[Prehospital emergency care of patients exposed to poisoning: Assessment of epidemiological, clinical characteristics and quality of care]. / Atención prehospitalaria urgente de los pacientes pediátricos expuestos a tóxicos: características epidemiológico-clínicas y evaluación de la calidad asistencial.

OBJECTIVE: To describe the characteristics of paediatric patients with suspected poisoning treated by advanced life support (ALS) units, and to evaluate quality indicators (QI) for the prehospital emergency care of these patients. METHOD: A one-year observational study of patients under 18 years of age exposed to poisoning and treated by an ALS unit of the Medical Emergency System in Catalonia. Severe clinical criteria were defined, with 8 QI being evaluated for prehospital emergency care of poisoned paediatric patients. RESULTS: The study included a total of 254 patients, with a median age of 14 years-old (p25-75 = 7-16), with intentional poisoning in 50.8% of cases. The most frequently involved toxic agent was carbon monoxide (CO) (33.8%). Poisoning was found in 48.8% of those patients, being serious in 16.5%. Intentionally (OR 5.1; 95% CI: 1.9-13.8) and knowledge of the time of exposure (OD 3.1; 95% CI: 1.3-7.3) were independent risk factors associated with the appearance of severe clinical symptoms. Five QI did not reach the quality standard and included, availability of specific clinical guidelines, activated charcoal administration in selected patients, oxygen therapy administration at maximum possible concentration in carbon monoxide poisoning, electrocardiographic assessment in patients exposed to cardiotoxic substances, and recording of the minimum data set. CONCLUSIONS: Paediatric patients attended by ALS units showed specific characteristics, highlighting the involvement of CO and adolescents with voluntary poisoning. The QI assessment was useful to detect weak points in the quality of care of these patients and to develop strategies for improvement.

The opioid crisis: Origins, trends, policies, and the roles of pharmacists.

PURPOSE: The purpose of this review is to (1) provide information concerning the opioid crisis including origins, trends, and some important related laws/policies; and (2) summarize the current involvement and impact of pharmacists in helping to address the crisis, as well as examine practices in other healthcare disciplines from which pharmacists might derive guidance and strategies. SUMMARY: Contributors to the opioid crisis included campaigns to treat pain as a fifth vital sign and to use opioids in treatment of non-cancer-related pain, as well as aggressive marketing of opioid analgesics by pharmaceutical companies. To address the crisis, numerous strategies have been implemented at the policy/legislative, health-system, and patient levels, such as prescription drug monitoring programs (PDMPs), increased regulation of pain clinics, and expanded use of naloxone. Pharmacists have a critical role to play in interventions to address opioid misuse and reduce harm resulting from misuse. Such interventions include patient screening and risk stratification, patient and community education and outreach concerning appropriate pain management, medication reviews/medication therapy management, education on safe storage and disposal, distribution of naloxone/opioid rescue kits and training on their proper use, and referral of patients to addiction treatment, among other strategies. CONCLUSION: Pharmacists have multiple, complex roles in addressing the opioid crisis. Outcomes of several studies provide substantial evidence that pharmacists can make an impact through appropriate pain management, use of PDMPs, opioid overdose prevention training, and medication reviews and counseling, among other interventions.

Antimicrobial use-related problems and their costs in surgery ward of Jimma University Medical Center: Prospective observational study.

INTRODUCTION: Antibiotics are among the most commonly misused of all drugs, which results in antibiotic resistance and waste of resources and it has not been studied in Ethiopia. Therefore, this study was carried out to assess antibiotic use-related problems and their costs among patients hospitalized at the surgical ward of Jimma University Medical Center. METHODS: Hospital-based prospective observational study was used to assess the prevalence, cost, and determinants of antibiotic use-related problems; multiple stepwise backward logistic regression analysis was done for a P value of < 0.25 to look for predictors of antibiotic use-related problems. Written informed consent was obtained and confidentiality was secured. RESULTS: Among 300 participants, antibiotic use-related problems (ABURPs) were found in 69.3% of the study participants. The direct total cost attributed to these problems was approximated to a minimum of 2230.15 US$. Independent predictors for antibiotic use-related problems were: indication for antibiotic use like: use of antibiotic for prophylaxis; p < 0.0001, antibiotic use for both therapeutic & prophylaxis; p < 0.0001, CDC wound class I and II; p = 0.016 and; p = 0.002 respectively, overall poly-pharmacy and greater than 2 antibiotic exposure during hospital stay; p = 0.019and p = 0.006 respectively and hospital stay for ≥21 days; p = 0.007. CONCLUSION: The prevalence of antibiotic use-related problems was high and resulted in extra cost. Antibiotic use for prophylaxis, prophylaxis, and treatment, poly-pharmacy, greater than 2 antibiotic exposures during the hospital stay, CDC wound class I and II, and duration of hospital stay of ≥ 21 days was found to be independent predictors of antibiotic use-related problems.

Polifarmacia en adulto mayor, impacto en su calidad de vida: revision de literatura / Polypharmacy in older adults and impact on their quality of life: literature review / Polifarmácia em idosos, impacto em sua qualidade de vida: revisão da literatura

RESUMEN: Objetivo: Conocer mediante el análisis del estado del conocimiento, el impacto de polifarmacia en calidad de vida de adultos mayores y cuál ha sido el rol de enfermería frente a esta problemática de salud. Métodos: Revisión descriptiva de 62 artículos originales de diversos diseños metodológicos, en bases de datos: EBSCO, PubMed, Web of Science, SciELO, Elsevier, SCOPUS y Dialnet. Resultados: La polifarmacia en adultos mayores se presenta con mayor frecuencia en el sexo femenino, en personas con bajo nivel de escolaridad, sumados a factores socioeconómico. Un gran porcentaje de adultos mayores presenta efecto cascada en consumo de fármacos, por cantidad de medicamentos consumidos y número de médicos consultados, produciendo interacciones farmacológicas, afectando funcionalidad y calidad de vida. Conclusiones: Es necesario mayor control de medicamentos consumidos por adultos mayores, para evitar efectos nocivos. Los profesionales de enfermería deben tener un rol educativo en este grupo etario, para disminuir polifarmacia e impulsar estilos de vida que fomenten el envejecimiento saludable.(AU)

ABSTRACT: Objective: To know, by analyzing the state of knowledge, the impact of the polypharmacy on the quality of life of older adults and the role of nursing when dealing with this health problem. Materials and Methods: Descriptive review of 62 original articles with multiple methodological designs, in the databases EBSCO, PubMed, Web of Science, SciELO, Elsevier, SCOPUS and Dialnet. Results: Polypharmacy in older adults is more frequent in the female sex and people with low level of education, and is associated with socioeconomic factors. A large percentage of older adults present with prescription cascade due to the amount of drugs consumed and the number of doctors consulted, leading to pharmacological interactions that affect functionality and quality of life. Conclusions: More control of drugs consumed by older adults is needed to avoid harmful effects. Nursing professionals should have an educational role in this age group to reduce polypharmacy and promote lifestyles that foster healthy ageing.(AU)

RESUMO: Objetivo: Conhecer, através da análise do estado do conhecimento, o impacto da polifarmácia na qualidade de vida do idoso e qual o papel da enfermagem diante desse problema de saúde. Métodos: Revisão descritiva de 62 artigos originais de vários desenhos metodológicos, nas bases de dados: EBSCO, PubMed, Web of Science, SciELO, Elsevier, SCOPUS e Dialnet. Resultados: A polifarmácia em idosos ocorre mais frequentemente no sexo feminino, em pessoas com baixa escolaridade, somada a fatores socioeconômicos. Uma grande porcentagem de idosos apresenta efeito cascata no consumo de medicamentos, pela quantidade de medicamentos consumidos e número de médicos consultados, produzindo interações farmacológicas, afetando a funcionalidade e a qualidade de vida. Conclusões: É necessário um maior controle dos medicamentos consumidos por idosos para evitar efeitos nocivos. Os profissionais de enfermagem devem ter papel educativo nessa faixa etária, para diminuir a polifarmácia e promover estilos de vida que promovam o envelhecimento saudável.(AU)

Economic Conditions and Drug and Opioid Overdose Deaths.

We examine the effects of state-level economic conditions including unemployment rates, median house price, median household income, insurance coverage, and annual and weekly work time on deaths on drug overdose deaths including from opioids and prescription opioids between 1999 and 2014. We employ difference-in-differences estimation controlling for state and year fixed effects, state-specific time trends, and demographic characteristics. Drug overdose deaths significantly declined with higher house prices, an effect driven by reduction in prescription-opioid mortality, by nearly 0.17 deaths per 100,000 (~4%) with a $10,000 increase in median house price. House price effects were more pronounced and only significant among males, non-Hispanic Whites, and individuals younger 45 years. Other economic indicators had insignificant effects. Our findings suggest that economic downturns that substantially reduce house prices such as the Great Recession can increase opioid-related deaths, suggesting that efforts to control access to such drugs should especially intensify during these periods.

Integrating Public Health and Health Care Strategies to Address the Opioid Epidemic: The Oregon Health Authority's Opioid Initiative.

CONTEXT: Oregon is experiencing an opioid overdose epidemic, similar to the United States as a whole. To address this crisis, the Oregon Health Authority (OHA) implemented a strategic Opioid Initiative, convening stakeholders and integrating public health and health care system activities across sectors. Recent data indicate progress: from 2015 to 2016, Oregon had the sharpest decline in prescription opioid overdose deaths of any state. PROGRAM: The Opioid Initiative, launched in 2015, focuses on integrating efforts to improve patient care and safety, and population health, by increasing access to nonopioid pain treatment, supporting medication-assisted treatment and naloxone access for people taking opioids, decreasing opioid prescribing, and using data to inform policies and interventions. IMPLEMENTATION: Four OHA projects highlight the integration: (1) a Medicaid Coordinated Care Organization Performance Improvement Project focused on decreasing risky opioid prescribing; (2) Health Evidence Review Commission guidelines that set coverage standards for opioid and nonopioid back pain treatments for Medicaid recipients; (3) statewide opioid prescribing guidelines; and (4) an opioid data dashboard. Each project involves a partnership between governmental public health, public and private health care systems, and external stakeholders. PROGRESS: From 2015 to 2017, the number of Oregonians on 90 or more Morphine Equivalent Doses (MEDs) decreased by 37%, from 11.1 per 1000 residents quarterly to 7.0 per 1000 residents quarterly. Prescription opioid overdose deaths decreased 20% from 4.5 per 100 000 in 2015 to 3.6 per 100 000 in 2016. Within the Medicaid population, the percentage of clients on 120 or more MEDs for 30 consecutive days decreased 27%, from 2.3% in December 2015 to 1.6% in September 2017. DISCUSSION: Oregon's integrated approach to address the opioid crisis spans public health and health care systems, engages key stakeholders, and uses data and evidence to inform policies. The progress to date is promising and may assist other states seeking to identify effective strategies to decrease opioid prescribing, misuse, and overdose.

Drug Misuse and Hepatitis C Virus Infection Profiles for Three Generations of Patients Being Monitored for Prescription Drug Adherence.

OBJECTIVES: Two epidemics in the United States are related: opioid drug injection and hepatitis C virus (HCV) infection. This study quantifies the relationship between illicit/prescription drug misuse and HCV infection in 3 population generations: baby boomers (born 1945-1965, inclusive), pre-baby boomers, and post-baby boomers. METHODS: This retrospective study included prescription drug consistency (March-December 2015) and HCV (2011-2015) patient test results performed at a large national clinical reference laboratory. HCV positivity, drug use consistency/inconsistency with prescribed drug information, type of inconsistent use, and inconsistent use of individual drug classes were assessed. RESULTS: This study evaluated 39,231 prescription drug monitoring and HCV sets of test results from 18,410 patients. Of these patients, 25.1% tested positive for HCV and 57.3% demonstrated drug test results that were inconsistent with the prescribed medication(s). The types of drug test inconsistency differed substantially between HCV-positive and -negative patients, particularly testing positive for both non-prescribed drugs and prescribed drugs. Specimens from HCV-positive baby boomer and post-baby boomers demonstrated non-prescribed use of opioids and many other drug classes more often than from HCV-negative patients. CONCLUSIONS: The rates of inconsistent drug test results and types of drugs misused suggest that HCV-positive patients are more likely than HCV-negative patients to display high-risk behavior, even beyond opioid use. This difference is most pronounced in the post-baby boomer generation. Healthcare professionals should consider these patterns and how they differ by generation when monitoring for both prescription and illicit drugs, the results of which can impact treatment decisions including prescribing analgesics.

A community pharmacy intervention for opioid medication misuse: A pilot randomized clinical trial.

OBJECTIVES: Community pharmacy continues to play a crucial role in the national response to the opioid epidemic. The purpose of this article is to describe the protocol for a pilot study that is examining the feasibility and acceptability of the Motivational Intervention-Medication Therapy Management (MI-MTM) model. This study also examines the preliminary clinical effect of MI-MTM for improving opioid medication misuse and patient activation in self-management of health conditions that increase risk for misuse. DESIGN: MI-MTM is a pharmacy-based integrated care model made up of 4 evidence-based practices: medication therapy management; brief motivational intervention; patient navigation; and naloxone training and referral. To test MI-MTM compared with Standard Medication Counseling (SMC), we are conducting a 2-group randomized single-blinded controlled trial with assessments at 3 time points. SETTING AND PARTICIPANTS: The study is being conducted within a western Pennsylvania university-based community pharmacy with 46 patients with opioid misuse (MI-MTM = 23; SMC = 23). MAIN OUTCOME MEASURES: Feasibility will be measured by capturing patient completion rate of MI-MTM sessions. Acceptability will be measured by administering satisfaction surveys regarding pharmacist and patient navigator services. Acceptability will also be captured by conducting intensive qualitative interviews. Preliminary effect of the intervention on misuse will be measured with the use of the Prescription Opioid Misuse Index and the Opioid Compliance Checklist. Activation in self-management will be measured with the use of the Patient Activation Measure. RESULTS: This project is currently recruiting, and results are to come. CONCLUSION: This study is the first in the United States to implement an evidence-based integrated behavioral intervention into the community pharmacy setting to address opioid medication misuse among pharmacy patients. The results of this study will provide necessary foundational data that allow further testing of this intervention model in a larger trial.

Abuse liability assessment for biologic drugs - All molecules are not created equal.

The development of novel drug candidates involves the thorough evaluation of potential efficacy and safety. To facilitate the safety assessment in light of global increases in prescription drug misuse/abuse, health authorities have developed guidance documents which provide a framework for evaluating the abuse liability of candidate therapeutics. The guidances do not distinguish between small molecules and biologics/biotherapeutics; however, there are key differences between these classes of therapeutics which are important drivers of concern for abuse. An analysis of these properties, including ability to distribute to the central nervous system, pharmacokinetic properties (e.g., half-life and metabolism), potential for off-target binding, and the physiochemical characteristics of biologic drug products suggests that the potential for abuse of a biologic is limited. Many marketed antibodies and recombinant proteins have been associated with adverse effects such as headache and dizziness. However, biologics have not historically engendered the rapid-onset psychoactive effects typically present for drugs of abuse, thus further underscoring their low risk for abuse potential. The factors to be taken into consideration before conducting nonclinical abuse liability studies with biologics are described herein; importantly, the aggregate assessment of these factors leads to the conclusion that abuse liability studies are unlikely to be necessary for this class of therapeutics.

Association of Prescription Drug Monitoring Program Use With Opioid Prescribing and Health Outcomes: A Comparison of Program Users and Nonusers.

Prescription drug monitoring programs (PDMPs) are a response to the prescription opioid epidemic, but their effects on prescribing and health outcomes remain unclear, with conflicting reports. We sought to determine if prescriber use of Oregon's PDMP led to fewer high-risk opioid prescriptions or overdose events. We conducted a retrospective cohort study from October 2011 through October 2014, using statewide PDMP data, hospitalization registry, and vital records. Early PDMP registrants (n = 927) were matched with clinicians who never registered during the study period, using baseline prescribing metrics in a propensity score. Generalized estimating equations were used to examine prescribing trends after PDMP registration, using 2-month intervals. We found a statewide decline in measures of per capita opioid prescribing. However, compared with nonregistrants, PDMP registrants did not subsequently have significantly fewer patients receiving high-dose prescriptions, overlapping opioid and benzodiazepine prescriptions, inappropriate prescriptions, prescriptions from multiple prescribers, or overdose events. At baseline, frequent PDMP users wrote fewer high-risk opioid prescriptions than infrequent users; this persisted during follow-up with few significant group differences in trend. Thus, although opioid prescribing declined statewide after implementing the PDMP, registrants did not show greater declines than nonregistrants. PERSPECTIVE: Factors other than PDMP use may have had greater influence on prescribing trends. Refinements in the PDMP program and related policies may be necessary to increase PDMP effects.

Opioid Use for Pain Management After Implementation of a Medicaid Short-Acting Opioid Quantity Limit.

BACKGROUND: The United States is currently experiencing an opioid abuse epidemic. Many policies and programs have been implemented at local, state, and national levels in an attempt to decrease prescription opioid addiction and overdose. On August 1, 2014, Colorado Medicaid implemented a policy change that limited the quantity of short-acting opioids (SAOs) that could be filled through the Medicaid benefit to no more than 4 tablets per day, or 120 tablets in 30 days. OBJECTIVE: To compare mean total daily dose (TDD) of opioids purchased by Kaiser Permanente Colorado (KPCO) Medicaid patients before and after implementation of the Medicaid SAO quantity limit. METHODS: This investigation used a pre/post study design to compare opioid use in Medicaid-eligible patients during the 90 days before implementation of the Medicaid quantity limit on August 1, 2014, and 90 days after full implementation of the change on December 31, 2014. The study was conducted at KPCO, an integrated care delivery system providing medical care for approximately 615,000 patients, of which over 54,000 are Medicaid members. Electronic medical and pharmacy records were used to identify patients and assess medication use. RESULTS: There was a small difference in opioid use in the population of Medicaid opioid users as evidenced by the median TDD of oral morphine equivalents (OME) purchased decreasing from 6.8 mg (IQR = 2.2-25.8) in the pre-implementation period to 6.6 mg (IQR = 1.7-24.0) in the postimplementation period (P = 0.027). The proportion of patients purchasing more than 120 mg OME per day and the proportion of patients purchasing long-acting opioids (LAOs) did not change significantly from the pre- to postimplementation period (OME > 120 of 4.2% vs. 3.6%, respectively, P = 0.290; LAO use of 12.9% vs. 13.6%, respectively, P = 0.465). CONCLUSIONS: This study found a statistically significant 3% decrease of 0.2 mg OME per day in the primary study population. A 24% reduction of 10 mg OME per day before and after implementation of the Medicaid SAO quantity limit was found in those patients identified as exceeding the Medicaid SAO quantity limit at baseline. These patients tended to be purchasing low to moderate total daily doses of opioids at baseline. DISCLOSURES: Internal funding was provided by the Department of Pharmacy at Kaiser Permanente Colorado. There are no external funding sources to disclose. Riggs, Milchak, Patel, and Heilmann are employed by Kaiser Permanente Colorado. The authors report no other potential conflicts of interest. Study concept and design were contributed by Riggs, Heilmann, and Billups, along with the other authors. Billups collected the data, and data interpretation was performed by Riggs, Milchak, and Flores, with assistance from the other authors. The manuscript was written primarily by Riggs, along with Flores, and revised by Billups, Milchak, Patel, and Heilmann.

Opioid Use Disorder and Pregnancy.

Over-prescription of opioid pain medications and increases in heroin use have contributed to the sharp rise in opioid-related hospitalizations and overdose deaths among young adults in the United States, including pregnant women. This has imposed substantial direct and indirect costs to our nation's health care system. Effective treatment with methadone and buprenorphine is available, but significant barriers to care may restrict access for many. Improved screening tools and expanded access to treatments for substance use disorders are keys to addressing the epidemic of opioid use disorder.

Prescription Opioid Misuse, Abuse, and Treatment in the United States: An Update.

OBJECTIVE: Prescription opioid abuse and dependence have escalated rapidly in the United States over the past 20 years, leading to high rates of overdose deaths and a dramatic increase in the number of people seeking treatment for opioid dependence. The authors review the scope of the abuse and overdose epidemic, prescription practices, and the assessment, treatment, and prevention of prescription opioid misuse and dependence. METHOD: The authors provide an overview of the literature from 2006 to the present, with the twin goals of highlighting advances in prevention and treatment and identifying remaining gaps in the science. RESULTS: A number of policy and educational initiatives at the state and federal government level have been undertaken in the past 5 years to help providers and consumers, respectively, prescribe and use opioids more responsibly. Initial reports suggest that diversion and abuse levels have begun to plateau, likely as a result of these initiatives. While there is a large body of research suggesting that opioid substitution coupled with psychosocial interventions is the best treatment option for heroin dependence, there is limited research focusing specifically on the treatment of prescription opioid dependence. In particular, the treatment of chronic pain in individuals with prescription opioid use disorders is underexplored. CONCLUSIONS: While policy and educational initiatives appear to be effective in decreasing prescription opioid abuse and misuse, research focusing on the development and evaluation of treatments specific to prescription opioid dependence and its common comorbidities (e.g., chronic pain, depression) is critically needed.

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.

Medicine 'misuse': Implications for health and environmental sustainability.

Recent decades have witnessed a global rise in the use of medical pharmaceuticals to combat disease. However, estimates suggest that over half of all medicines are prescribed, dispensed or sold inappropriately, and that half of all patients fail to take them as directed. Bringing together research from across the medical, natural and social sciences, this paper considers what we know about the causes, impacts and implications of medicine misuse in relation to health, the sustainable use of pharmaceuticals and their unintended effects in the environment. We suggest that greater insight and understanding of medicine misuse can be gained by integrating the biomedical-focused approaches used in public health with approaches that consider the social and environmental determinants of medical prescribing and consuming practices.

The Burden of Undiagnosed Opioid Abuse Among Commercially Insured Individuals.

OBJECTIVES: Estimate the prevalence and healthcare costs of undiagnosed opioid abuse among commercially insured individuals. STUDY DESIGN: Retrospective analysis of de-identified pharmacy and medical claims data and publicly-available survey data (no IRB approval required). METHODS: This study focused on commercially insured individuals. Rates of prescription pain-reliever abuse/dependence ("abuse") among individuals ages ≥12 were calculated using National Survey on Drug Use and Health (NSDUH) public-use data for 2006-2011 and assumed to capture both diagnosed and undiagnosed opioid abuse. Rates of undiagnosed opioid abuse were calculated as the difference between NSDUH rates and published rates of diagnosed opioid abuse. OptumHealth Reporting and Insights claims data were used to estimate the healthcare costs of undiagnosed abuse. Diagnosed abusers ages 12-64 were identified using ICD-9-CM diagnosis codes for opioid abuse/dependence. Pre-diagnosis costs were assumed to be a proxy for undiagnosed opioid abuse costs. The ratio of undiagnosed to diagnosed abuse costs was calculated as the ratio of annual per-patient healthcare costs between pre-diagnosis and post-diagnosis periods. RESULTS: While rates of diagnosed opioid abuse among commercially insured individuals increased from 0.07% in 2006 to 0.19% in 2011, rates of undiagnosed abuse decreased from 0.42% to 0.38% over the same time period. Annual per-patient healthcare costs of undiagnosed abusers were 69.2% of those of diagnosed abusers. CONCLUSIONS: Per-patient healthcare costs of undiagnosed abusers among the commercially insured are estimated to be lower than those of diagnosed abusers. However, the higher prevalence of undiagnosed opioid abuse implies that undiagnosed abuse represents a substantial burden to commercial payers.

Opioid education and nasal naloxone rescue kits in the emergency department.

INTRODUCTION: Emergency departments (EDs) may be high-yield venues to address opioid deaths with education on both overdose prevention and appropriate actions in a witnessed overdose. In addition, the ED has the potential to equip patients with nasal naloxone kits as part of this effort. We evaluated the feasibility of an ED-based overdose prevention program and described the overdose risk knowledge, opioid use, overdoses, and overdose responses among participants who received overdose education and naloxone rescue kits (OEN) and participants who received overdose education only (OE). METHODS: Program participants were surveyed by telephone after their ED visit about their substance use, overdose risk knowledge, history of witnessed and personal overdoses, and actions in a witnessed overdose including use of naloxone. RESULTS: A total of 415 ED patients received OE or OEN between January 1, 2011 and February 28, 2012. Among those, 51 (12%) completed the survey; 37 (73%) of those received a naloxone kit, and 14 (27%) received OE only. Past 30-day opioid use was reported by 35% OEN and 36% OE, and an overdose was reported by 19% OEN and 29% OE. Among 53% (27/51) of participants who witnessed another individual experiencing an overdose, 95% OEN and 88% OE stayed with victim, 74% OEN and 38% OE called 911, 26% OEN and 25% OE performed rescue breathing, and 32% OEN (n=6) used a naloxone kit to reverse the overdose. We did not detect statistically significant differences between OEN and OE-only groups in opioid use, overdose or response to a witnessed overdose. CONCLUSION: This is the first study to demonstrate the feasibility of ED-based opioid overdose prevention education and naloxone distribution to trained laypersons, patients and their social network. The program reached a high-risk population that commonly witnessed overdoses and that called for help and used naloxone, when available, to rescue people. While the study was retrospective with a low response rate, it provides preliminary data for larger, prospective studies of ED-based overdose prevention programs.