Tramadol utilization among patients with higher risk of adverse drug events: A claims analysis of commercially insured and Medicare Advantage members.

OBJECTIVE: To assess prescribing of tramadol among patients with contraindications and higher risks of adverse events in a large population of commercially insured and Medicare Advantage members. DESIGN: We performed a cross-sectional analysis evaluating tramadol utilization in patients with higher risk of adverse outcomes. SETTING: This study utilized 2016-2017 data from the Optum Clinformatics Data Mart. PATIENTS AND PARTICIPANTS: Patients with at least one tramadol prescription without a cancer or sickle cell diagnosis during the study period. MAIN OUTCOME MEASURES: We first determined if tramadol was prescribed among patients with contraindications or risk factors for adverse outcomes. We then determined if patient demographic or clinical factors were associated with the use of tramadol in these higher-risk scenarios using multivariable logistic regression models. RESULTS: Among patients with at least one prescription for tramadol, 19.66 percent (99 percent CI: 19.57-19.75) concurrently received an interacting cytochrome P450 isoenzyme medication, 19.24 percent (99 percent CI: 19.15-19.33) concurrently received a serotonergic medication, and 7.93 percent (99 percent CI: 7.88-8.00) concurrently received a benzodiazepine. Additionally, 1.59 percent (99 percent CI: 1.56-1.61) of patients who received tramadol also had a seizure disorder, while 0.55 percent (99 percent CI: 0.53-0.56) of patients were under the age of 18. Overall, nearly one in three patients (31.17 percent) received tramadol in the presence of at least one of these risks (99 percent CI: 31.06-31.27). CONCLUSION: Almost one in three patients prescribed tramadol had a clinically significant drug interaction or contraindication for use, suggesting that prescribers often disregard these concerns. Real-world studies are needed to better understand the likelihood of harms associated with the use of tramadol in these contexts.

Initial Patterns of Prescription Opioid Supply and Risk of Mortality Among Insured Adults in the United States.

OBJECTIVE: To examine the association between initial patterns of prescription opioid supply (POS) and risk of all-cause mortality among an insured opioid-naïve patient population in the United States (US). METHODS: This retrospective observational cohort study used de-identified, administrative health care claims data from a large national insurer (Optum Clinformatics Data Mart) from 2010 to 2015. Participants included insured, cancer-free adults prescribed opioid analgesics. Prescription opioids received during the first 6 months of therapy were used to categorize initial patterns of POS as daily or nondaily. Cox regression was used to estimate the association of initial patterns of POS with all-cause mortality within one year of follow-up, adjusting for baseline covariates to control for confounding. RESULTS: A total of 4,054,417 patients were included, of which 2.75% had incident daily POS; 54.8% were female; median age was 50 years; mean Charlson comorbidity index (CCI) was 0.21 (standard deviation = 0.77); and mean daily morphine milligram equivalent was 34.61 (95% confidence intervals: 34.59, 34.63). There were 2068 more deaths per 100,000 person-years among patients who were prescribed opioids daily than nondaily. After adjusting for baseline covariates, the hazard of all-cause mortality among patients with incident daily POS was nearly twice that among those prescribed nondaily (hazard ratio [HR] = 1.94; 95% confidence intervals: 1.84, 2.04). CONCLUSIONS: Among insured adult patients with noncancer pain, incident chronic POS was associated with a significantly increased risk of all-cause mortality over at most 1 year of follow-up. Because these results may be susceptible to bias, more research is needed to establish causality.

Prescriber and pharmacist understanding of revised Rhode Island pain management regulations.

INTRODUCTION: Federal agencies and national associations have implemented action plans in response to the opioid crisis. Furthermore, over 30 states have enacted legislation with opioid-related restrictions, guidance, or requirements. Following recommendations from the governor-appointed Overdose Prevention and Intervention Task Force, the Rhode Island Department of Health developed an original and updated version of Pain Management Regulations in March 2017 and July 2018, respectively. Our study aimed to identify disparities in interpretation and misconceptions of the updated Rhode Island Department of Health new Pain Management Regulations. METHODS: Our 29-question survey evaluated pharmacist and prescriber knowledge of regulations, with special attention given to pain management in patients with cancer. RESULTS: Thirty-two prescribers and 33 pharmacists completed the survey. The survey identified significant variance in regulation knowledge. Pharmacists correctly identified diagnosis exclusions 13-84% of the time, with a much greater understanding when diagnosis language was used instead of ICD-10 codes. Prescribers correctly identified exclusions 24-46% of the time, with little difference noted when using diagnosis language versus ICD-10 codes. The majority (59.3%) of pharmacists misclassified patients with no prescription dispensed in 30 days as patients who would be considered opioid-naïve. Both prescribers and pharmacists commonly misidentified the frequency with which the prescription drug monitoring program needs to be checked, although in both scenarios were stricter than the regulations themselves. In addition, there were significant differences in interpretation regarding naloxone co-prescribing requirements and patient awareness of naloxone co-prescribing between prescribers and pharmacists. CONCLUSION: Our findings outline several misinterpretations that affect access to chronic and cancer-related pain opioid prescriptions, despite several Rhode Island Department of Health-initiated interventions. When adopting regulations, states should proactively develop educational initiatives to avoid access challenges for patients with diagnoses of exclusion.

Concurrent Utilization of Prescription Opioids and Non-opioid Controlled Substances: Rhode Island Prescription Drug Monitoring Program, 2018.

OBJECTIVE: To estimate the prevalence of concurrent prescription opioid and non-opioid controlled substance use in Rhode Island (RI). METHODS: We conducted a cross sectional observational study using data from the RI Prescription Drug Monitoring Program on controlled substance prescriptions dispensed in 2018. We estimated the prevalence of concurrent use of other prescribed controlled substances among adults who received at least one opioid prescription. RESULTS: In 2018, 142,692 RI adult residents received at least one opioid prescription, of whom 25.1% (99% confidence interval [CI]: 24.8-25.4) were concurrently prescribed at least one other controlled substance, including benzodiazepines (17.0%, 99% CI: 16.8-17.3), medications for insomnia (4.0%, 99% CI: 3.9-4.2), and stimulants (3.8%, 99% CI: 3.6-3.9). CONCLUSION: The concurrent use of prescription opioids and other prescribed controlled substances is common. Our findings suggest an urgent need to implement focused initiatives to address controlled substance polypharmacy to reduce the risk of overdose.

Interprofessional Substance Use Disorder Education in Health Professions Education Programs: A Scoping Review.

PURPOSE: The authors conducted this scoping review to (1) provide a comprehensive evaluation and summation of published literature reporting on interprofessional substance use disorder (SUD) education for students in health professions education programs and (2) appraise the research quality and outcomes of interprofessional SUD education studies. Their goals were to inform health professions educators of interventions that may be useful to consider as they create their own interprofessional SUD courses and to identify areas of improvement for education and research. METHOD: The authors searched 3 Ovid MEDLINE databases (MEDLINE, In-Process & Other Non-Indexed Citations, and Epub Ahead of Print), Embase.com, ERIC via FirstSearch, and Clarivate Analytics Web of Science from inception through December 7, 2018. The authors used the Medical Education Research Study Quality Instrument (MERSQI) to assess included studies' quality. RESULTS: The authors screened 1,402 unique articles, and 14 met inclusion criteria. Publications dated from 2014 to 2018. Ten (71%) included students from at least 3 health professions education programs. The mean MERSQI score was 10.64 (SD = 1.73) (range, 7.5-15). Interventions varied by study, and topics included general substance use (n = 4, 29%), tobacco (n = 4, 29%), alcohol (n = 3, 21%), and opioids (n = 3, 21%). Two studies (14%) used a nonrandomized 2-group design. Four (29%) included patients in a clinical setting or panel discussion. Ten (72%) used an assessment tool with validity evidence. Studies reported interventions improved students' educational outcomes related to SUDs and/or interprofessionalism. CONCLUSIONS: Interprofessional SUD educational interventions improved health professions students' knowledge, skills, and attitudes toward SUDs and interprofessional collaboration. Future SUD curriculum design should emphasize assessment and measure changes in students' behaviors and patient or health care outcomes. Interprofessional SUD education can be instrumental in preparing the future workforce to manage this pressing and complex public health threat.

Missed opportunities for HIV screening in pharmacies and retail clinics.

In the wake of new recommendations to offer HIV screening to everyone aged 13-64 years and to start all people living with HIV/AIDS on highly active antiretroviral therapy (HAART) regardless of CD4 count, the need to generate widespread, scalable HIV screening programs is greater than ever. Nearly 50,000 new HIV infections occur in the United States each year, and the Centers for Disease Control and Prevention estimates that approximately half of these new infections are transmitted by individuals who are unaware of their HIV serostatus. Numerous barriers to screening exist, including the lack of primary care for many at-risk patients, expense of screening in traditional settings, and need for repeat testing in high-risk populations. With their relative accessibility and affordability, community pharmacies and retail clinics within those pharmacies are practical and appealing venues for expanded HIV screening. For widespread pharmacy-based testing to become a reality, policymakers and corporate pharmacy leadership would need to develop innovative solutions to the existing time pressures of pharmacists' behind-the-counter functions and absence of reimbursement for direct patient care services. Pharmacists nationwide should also receive training to assist with risk reduction counseling and linkage to care for customers purchasing the new over-the-counter HIV test.