug misuse is an escalating public health problem that is prevalent among college students. Various factors, such as sex, age, race, mental health conditions, and fraternity and sorority membership, increase the risk for prescription drug misuse. Peer influences may also pose significant risks for starting prescription drug misuse, because peers are the primary source of misused prescription drugs among college students. OBJECTIVES: To examine college students' beliefs about prescription drug misuse among their peers and to understand their beliefs about the available and potential intervention efforts to reduce prescription drug misuse. METHOD: We conducted a cross-sectional survey of 312 college students aged 18 to 30 years who were enrolled in a large midwestern US university. The survey included questions about the responders' demographic characteristics, beliefs, and perceptions regarding prescription drug misuse among their peers and potential reduction programs for prescription drug misuse. RESULTS: The respondents' mean age was 21 years, and most (65%) respondents were women. A majority (90%) of the respondents were enrolled in the university as full-time students. More than 60% of the respondents reported knowing someone with prescription drug misuse in the past 12 months. Fraternity or sorority members were more likely to report peer prescription drug misuse than nonmembers (83% vs 60%, respectively; P = .017). Stimulants were the most misused drug class, accounting for 75% of all reported peer prescription drug misuse. Approximately 60% of the misused prescription drugs were sourced from peers, which included friends, roommates, and classmates. A total of 73% of respondents said that prescription drug misuse was a problem among college students and 67% agreed that interventions were needed to reduce prescription drug misuse. The perceived need for interventions varied by peer prescription drug misuse. A total of 90% of students whose peers did not misuse prescription drugs said that interventions were needed, but only 67% of those with peer prescription drug misuse thought that interventions were needed. CONCLUSION: Our findings indicate that peer prescription drug misuse is very common among college students, and the most misused drug class is stimulants. Survey respondents perceived that the current interventions used to address prescription drug misuse are not very effective or may not be targeting the right population. Peer prescription drug misuse influences college students' perceptions about the risks and harms of prescription drug misuse, as well as the need for interventions.

Factors associated with oral fingolimod use over injectable disease- modifying agent use in multiple sclerosis.

Background: Fingolimod is the first approved oral disease-modifying agent (DMA) in 2010 to treat Multiple Sclerosis (MS). There is limited real-world evidence regarding the determinants associated with fingolimod use in the early years. Objective: The objective of this study was to examine the factors associated with fingolimod prescribing in the initial years after the market approval. Methods: A retrospective, longitudinal study was conducted involving adults (≥18 years) with MS from the 2010-2012 IBM MarketScan. Individuals with MS were selected based on ICD-9-CM: 340 and a newly initiated DMA prescription. Based on the index/first DMA prescription, patients were classified as fingolimod or injectable users. All covariates were measured during the six months baseline period prior to the index date. Multivariable logistic regression was performed to determine the predisposing, enabling, and need factors, conceptualized as per the Andersen Behavioral Model (ABM), associated with prescribing of fingolimod versus injectable DMA for MS. Results: The study cohort consisted of 3118 MS patients receiving DMA treatment. Of which, 14.4% of patients with MS initiated treatment with fingolimod within two years after the market entry, while the remaining 85.6% initiated with injectable DMAs. Multivariable regression revealed that the likelihood of prescribing oral DMA increased by 2-3 fold during 2011 and 2012 compared to 2010. Patients with ophthalmic (adjusted odds ratio [aOR]-2.60), heart (aOR-2.21) and urinary diseases (aOR-1.37) were more likely to receive fingolimod. Patients with other neurological disorders (aOR-0.50) were less likely to receive fingolimod than those without neurological disorders. Use of symptomatic medication (for impaired walking (aOR-2.60), bladder dysfunction (aOR-1.54), antispasmodics (aOR-1.48), and neurologist consultation (aOR-1.81) were associated with higher odds of receiving fingolimod. However, patients with non-MS associated emergency visits (aOR-0.64) had lower odds of receiving fingolimod than those without emergency visits. Conclusions: During the initial years after market approval, patients with highly active MS were more likely to receive oral fingolimod than injectable DMAs. More research is needed to understand the determinants of newer oral DMAs.

Impact of COVID-19 related policy changes on filling of opioid and benzodiazepine medications.

BACKGROUND: Healthcare access has changed drastically during the COVID-19 pandemic. Elective medical procedures, including routine office visits, were restricted raising concerns regarding opioid and benzodiazepine provider and prescription availability. OBJECTIVE: To examine how the cancelation of elective medical procedures due to COVID-19 impacted the dispensing of opioid and benzodiazepine prescriptions in Texas. METHODS: Interrupted time series analyses were preformed to examine changes in prescription trends for opioids and benzodiazepines before and after the restriction on elective medical procedures. Samples of patients who filled an opioid or benzodiazepine prescription from January 5, 2020 to May 12, 2020 were identified from the Texas Prescription Monitoring Program. Elective medical procedures were restricted starting March 23, 2020 indicating the beginning of the intervention period. RESULTS: Restricting elective procedures was associated with a significant decrease in the number of patients (ß = -6029, 95%CI = -8810.40, -3246.72) and prescribers (ß = -2784, 95%CI = -3671.09, -1896.19) filling and writing opioid prescriptions, respectively. Also, the number of patients filling benzodiazepine prescriptions decreased significantly (ß = -1982, 95%CI = -3712.43, -252.14) as did the number of prescribers (ß = -708.62, 95%CI = -1190.54, -226.71). CONCLUSION: Restricting elective procedures resulted in a large care gap for patients taking opioid or benzodiazepine prescriptions.

Trends and patterns in the use of opioids among metastatic breast cancer patients.

Opioid use among metastatic breast cancer (MBC) patients has not been well-studied. This study examined the trends and patterns of opioid use among working-age, privately insured patients diagnosed with MBC. Using MarketScan data, we identified female patients diagnosed with MBC in 2006-2015. We determined the proportion of patients who filled a prescription for an opioid and calculated days' supply and daily morphine milligram equivalents (MMEs) from 1 year prior to diagnosis till 1 year after. We assessed the trend in opioid use over the 10-year study period and examined opioid usage patterns after the diagnosis of MBC. Among 24,752 patients included, 11,579 (46.8%) had an opioid prescription within 1 year before diagnosis of MBC, and 20,416 (81.4%) had an opioid prescription within 1 year after diagnosis. The proportion of patients with opioid prescriptions after diagnosis was relatively stable from 2006 to 2015. However, both the median daily MME and median days' supply decreased over time with most of the decline from the subgroup of patients with prior prescription opioid use. Most patients received an opioid prescription in the first month after diagnosis (57.3%), dropping to approximately 20% from 3 to 12 months after diagnosis. Also, the median days' supply increased substantially during the year after diagnosis for patients who received opioids (from 7 to 19). Most women with MBC require opioid analgesia within the first month after diagnosis. Judicious, long-term management of pain after diagnosis of MBC will continue to be necessary for many patients.

Comparative Adherence Trajectories of Oral Fingolimod and Injectable Disease Modifying Agents in Multiple Sclerosis.

BACKGROUND: Oral fingolimod is convenient to use than injectable disease modifying agents (DMAs) in patients with multiple sclerosis (MS). However, the existing literature regarding the comparative adherence trajectories between oral fingolimod and injectable DMAs is limited. OBJECTIVE: To compare the adherence trajectories between oral DMA, fingolimod, and injectable DMAs in patients with MS. METHODS: A retrospective longitudinal study was conducted using adults (≥18 years) with MS (ICD-9-CM: 340 and a DMA prescription) from the IBM MarketScan Commercial Claims and Encounters Database between 2010 and 2012. Patients were grouped into oral fingolimod or injectable DMA users based on the index DMA among patients with MS. The annual DMA adherence trajectories, based on the proportion of days covered (PDC), were examined using group-based trajectory modeling (GBTM) during the one-year follow-up period after treatment initiation. Multivariable multinomial logistic regression using stabilized inverse probability treatment weights (IPTW) was performed to assess the association between the DMA route of administration (Oral vs Injectable) and the adherence trajectory groups. The balance of covariates between oral and injectable DMAs before and after IPTW was checked against a standardized difference threshold of 0.25. RESULTS: The study cohort consisted of 1,700 MS patients who were initiated with oral (15.8%) or injectable (84.2%) DMAs between 2010 and 2012. The adherence rates (PDC≥0.8) in oral fingolimod and injectable DMA users were found to be 64.7% and 50.8%, respectively. The GBTM grouped individuals in the study cohort into three adherence trajectories - rapid discontinuers (23.5%), complete adherers (49.9%), and slow decliners (26.6%). The multinomial logistic regression model with stabilized IPTW revealed that oral fingolimod users had higher odds to be a complete adherer (adjusted odds ratio [AOR]: 2.78, 95% CI: 1.85-4.16) or a slow discontinuer (AOR: 2.62, 95% CI: 1.70-4.05) than injectable DMA users. CONCLUSIONS: Oral DMA fingolimod was associated with better adherence than injectable DMAs across group-based trajectories. Further research is warranted to evaluate the adherence trajectories with newer oral DMAs introduced in the last decade for MS.

Does Social Desirability Influence Preceptors' Completion of Student Experiential Evaluations?

Many variables influence a preceptor's experiential evaluation of a pharmacy learner. However, the impact of social desirability bias, or the measure of an individual's need for social approval, and its impact on the truthfulness of an evaluation is not well understood. Social desirability may present a barrier to students receiving accurate and truthful evaluations. Differences in the effect of social desirability may be seen between full-time faculty and non-faculty preceptors. Colleges of pharmacy should work to support preceptors by providing professional development, standardizing evaluation processes, and ensuring two-way communication. Additionally, a social desirability measure could be used for each preceptor and used by the experiential team to identify preceptors potentially in need of additional development. Future studies should evaluate the effect of social desirability on how preceptors complete evaluations, and propose methods to mitigate this form of bias in the evaluation process.

Factors Associated with Prescribing Oral Disease Modifying Agents in Multiple Sclerosis: a Real-world Analysis of Electronic Medical Records.

BACKGROUND: Little is known about the factors associated with the selection of Disease Modifying Agents (DMA) for the management of Multiple Sclerosis (MS) since the introduction of oral DMAs in 2010. OBJECTIVES: To examine the factors associated with initiation of oral DMAs in patients with MS using data from electronic medical records (EMR). METHODS: A retrospective longitudinal study was conducted using TriNetX, a federated EMR network of over 38 million patients from the US, from 2009-2019. Adult (≥18 years) patients with MS from the United States were identified using a MS diagnosis (ICD-9-CM: 340 or ICD-10-CM: G35) and a newly prescribed DMA with a one-year baseline period. Patients with new DMA prescriptions were classified as oral or injectable users based on their index medication. A multivariable logistic regression model was used to determine the predisposing (age category, sex, race, and ethnicity), enabling (time-period), and need factors (comorbidities, MS symptoms, symptomatic medication, and healthcare utilization) associated with initiation of an oral versus injectable DMA. RESULTS: The study cohort consisted of 7,511 MS patients with a newly prescribed DMA, of whom most were 18-44 years old (48.33%), female (75.18%), and white (80.92%). About 42.32% of MS patients were diagnosed with at least one comorbidity (mean±SD: 0.86±1.37). Two thirds (66.32%) of the patients with MS started injectable DMAs, and the remaining one third (33.68%) started oral DMAs. Multivariable regression revealed that middle-aged (45-64 years; Adjusted Odds Ratio [aOR]=0.88; 95% Confidence Interval [CI]: 0.79-0.98) and older adults (≥65 years; aOR=0.67, 95% CI: 0.53-0.84) were associated with a decreased likelihood of receiving oral DMAs. The presence of general symptoms (aOR=1.26, 95% CI: 1.10-1.45) and cerebellar symptoms (aOR=1.56, 95% CI: 1.26-1.93) was associated with an increased likelihood of an oral DMA. However, the presence of sensory symptoms (aOR: 0.72, 95% CI: 0.59-0.88) was associated with a decreased likelihood of an oral DMA. Comorbidities such as renal failure (aOR=0.16, 95%% 0.04-0.62), obesity (aOR=0.60, 95% CI: 0.45-0.80), drug abuse (aOR=0.61, 95% CI: 0.38-0.99), and other neurological disorders (aOR=0.82, 95% CI: 0.69-0.96) were associated with a decreased likelihood of receiving an oral DMA prescription. While the use of analgesics (aOR=0.78, 95% CI: 0.69-0.88) was associated with decreased likelihood, the use of antispasmodics (aOR=1.14, 95% CI: 1.01-1.28) was associated with an increased likelihood of receiving an oral DMA. Relative to the time-period when first oral DMAs entered into the market (2010-11), with time, the likelihood of prescribing oral DMA increased by multiple folds (2012-13, aOR=4.30, 95% CI: 3.08-6.00; 2014-15, aOR=19.34, 95% CI: 14.10-26.54; 2016-17, aOR=17.63, 95% CI: 12.76-24.35; and 2018-19, aOR=20.73, 95% CI: 14.64-29.37). CONCLUSIONS: Oral DMA use steadily increased over the years, with one in three MS patients receiving oral agents. Both demographic and clinical factors were associated with the initiation of oral DMA over injectable DMA.