Prescribing Patterns and Use of Risk-Reduction Tools After Implementing an Opioid-Prescribing Protocol.

BACKGROUND: The literature on results from primary care-based opioid-prescribing protocols is small and results have been mixed. To advance this field, we evaluated whether opioid prescribing changed after a comprehensive protocol was implemented and whether change was associated with the number and type of risk reduction tools adopted. METHODS: Electronic medical record data were obtained for 2607 patients. Demographics, Patient Health Questionnaire-9 scores, body mass index, and utilization levels of protocol elements were measured for 24 months prior and 18 months post implementation of an opioid-prescribing protocol within a federally qualified health center. χ2 and t-tests were computed to estimate change in opioid prescribing, morphine-equivalent dose, comedication prescribing, and number and type of protocol elements utilized. RESULTS: The opioid protocol was associated with an increase in urine drug screens from 18.3% to 26.8% from pre to postimplementation (P < .0001). There was no significant increase in opioid treatment agreements. Tramadol (21.4% to 16.8%, P = .0006) and antidepressant (56.0% to 51.6%, P = .012) prescribing significantly decreased. Total opioid prescriptions and maximum morphine-equivalent doses were similar from pre to postimplementation. Protocol elements were more often used when patients had a higher opioid dose and were receiving benzodiazepines. CONCLUSIONS: Implementing a multi-faceted opioid-prescribing protocol was not associated with change in number or dose of opioid prescriptions but was associated with greater use of urine drug screens, and risk reduction tools were used more often in high-risk patients. Implementation research is needed to identify barriers to maximizing adherence to opioid protocols.

The association between depression and type of treatments received for chronic low back pain.

BACKGROUND: Depression is associated with receipt of opioids in non-cancer pain. OBJECTIVES: To determine whether the receipt of opioid therapy modifies the relationship of depression and use of multiple non-opioid pain treatments. METHODS: Patients (n = 320) with chronic low back pain (CLBP) were recruited from family medicine clinics and completed questionnaires that measured use of home remedies, physical treatments requiring a provider and non-opioid medication treatments. A binary variable defined use (yes/no) of all three non-opioid treatment categories. Depression (yes/no) was measured with the PHQ-2. The use of opioids (yes/no) was determined by medical record abstraction. Unadjusted and adjusted logistic regression models, stratified on opioid use, estimated the association between depression and use of all three non-opioid treatments. RESULTS: Participants were mostly female (71.3%), non-white (57.5%) and 69.4% were aged 18 to 59 years. In adjusted analyses stratified by opioid use, depression was not significantly associated with using three non-opioid treatments (OR = 2.20; 95% CI = 0.80-6.07) among non-opioid users; but among opioid users, depression was significantly associated with using three non-opioid treatments (OR = 3.21; 95% CI: 1.14-8.99). These odds ratios were not significantly different between opioid users and non-users (P = 0.609). CONCLUSION: There is modest evidence to conclude that patients with CLBP and comorbid depression, compared with those without depression, were more likely to try both opioid and non-opioid pain treatments. Non-response to other pain treatments may partly explain why depression is associated with greater prescription opioid use.

Sexual Dysfunction in Primary Care: An Exploratory Descriptive Analysis of Medical Record Diagnoses.

BACKGROUND: The prevalence of sexual dysfunction (SDx) diagnoses in primary care settings is not well known, which is a concern because of the high prevalence of comorbid chronic health conditions in patients diagnosed with SDx. AIM: To explore the relation of SDx diagnosis, chronic health conditions, and prescription medications commonly associated with SDx for men and women in primary care using medical records diagnoses. METHODS: Exploratory descriptive analyses were used to interpret secondary data from a primary care patient database. The database included patient data from 3 family and internal medicine clinics in the St Louis metropolitan area from July 1, 2008 to June 30, 2015. Analysis included key demographic variables, chronic illness, and health conditions of hypertension, pain, prostate disorder, menopause, substance abuse, depression, anxiety, and associated medications. Analysis of the database yielded 30,627 adult patients (men: n = 12,097, mean age = 46.8 years, 65.6% white race; women: n = 18,530, mean age = 46.6 years, 59.2% white race) with significant comorbid associations between SDx and other chronic illness, health conditions, and medication prescription. RESULTS: Depression, anxiety, pain, hypertension, diabetes, and psychotropic medication use were significantly associated with SDx for men and women. Examination of specific SDx diagnoses showed erectile dysfunction to be significantly associated with all tested variables for men. For women, pain-related SDx diagnoses were associated more with chronic illness, health conditions, and medication use than were psychosexual SDx diagnoses (eg, orgasm), except for menopause. Prevalence varied by sex, with a higher prevalence rate of any SDx for men (13.5%) than for women (1.0%), although sex comparisons were not part of the analytics. CLINICAL TRANSLATION: This study suggests the diagnosis of SDx is closely associated with other common chronic illness and health conditions and could go underdiagnosed in women in primary care. STRENGTHS AND LIMITATIONS: The cross-sectional nature of the study limits the ability to draw causal conclusions related to the nature of the associated conditions with SDx diagnoses. The generalizability of the findings also might be limited given the specific demographic or health makeup of the St Louis area where the study was conducted. CONCLUSION: The high comorbidity of SDx with mental health, chronic pain and illnesses, and medication use adds to the growing evidence that sexual health and functioning are essential components of overall well-being and holistic care for men and women. Heiden-Rootes KM, Salas J, Gebauer S, et al. Sexual Dysfunction in Primary Care: An Exploratory Descriptive Analysis of Medical Record Diagnoses. J Sex Med 2017;14:1318-1326.