The protocol of the Application of Economics & Social psychology to improve Opioid Prescribing Safety trial 2 (AESOPS-2): Availability of opioid harm.

BACKGROUND: High levels of opioid prescribing in the United States has resulted in an alarming trend in opioid-related harms. The objective of Trial 2 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-2) is to dampen the intensity and frequency of opioid prescribing in accordance with the Centers for Disease Control and Prevention recommendation to "go low and slow". We aim to accomplish this by notifying clinicians of harmful patient outcomes, which we expect to increase the mental availability of risks associated with opioid use. METHODS: The trial is multi-site. Random assignment determines if prescribers to persons who suffer an opioid overdose (fatal or nonfatal) learn of this event (intervention) or practice usual care (control). Clinicians in the intervention group receive a letter notifying them of their patient's overdose. The primary outcome is the change in clinician weekly milligram morphine equivalent (MME) prescribed in a 6-month period before and after receiving the letter. Additional outcomes are the change in the proportion of patients prescribed at least 50 daily MME and in the proportion of patients referred to medication assisted treatment. Group differences in these outcomes will be compared using an intent-to-treat difference-in-differences framework with a mixed-effects regression model to estimate clinician MME. DISCUSSION: The AESOPS-2 trial will provide new knowledge about whether increasing prescribers' awareness of patients' opioid-related overdoses leads to a reduction in opioid prescribing. Additionally, this trial may better inform how to reduce opioid use disorder and opioid overdoses by lowering population exposure to these drugs. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04758637.

The protocol of the Application of Economics & Social psychology to improve Opioid Prescribing Safety Trial 1 (AESOPS-1): Electronic health record nudges.

BACKGROUND: There is a lack of evidence that long-term opioid use offers benefit for noncancer pain and an abundance of evidence of harm. Despite clinical guidelines and education, prescribing continues at a higher rate than before the opioids crisis. The objective of trial 1 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-1) is to discourage unnecessary opioid prescribing in primary care by applying "behavioral insights"-empirically-tested social and psychological interventions that affect choice. METHODS: AESOPS-1 randomizes primary care clinics in Illinois and California to behavioral intervention or control. Both arms receive opioid guideline education. Clinics randomized to the behavioral intervention arm receive nudges within the electronic health record (EHR) including: 1) an "accountable justification" entered in the chart, 2) a precommitment to address high-risk prescriptions, and 3) a "PainTracker" that broadens discussions about pain. The control arm receives no EHR-based intervention. The primary outcome is the change in weekly milligram morphine equivalents (MME) prescribed. The secondary outcome is the change in the proportion of patients prescribed at least 50 daily MME. To evaluate these outcomes, we will use a difference-in-differences mixed-effects regression model on clinician MME weekly or daily dose. The analysis will be "intent-to-treat." The intervention period is 18-months, with a 6-month follow-up period to measure persistence of effects. DISCUSSION: The AESOPS-1 trial will evaluate the effect of EHR-based interventions in reducing noncancer opioid prescribing in primary care. AESOPS-1 may demonstrate practical and scalable strategies to lower unnecessary population exposure to opioids.

Symptom Burden Among Community-Dwelling Older Adults in the United States.

OBJECTIVES: To determine the prevalence and impact of common co-occurring symptoms among community-dwelling older adults in the United States. DESIGN: The National Health and Aging Trends Study is a nationally representative, prospective study with annual data collection between 2011 and 2017. SETTING: Community-based, in-person interviews (survey response rates, 71%-96%). PARTICIPANTS: A total of 7,609 community-dwelling Medicare beneficiaries, 65 years or older. MEASUREMENTS: Symptoms assessed at baseline include pain, fatigue, breathing difficulty, sleeping difficulty, depressed mood, and anxiety. Total symptom count ranged from zero to six. Several outcomes were examined, including grip strength, gait speed, and overall lower-extremity function as well as incidence of recurrent falls (two or more per year), hospitalization, disability, nursing home admission, and mortality. RESULTS: Prevalence of zero, one, two, three, and four or more symptoms was 25.0%, 26.6%, 20.7%, 14.0%, and 13.6%, respectively. Symptom count increased with advancing age and was higher in women than in men. Pain and fatigue were the most common co-occurring symptoms. Higher symptom count was associated with decreased physical capacity. For example, participants with one, two, three, and four or more symptoms had gait speeds that were 0.04, 0.06, 0.09, and 0.13 m/s slower, respectively, than those with no symptoms, adjusting for specific diseases, total number of diseases, and other potential confounders (P < .001). The risk of several adverse outcomes also increased with greater symptom count. For example, compared with those with no symptoms, the adjusted risk ratios for recurrent falls were 1.48 (95% confidence interval [CI] = 1.30-1.70), 1.54 (95% CI = 1.32-1.80), 1.90 (95% CI = 1.55-2.32), and 2.38 (95% CI = 2.00-2.83) for older adults with one, two, three, and four or more symptoms, respectively. CONCLUSIONS: Symptoms frequently co-occur among community-dwelling older adults and are strongly associated with increased risk of a range of adverse outcomes. Symptoms represent a potential treatment target for improving outcomes and should be systematically captured in health records. J Am Geriatr Soc 67:223-231, 2019.

Trends in Opioid Dosing Among Washington State Medicaid Patients Before and After Opioid Dosing Guideline Implementation.

UNLABELLED: By 2007, opioid-related mortality in Washington state (WA) was 50% higher than the national average, with Medicaid patients showing nearly 6 times the mortality of commercially-insured patients. In 2007, the WA Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain was released, which recommended caution in prescribing >120 mg morphine-equivalent dose per day for patients not showing clinically meaningful improvement in pain and function. We report on opioid dosing in the WA Medicaid fee-for-service population for 273,200 adults with a paid claim for an opioid prescription between April 1, 2006 and December 31, 2010. Linear regression was used to test for trends in dosing over that time period, with quarter-year as the independent variable and median daily dose as the dependent variable. Prescription opioid use among WA Medicaid adults peaked in 2009, as evidenced by the unique number of opioid users (105,232), the total number of prescriptions (556,712), and the total person-years of prescription opioid use (29,442). Median opioid dose was unchanged from 2006 to 2010 at 37.5 mg morphine-equivalent dose, but doses at the 75th, 90th, 95th, and 99th percentiles declined significantly (P < .001). These results suggest that opioid treatment guidelines with dosing guidance may be able to reduce high-dose opioid use without affecting the median dose used. PERSPECTIVE: Some fear that opioid dosing guidelines might restrict access to opioid therapy for patients who could benefit. However, there is evidence that high-dose opioid therapy entails significant risks without demonstrated benefit. These findings indicate that high-dose opioid therapy can be reduced without altering median opioid dose in a Medicaid population.

Opioid poisonings in Washington State Medicaid: trends, dosing, and guidelines.

BACKGROUND: Opioid poisonings have increased as use of prescription opioid medications have increased. To reduce these poisonings, guidelines for chronic opioid use have been implemented. However, if opioid poisonings occur in individuals who do not have high prescribed doses and who are not chronic opioid users, the current guidelines may need revision. OBJECTIVES: To examine changes in rates of methadone and other opioid poisonings after implementation of the WA State Opioid Guideline in 2007 and to examine the prescription history before poisonings. METHODS: The study sample consisted of individuals who had at least 1 paid claim for an opioid prescription in the Medicaid fee-for-service system between April 2006 and December 2010 and had an emergency department or inpatient hospital claim for an opioid poisoning. RESULTS: Methadone poisonings occurred at 10 times the rate of other prescription opioid poisonings and increased between 2006 and 2010. Rates of other prescription opioid poisonings appeared to level off after implementation of the WA opioid guideline in 2007. Among individuals with nonmethadone opioid poisonings, only 44% had chronic opioid use, 17% had prescribed doses in the week before the poisoning >120 mg/d morphine-equivalent dose (MED), 28% had doses <50 mg/d MED, and 48% had concurrent sedative prescriptions. CONCLUSIONS: It may be prudent to revise guidelines to address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use. Research is needed to establish the best strategies to prevent opioid poisonings.

Primary Results of the Patient-Centered Disease Management (PCDM) for Heart Failure Study: A Randomized Clinical Trial.

IMPORTANCE: Heart failure (HF) has a major effect on patients' health status, including their symptom burden, functional status, and health-related quality of life. OBJECTIVE: To determine the effectiveness of a collaborative care patient-centered disease management (PCDM) intervention to improve the health status of patients with HF. DESIGN, SETTING, AND PARTICIPANTS: The Patient-Centered Disease Management (PCDM) trial was a multisite randomized clinical trial comparing a collaborative care PCDM intervention with usual care in patients with HF. A population-based sample of 392 patients with an HF diagnosis from 4 Veterans Affairs centers who had a Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score of less than 60 (heavy symptom burden and impaired functional status and quality of life) were enrolled between May 2009 and June 2011. INTERVENTIONS: The PCDM intervention included collaborative care by a multidisciplinary care team consisting of a nurse coordinator, cardiologist, psychiatrist, and primary care physician; home telemonitoring and patient self-management support; and screening and treatment for comorbid depression. MAIN OUTCOMES AND MEASURES: The primary outcome was change in the KCCQ overall summary score at 1 year (a 5-point change is clinically significant). Mortality, hospitalization, and depressive symptoms (Patient Health Questionnaire 9) were secondary outcomes. RESULTS: There were no significant differences in baseline characteristics between patients randomized to the PCDM intervention (n=187) vs usual care (n=197); baseline mean KCCQ overall summary scores were 37.9 vs 36.9 (P=.48). There was significant improvement in the KCCQ overall summary scores in both groups after 1 year (mean change, 13.5 points in each group), with no significant difference between groups (P=.97). The intervention was not associated with greater improvement in the KCCQ overall summary scores when the effect over time was estimated using 3-month, 6-month, and 12-month data (P=.74). Among secondary outcomes, there were significantly fewer deaths at 1 year in the intervention arm (8 of 187 [4.3%]) than in the usual care arm (19 of 197 [9.6%]) (P = .04). Among those who screened positive for depression, there was a greater improvement in the Patient Health Questionnaire 9 scores after 1 year in the intervention arm than in the usual care arm (2.1 points lower, P=.01). There was no significant difference in 1-year hospitalization rates between the intervention arm and the usual care arm (29.4% vs 29.9%, P=.87). CONCLUSIONS AND RELEVANCE: This multisite randomized trial of a multifaceted HF PCDM intervention did not demonstrate improved patient health status compared with usual care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00461513.

A pain research agenda for the 21st century.

UNLABELLED: Chronic pain represents an immense clinical problem. With tens of millions of people in the United States alone suffering from the burden of debilitating chronic pain, there is a moral obligation to reduce this burden by improving the understanding of pain and treatment mechanisms, developing new therapies, optimizing and testing existing therapies, and improving access to evidence-based pain care. Here, we present a goal-oriented research agenda describing the American Pain Society's vision for pain research aimed at tackling the most pressing issues in the field. PERSPECTIVE: This article presents the American Pain Society's view of some of the most important research questions that need to be addressed to advance pain science and to improve care of patients with chronic pain.

Changes in opioid prescribing for Washington workers' compensation claimants after implementation of an opioid dosing guideline for chronic noncancer pain: 2004 to 2010.

UNLABELLED: An opioid overdose epidemic emerged in the United States following increased opioid prescribing for chronic noncancer pain. In 2007, Washington State agencies implemented an opioid dosing guideline on safe prescribing for chronic noncancer pain. The objective of this population-based observational study was to evaluate opioid use and dosing before and after guideline implementation. We identified 161,283 workers aged 18 to 64 years with ≥1 opioid prescriptions in Washington Workers' Compensation, April 1, 2004, to December 31, 2010. Prevalence and incidence rates of opioid use were assessed. We compared pre- and postguideline chronic and high-dose use (≥120 mg/d) among incident users. The mean monthly prevalence of opioid use declined by 25.6% between 2004 (14.4%) and 2010 (10.7%). Fewer incident users went on to chronic opioid therapy in the postguideline period (4.7%; 95% confidence interval [CI], 4.5-5.0%) than in the preguideline period (6.3%; 95% CI, 6.1-6.6%). Compared with preguideline incident users, postguideline incident users were 35% less likely to receive high doses (adjusted odds ratio = .65; 95% CI, .59-.71). Although the extent to which decreases were due to the guidelines is uncertain, to our knowledge, this is the first report of significant decreases in chronic and high-dose prescription opioid use among incident users. PERSPECTIVE: Evidence-based strategies for opioid risk management are needed to help abate the epidemic of opioid-related morbidity and mortality. The study findings suggest that opioid dosing guidelines that specify a "yellow flag" dosing threshold may be a useful tool in preventing escalation of doses into ranges associated with increased mortality risk.

Opioid poisonings and opioid adverse effects in workers in Washington state.

OBJECTIVE: To examine trends in opioid poisonings and adverse effects in Washington (WA) State and nationally. METHODS: We calculated rates of opioid poisonings and adverse effects and examined opioid prescriptions in the WA workers' compensation system, 2004-2010. Using Health Care Cost and Utilization Project (HCUP), Nationwide Inpatient Sample (NIS) data, we also calculated national rates of opioid poisonings and adverse effects, 1993-2010. RESULTS: We identified 96 opioid poisonings and 312 opioid-related adverse effects in WA, 2004-2010. The rates did not change substantially over these years. Most poisonings and adverse effects occurred in cases without chronic opioid use and with prescribed doses <120 mg/day morphine-equivalent dose. Nationally, the rates of opioid poisonings and adverse effects increased significantly from 1993 to 2010. CONCLUSIONS: Many poisonings and adverse effects occurred in patients without high dose or long-term opioid therapy, suggesting that opioid dosing and duration guidelines may not be sufficient to reduce morbidity related to prescription opioid use.

Baseline comparison of three health utility measures and the feeling thermometer among participants in the Action to Control Cardiovascular Risk in Diabetes trial.

BACKGROUND: Health utility (HU) measures are used as overall measures of quality of life and to determine quality adjusted life years (QALYs) in economic analyses. We compared baseline values of three HUs including Short Form 6 Dimensions (SF-6D), and Health Utilities Index, Mark II and Mark III (HUI2 and HUI3) and the feeling thermometer (FT) among type 2 diabetes participants in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. We assessed relationships between HU and FT values and patient demographics and clinical variables. METHODS: ACCORD was a randomized clinical trial to test if intensive controls of glucose, blood pressure and lipids can reduce the risk of major cardiovascular disease (CVD) events in type 2 diabetes patients with high risk of CVD. The health-related quality of life (HRQOL) sub-study includes 2,053 randomly selected participants. Interclass correlations (ICCs) and agreement between measures by quartile were used to evaluate relationships between HU's and the FT. Multivariable regression models specified relationships between patient variables and each HU and the FT. RESULTS: The ICCs were 0.245 for FT/SF-6D, 0.313 for HUI3/SF-6D, 0.437 for HUI2/SF-6D, 0.338 for FT/HUI2, 0.337 for FT/HUI3 and 0.751 for HUI2/HUI3 (P < 0.001 for all). Common classification by quartile was found for the majority (62%) of values between HUI2 and HUI3, which was significantly (P < 0.001) higher than between other HUs and the FT: SF-6D/HUI3 = 40.8%, SF-6D/HUI2 = 40.9%, FT/HUI3 = 35.0%, FT/HUI2 = 34.9%, and FT/SF-6D = 31.9%. Common classification was higher between SF-6D/HUI2 and SF-6D/HUI3 (P < 0.001) than between FT/SF-6D, FT/HUI2, and FT/HUI3. The mean difference in HU values per patient ranged from -0.024 ± 0.225 for SF-6D/ HUI3 to -0.124 ± 0.133 for SF-6D/HUI2. Regression models were significant; clinical and demographic variables explained 6.1% (SF-6D) to 7.7% (HUI3) of the variance in HUs. CONCLUSIONS: The agreements between the different HUs were poor except for the two HUI measures; therefore HU values derived different measures may not be comparable. The FT had low agreement with HUs. The relationships between HUs and demographic and clinical measures demonstrate how severity of diabetes and other clinical and demographic factors are associated with HUs and FT measures. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00000620.

Long-term chronic opioid therapy discontinuation rates from the TROUP study.

OBJECTIVE: To report chronic opioid therapy discontinuation rates after five years and identify factors associated with discontinuation. METHODS: Medical and pharmacy claims records from January 2000 through December 2005 from a national private health network (HealthCore), and Arkansas (AR) Medicaid were used to identify ambulatory adult enrollees who had 90 days of opioids supplied. Recipients were followed until they discontinued opioid prescription fills or disenrolled. Kaplan Meier survival models and Cox proportional hazards models were estimated to identify factors associated with time until opioid discontinuation. RESULTS: There were 23,419 and 6,848 chronic opioid recipients followed for a mean of 1.9 and 2.3 years in the HealthCore and AR Medicaid samples. Over a maximum follow up of 4.8 years, 67.0% of HealthCore and 64.9% AR Medicaid recipients remained on opioids. Recipients on high daily opioid dose (greater than 120 milligrams morphine equivalent (MED)) were less likely to discontinue than recipients taking lower doses: HealthCore hazard ratio (HR) = 0.66 (95%CI: 0.57-0.76), AR Medicaid HR = 0.66 (95%CI: 0.50-0.82). Recipients with possible opioid misuse were also less likely to discontinue: HealthCore HR = 0.83 (95%CI: 0.78-0.89), AR Medicaid HR = 0.78 (95%CI: 0.67-0.90). CONCLUSIONS: Over half of persons receiving 90 days of continuous opioid therapy remain on opioids years later. Factors most strongly associated with continuation were intermittent prior opioid exposure, daily opioid dose ≥ 120 mg MED, and possible opioid misuse. Since high dose and opioid misuse have been shown to increase the risk of adverse outcomes special caution is warranted when prescribing more than 90 days of opioid therapy in these patients.

Descriptive study of partners' experiences of living with severe heart failure.

PURPOSE: This qualitative study sought to describe the experiences of living with severe heart failure (HF) from the perspective of the partner. METHODS: In-depth, semistructured interviews were conducted with 14 partners of individuals diagnosed with severe HF. Content analysis was performed to derive the main themes and subthemes of responses. RESULTS: Three main themes were derived from the data: (1) My Experience of HF in My Loved One, (2) Experience With Healthcare Providers, and the (3) Patient's Experience of HF as Perceived by the Partner. CONCLUSION: The severity of the patient's disease limited the partner's lifestyle, resulting in social isolation and difficulties in planning for the future for both the patient and the partner. The partners were unprepared to manage the disease burden at home without consistent information and assistance by healthcare providers. Moreover, end-of-life planning was neither encouraged by healthcare providers nor embraced by patients or partners.

An analysis of heavy utilizers of opioids for chronic noncancer pain in the TROUP study.

CONTEXT: Although opioids are increasingly used for chronic noncancer pain (CNCP), we know little about opioid dosing patterns among individuals with CNCP in usual care settings, and how these are changing over time. OBJECTIVES: To investigate the distribution of mean daily dose and mean days supply among patients with CNCP in two disparate populations, one national and commercially insured population (HealthCore) and one state based and publicly insured (Arkansas Medicaid), for years 2000 and 2005. METHODS: For individuals with any opioid use, we calculated the distribution of mean daily dose (in milligram morphine equivalents), mean days supply in a year, mean annual dose, and patient characteristics associated with heavy utilizers of opioids. RESULTS: Between 2000 and 2005, across all percentiles, there was little change in the mean daily opioid dose. In HealthCore, mean days supply increased most rapidly at the top end of the days supply distribution, whereas in Arkansas Medicaid, the greatest increases were near the median of days supply. In HealthCore, the top 5% of users accounted for 70% of total use (measured in milligram morphine equivalents), and the top 5% of Arkansas Medicaid users accounted for 48% of total use. The likelihood of heavy opioid utilization was increased among individuals with multiple pain conditions, and in HealthCore, among those with mental health and substance use disorders. CONCLUSION: Opioid use is heavily concentrated among a small percent of patients. The characteristics of these high utilizers need to be further established, and the benefits and risks of their treatment evaluated.

The prescribed opioids difficulties scale: a patient-centered assessment of problems and concerns.

OBJECTIVES: Chronic opioid therapy for chronic noncancer pain has increased dramatically in recent years. Research on associated risks has typically focused on opioid abuse and dependence, and opioid misuse or aberrant drug use behaviors, but these risks have been defined from the providers' perspective. The aim of this article was to develop a psychometrically sound method for assessing difficulties patients attribute to chronic opioid therapy. METHODS: A cross-sectional, observational study of patients prescribed opioids for chronic noncancer pain was conducted in a large integrated service delivery network in Washington State. Data were obtained from a phone interview and electronic health records including pharmacy data. Exploratory and confirmatory factor analyses were conducted using a split sample design. RESULTS: The interview response rate was 56.5% and a total of 1144 patients were included in analyses. A 2 factor solution was obtained and replicated with excellent fit statistics. Two correlated factors were identified-opioid control concerns and psychosocial problems-with 50% of the sample reporting difficulties with prescribed opioids: 24% reported elevated psychosocial problems and 36% reported elevated concerns about controlling their use of prescribed opioids. DISCUSSION: The Prescribed Opioid Difficulties Scale identifies common difficulties that patients ascribe to chronic opioid therapy. This scale may provide both an entry point and a framework for a patient-centered clinical dialog about the pros and cons of use of opioid medicines for managing chronic pain.

Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and medicaid insurance plans: The TROUP Study.

The use of chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) has increased dramatically in the past two decades. There has also been a marked increase in the abuse of prescribed opioids and in accidental opioid overdose. Misuse of prescribed opioids may link these trends, but has thus far only been studied in small clinical samples. We therefore sought to validate an administrative indicator of opioid misuse among large samples of recipients of COT and determine the demographic, clinical, and pharmacological risks associated with possible and probable opioid misuse. A total of 21,685 enrollees in commercial insurance plans and 10,159 in Arkansas Medicaid who had at least 90 days of continuous opioid use 2000-2005 were studied for one year. Criteria were developed for possible and probable opioid misuse using administrative claims data concerning excess days supplied of short-acting and long-acting opioids, opioid prescribers and opioid pharmacies. We estimated possible misuse at 24% of COT recipients in the commercially insured sample and 20% in the Medicaid sample and probable misuse at 6% in commercially insured and at 3% in Medicaid. Among non-modifiable factors, younger age, back pain, multiple pain complaints and substance abuse disorders identify patients at high risk for misuse. Among modifiable factors, treatment with high daily dose opioids (especially >120 mg MED per day) and short-acting Schedule II opioids appears to increase the risk of misuse. The consistency of the findings across diverse patient populations and the varying levels of misuse suggest that these results will generalize broadly, but await confirmation in other studies.

Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the TROUP study.

OBJECTIVES: Use of prescription opioids for chronic pain is increasing, as is abuse of these medications, though the nature of the link between these trends is unclear. These increases may be most marked in patients with mental health (MH) and substance use disorders (SUDs). We analyzed trends between 2000 and 2005 in opioid prescribing among individuals with noncancer pain conditions (NCPC), with and without MH and SUDs. METHODS: Secondary data analysis of longitudinal administrative data from 2 dissimilar populations: a national, commercially insured population and Arkansas Medicaid enrollees. We examined these opioid outcomes: (1) rates of any prescription opioid use in the past year, (2) rates of chronic use of prescription opioids (greater than 90 d in the past year), (3) mean days supply of opioids, (4) mean daily opioid dose in morphine equivalents, and (5) percentage of total opioid dose that was Schedule II opioids. RESULTS: In 2000, among individuals with NCPC, chronic opioid use was more common among those with a MH or SUD than among those without in commercially insured (8% vs. 3%, P<0.001) and Arkansas Medicaid (20% vs. 13%, P<0.001) populations. Between 2000 and 2005, in commercially insured, rates of chronic opioid use increased by 34.9% among individuals with an MH or SUD and 27.8% among individuals without these disorders. In Arkansas Medicaid chronic, opioid use increased by 55.4% among individuals with an MH or SUD and 39.8% among those without. DISCUSSION: Chronic use of prescription opioids for NCPC is much higher and growing faster in patients with MH and SUDs than in those without these diagnoses. Clinicians should monitor the use of prescription opioids in these vulnerable groups to determine whether opioids are substituting for or interfering with appropriate MH and substance abuse treatment.

Age and sex trends in long-term opioid use in two large American health systems between 2000 and 2005.

OBJECTIVE: To estimate recent age- and sex-specific changes in long-term opioid prescription among patients with chronic pain in two large American Health Systems. DESIGN: Analysis of administrative pharmacy data to calculate changes in prevalence of long-term opioid prescription (90 days or more during a calendar year) from 2000 to 2005, within groups based on sex and age (18-44, 45-64, and 65 years and older). Separate analyses were conducted for patients with and without a diagnosis of a mood disorder or anxiety disorder. Changes in mean dose between 2000 and 2005 were estimated, as were changes in the rate of prescription for different opioid types (short-acting, long-acting, and non-Schedule 2). PATIENTS: Enrollees in HealthCore (N = 2,716,163 in 2000) and Arkansas Medicaid (N = 115,914 in 2000). RESULTS: Within each of the age and sex groups, less than 10% of patients with a chronic pain diagnosis in HealthCore, and less than 33% in Arkansas Medicaid, received long-term opioid prescriptions. All age, sex, and anxiety/depression groups showed similar and statistically significant increases in long-term opioid prescription between 2000 and 2005 (35-50% increase). Per-patient daily doses did not increase. CONCLUSIONS: No one group showed especially large increases in long-term opioid prescriptions between 2000 and 2005. These results argue against a recent epidemic of opioid prescribing. These trends may result from increased attention to pain in clinical settings, policy or economic changes, or provider and patient openness to opioid therapy. The risks and benefits to patients of these changes are not yet established.

Characteristics of patients with chronic pain accessing treatment with medical cannabis in Washington State.

OBJECTIVES: This study was conducted to better understand the characteristics of chronic pain patients seeking treatment with medicinal cannabis (MC). DESIGN: Retrospective chart reviews of 139 patients (87 males, median age 47 years; 52 females, median age 48 years); all were legally qualified for MC use in Washington State. SETTING: Regional pain clinic staffed by university faculty. INCLUSION CRITERIA: age 18 years and older; having legally accessed MC treatment, with valid documentation in their medical records. All data were de-identified. MAIN OUTCOME MEASURES: Records were scored for multiple indicators, including time since initial MC authorization, qualifying condition(s), McGill Pain score, functional status, use of other analgesic modalities, including opioids, and patterns of use over time. RESULTS: Of 139 patients, 15 (11 percent) had prior authorizations for MC before seeking care in this clinic. The sample contained 236.4 patient-years of authorized MC use. Time of authorized use ranged from 11 days to 8.31 years (median of 1.12 years). Most patients were male (63 percent) yet female patients averaged 0.18 years longer authorized use. There were no other gender-specific trends or factors. Most patients (n = 123, 88 percent) had more than one pain syndrome present. Myofascial pain syndrome was the most common diagnosis (n = 114, 82 percent), followed by neuropathic pain (n = 89, 64 percent), discogenic back pain (n = 72, 51.7 percent), and osteoarthritis (n = 37, 26.6 percent). Other diagnoses included diabetic neuropathy, central pain syndrome, phantom pain, spinal cord injury, fibromyalgia, rheumatoid arthritis, HIV neuropathy, visceral pain, and malignant pain. In 51 (37 percent) patients, there were documented instances of major hurdles related to accessing MC, including prior physicians unwilling to authorize use, legal problems related to MC use, and difficulties in finding an affordable and consistent supply of MC. CONCLUSIONS: Data indicate that males and females access MC at approximately the same rate, with similar median authorization times. Although the majority of patient records documented significant symptom alleviation with MC, major treatment access and delivery barriers remain.

Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders.

Long-term opioid therapy for non-cancer pain has increased. Caution is advised in prescribing for persons with substance use disorders, but little is known about actual health plan practices. This paper reports trends and characteristics of long-term opioid use in persons with non-cancer pain and a substance abuse history. Using health plan data (1997-2005), the study compared age-sex-standardized rates of incident, incident long-term and prevalent long-term prescription opioid use, and medication use profiles in those with and without substance use disorder histories. The CONsortium to Study Opioid Risks and Trends study included adult enrollees of two health plans, Kaiser Permanente of Northern California (KPNC) and Group Health Cooperative (GH) of Seattle, Washington. At KPNC (1999-2005), prevalence of long-term use increased from 11.6% to 17.0% for those with substance use disorder histories and from 2.6% to 3.9% for those without substance use disorder histories. Respective GH rates (1997-2005), increased from 7.6% to 18.6% and from 2.7% to 4.2%. Among persons with an opioid disorder, KPNC rates increased from 44.1% to 51.1%, and GH rates increased from 15.7% to 52.4%. Long-term opioid users with a prior substance abuse diagnosis received higher dosage levels, were more likely to use Schedule II and long-acting opioids, and were more often frequent users of sedative-hypnotic medications in addition to their opioid use. Since these patients are viewed as higher risk, the increased use of long-term opioid therapy suggests the importance of improved understanding of the benefits and risks of opioid therapy among persons with a history of substance abuse, and the need for more careful screening for substance abuse history than is the usual practice.