Association of Decreased Postsurgical Opioid Prescribing With Patients' Satisfaction With Surgeons.

Importance: Opioid overdose is the leading cause of injury-related death in the United States. Several studies have shown that surgeons overprescribe opioids, and guidelines for appropriate opioid prescribing are available. Concern about patient-reported satisfaction scores may be a barrier to surgeons adopting guideline-directed prescribing. Objective: To determine whether decreased opioid prescribing is associated with a decrease in patient-reported satisfaction with their surgeon. Design, Setting, and Participants: Retrospective analysis of clinician satisfaction scores at Dartmouth-Hitchcock Medical Center obtained in 2 periods: 1 before (period A) and 1 after (period B) an educational intervention that resulted in decreased opioid prescribing. The analysis included 11 surgeons who performed 5 common outpatient general surgical operations on 996 patients. Data were analyzed between March and August 2018. Main Outcomes and Measures: Patient-reported overall satisfaction rating of the surgeon (scale, 0-10). This was collected by a nonstudy-related, routine general institutional survey of approximately 40% of all outpatient encounters. Results: Of the total number of patients, 67% were women (667 of 996), and the mean patient age was 58 years. Comparing period A with B, the proportion of patients prescribed opioids decreased from 90.2% (n = 367 of 407) to 72.8% (n = 429 of 589) (P < .001). The mean number of opioid pills per prescription decreased from 28.3 to 13.3 (P < .001) and significantly decreased for each of the 11 surgeons. One hundred five of 996 patients (10.5%) undergoing index operations responded to the survey. There was no difference in the mean clinician satisfaction ratings from period A vs B (9.70 vs 9.65; P = .69). During the study periods, 640 total surveys were collected referencing these surgeons (including outpatient encounters associated with operations other than the 5 index cases). There was no difference in the mean satisfaction ratings from period A vs period B (9.55 vs 9.59; P = .62). When individual clinicians were analyzed, none had a significant difference in overall satisfaction rating from period A vs period B. Conclusions and Relevance: Despite a marked decrease in the proportion of patients receiving opioids and in the number of pills prescribed, there was no significant change in clinician satisfaction ratings.

Pharmacy-related theft of controlled substances: RxPATROL® findings.

OBJECTIVE: To characterize pharmacy-related theft data reported to the Rx Pattern Analysis Tracking Robberies and Other Losses (RxPATROL®) database during the time periods before (2007-2010) and after (2011-2016) the August 2010 switch to reformulated OxyContin® (oxycodone hydrochloride) extended-release tablets (Purdue Pharma L.P.). METHODS: The RxPATROL® database was queried to identify characteristics associated with theft of drug products. Variables analyzed included incident counts, drugs involved (OxyContin or other oxycodone products), pharmacy-security features, and other incident-related information. The data captured from 2007 to 2010, defined as the original formulation period, were compared with those captured from 2011 to 2016, defined as the post-reformulation period. RESULTS: A total of 6,905 incidents were reported from 2007 to 2016, with robbery (51.8 percent) and burglary (26.4 percent) being the most commonly reported incidents. The number of total robbery incidents reported peaked in 2010 and remained steady. Incidents reported as robberies that involved OxyContin initially increased from 2007 to 2010 and then steadily decreased from 296 in 2010 to 13 in 2016. Total burglary reports decreased from 2009 to 2015 and slightly increased from 2015 to 2016. Total burglary reports that involved OxyContin decreased after 2009. Total burglary reports that involved oxycodone remained steady from 2009 to 2014, decreased from 2014 to 2015, and remained steady from 2015 to 2016. The majority of reported incidents occurred on weekdays and involved suspects who entered and exited through the front door at pharmacies without security features such as alarms, dead bolts, and cameras. CONCLUSION: Following replacement of the original formulation of OxyContin with a new formulation that has abuse-deterrent properties in 2010, pharmacy thefts of OxyContin reported to the RxPATROL® database decreased. The decreases were not fully explained by concurrent trends in total robbery or burglary incidents reported to the RxPATROL® database over the same time period.

The effect of a potentially tamper-resistant oxycodone formulation on opioid use and harm: main findings of the National Opioid Medications Abuse Deterrence (NOMAD) study.

BACKGROUND: Escalation of pharmaceutical opioid use and harm in North America is well-documented, with similar issues emerging in Australia. One response is the development of tamper-resistant formulations of opioids. A potentially tamper-resistant formulation of controlled-release oxycodone was introduced in Australia in April, 2014, rapidly replacing the non-tamper-resistant formulation. Our study is the most systematic and comprehensive examination of the impact of a new opioid formulation to date, assessing the effect of tamper-resistant formulation of controlled-release oxycodone on population-level opioid use and opioid-related harm (ie, overdose, help-seeking, and treatment-seeking); and opioid use, tampering, and preference for the tamper-resistant formulation of controlled-release oxycodone compared with other drugs or formulations among sentinel populations likely to tamper with pharmaceutical opioids. METHODS: We conducted interrupted time-series analyses of opioid sales data and multiple routinely collected health datasets, followed up a cohort of people who tamper with pharmaceutical opioids before and after the introduction of the tamper-resistant formulation of controlled-release oxycodone, and analysed annual surveys of people who inject drugs. Data were collected from several Australian states: New South Wales, South Australia, and Tasmania. Meta-analyses (weighted Z tests) were conducted to synthesise across data sources providing evidence for a given indicator. FINDINGS: At the population level, we found reduced sales of higher strengths of controlled-release oxycodone and increased sales of other oxycodone formulations. No significant effect was observed among population-level indicators of opioid overdose, or help or treatment-seeking. Mortality data were not available for inclusion at the time of our study. Meta-analyses across sentinel populations (ie, prospective cohort, surveys of people who inject drugs, and clients of supervised injecting facilities or needle and syringe programmes) indicated reduced controlled-release oxycodone use via tampering (mainly injection), with no evidence of switching to heroin or other drug use. INTERPRETATION: This formulation of controlled-release oxycodone reduced tampering with pharmaceutical opioids among people who inject drugs, but did not affect population-level opioid use or harm. FUNDING: Mundipharma Australia, the Australian Government, and the National Health and Medical Research Council.

Impact of pharmacists assisting with prescribing and undertaking medication review on oxycodone prescribing and supply for patients discharged from surgical wards.

WHAT IS KNOWN AND OBJECTIVES: Overprescribing of oxycodone is a contributor to the epidemic of prescription opioid misuse and deaths. Practice models to optimize oxycodone prescribing and supply need to be evaluated. We explored the impact of pharmacist-assisted discharge prescribing and medication review on oxycodone prescribing and supply for patients discharged from surgical wards. METHODS: A retrospective audit was conducted on two surgical inpatient wards following a 16-week prospective pre- and post-intervention study. During the pre-intervention period, discharge prescriptions were prepared by hospital doctors and then reviewed by a ward pharmacist (WP) before being dispensed. Post-intervention, prescriptions were prepared by a project pharmacist in consultation with hospital doctors and then reviewed by a WP and dispensed. MAIN ENDPOINTS WERE THE FOLLOWING: Proportion of patients who were prescribed, and proportion supplied, oxycodone on discharge; Median amount (milligrams) of oxycodone prescribed and supplied, for patients who were prescribed and supplied at least one oxycodone-containing preparation, respectively. RESULTS: A total of 320 and 341 patients were evaluated pre- and post-intervention, respectively. Pre-intervention, 75.6% of patients were prescribed oxycodone; after WP review, 60.3% were supplied oxycodone (P<.01); the median amount both prescribed and supplied was 100 milligrams/patient. Post-intervention, 68.6% of patients were prescribed oxycodone; after WP review, 57.8% were supplied oxycodone (P<.01); median amount prescribed and supplied was 50 milligrams/patient (difference in amount prescribed and supplied: 50 milligrams, P<.01). WHAT IS NEW AND CONCLUSION: WP review of doctor-prepared prescriptions reduced the proportion of patients who were supplied oxycodone but not the amount supplied/patient. Having a pharmacist assist with prescribing reduced the amount of oxycodone supplied.

Sustained reduction of diversion and abuse after introduction of an abuse deterrent formulation of extended release oxycodone.

BACKGROUND: The development of abuse deterrent formulations is one strategy for reducing prescription opioid misuse and abuse. A putative abuse deterrent formulation of oxycodone extended release (OxyContin®) was introduced in 2010. Early reports demonstrated reduced abuse and diversion, however, an analysis of social media found 32 feasible methods to circumvent the abuse deterrent mechanism. We measured trends of diversion, abuse and street price of OxyContin to assess the durability of the initial reduction in abuse. METHODS: Data from the Poison Center Program, Drug Diversion Program, Opioid Treatment Program, Survey of Key Informant Patients Program and StreetRx program of the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS®) System were used. The average quarterly rates of abuse and diversion for OxyContin were compared from before reformulation to the rate in second quarter 2015. Rates were adjusted for population using US Census data and drug availability. RESULTS: OxyContin abuse and diversion declined significantly each quarter after reformulation and persisted for 5 years. The rate of abuse of other opioid analgesics increased initially and then decreased, but to lesser extent than OxyContin. Abuse through both oral and non-oral routes of self-administration declined following the reformulation. The geometric mean difference in the street price of reformulated OxyContin was 36% lower than the reformulated product in the year after reformulation. DISCUSSION: Despite methods to circumvent the abuse deterrent mechanism, abuse and diversion of OxyContin decreased promptly following the introduction of a crush- and solubility- resistant formulation and continued to decrease over the subsequent 5 years.

Rates of opioid dispensing and overdose after introduction of abuse-deterrent extended-release oxycodone and withdrawal of propoxyphene.

IMPORTANCE: In the second half of 2010, abuse-deterrent extended-release oxycodone hydrochloride (OxyContin; Purdue Pharma) was introduced and propoxyphene was withdrawn from the US market. The effect of these pharmaceutical market changes on opioid dispensing and overdose rates is unknown. OBJECTIVE: To evaluate the association between 2 temporally proximate changes in the opioid market and opioid dispensing and overdose rates. DESIGN, SETTING, AND PARTICIPANTS: Claims from a large national US health insurer were analyzed, using an interrupted time series study design. Participants included an open cohort of 31.3 million commercially insured members aged 18 to 64 years between January 1, 2003, and December 31, 2012, with median follow-up of 20 months (last follow-up, December 31, 2012). EXPOSURES: Introduction of abuse-deterrent OxyContin (resistant to crushing or dissolving) on August 9, 2010, and market withdrawal of propoxyphene on November 19, 2010. MAIN OUTCOMES AND MEASURES: Standardized opioid dispensing rates and prescription opioid and heroin overdose rates were the primary outcomes. We used segmented regression to analyze changes in outcomes from 30 quarters before to 8 quarters after the 2 interventions. RESULTS: Two years after the opioid market changes, total opioid dispensing decreased by 19% from the expected rate (absolute change, -32.2 mg morphine-equivalent dose per member per quarter [95% CI, -38.1 to -26.3]). By opioid subtype, the absolute change in dispensing by milligrams of morphine-equivalent dose per member per quarter at 2 years was -11.3 (95% CI, -12.4 to -10.1) for extended-release oxycodone, 3.26 (95% CI, 1.40 to 5.12) for other long-acting opioids, -8.19 (95% CI, -9.30 to -7.08) for propoxyphene, and -16.2 (95% CI, -18.8 to -13.5) for other immediate-release opioids. Two years after the market changes, the estimated overdose rate attributed to prescription opioids decreased by 20% (absolute change, -1.10 per 100,000 members per quarter [95% CI, -1.47 to -0.74]), but heroin overdose increased by 23% (absolute change, 0.26 per 100,000 members per quarter [95% CI, -0.01 to 0.53]). CONCLUSIONS AND RELEVANCE: Opioid dispensing and prescription opioid overdoses decreased substantially after 2 major changes in the pharmaceutical market in late 2010. Pharmaceutical market interventions may have value in combatting the prescription opioid overdose epidemic, but heroin overdose rates continue to increase. Complementary strategies to identify and treat opioid abuse and addiction are urgently needed.

Evaluating the potential impact of a reformulated version of oxycodone upon tampering, non-adherence and diversion of opioids: the National Opioid Medications Abuse Deterrence (NOMAD) study protocol.

AIMS: A new oxycodone formulation (Reformulated OxyContin® was released in Australia, early 2014. It was developed as a tamper-resistant ('abuse-deterrent') formulation of the drug. We summarize methods used in the National Opioid Medication Abuse Deterrence (NOMAD) study, which will examine: (i) whether there is a reduction in extra-medical use (including via tampering) of OxyContin® following the introduction of Reformulated OxyContin®; (ii) potential changes in extra-medical use of non-abuse-deterrent forms of oxycodone, other pharmaceutical opioids and illicit drugs; (iii) whether methods of tampering with Reformulated OxyContin® become widespread over time; (iv) Reformulated OxyContin®'s attractiveness on the illicit market; and (v) sales, prescriptions and harms related to OxyContin® and other drugs. METHODS: There are three major components. First, analyses of existing routine data sources such as: pharmaceutical sales; prescribing data; data on drug overdose deaths; and survey data on drug use in the general population and among people who inject drugs; secondly, specific data on OxyContin® collected through the Illicit Drug Reporting System; and thirdly, a prospective cohort of n = 606 people who regularly misuse or tamper with pharmaceutical opioids was formed prior to the introduction of Reformulated OxyContin®, followed-up twice post-release to examine potential changes after Reformulated OxyContin®'s introduction. DISCUSSION: The study's strengths lie in varied data collections; interrupted time-series analysis; and prospective cohort. To our knowledge, this is one of the most comprehensive and transparently conducted studies conducted to date of the potential impact of an opioid medication upon use, tampering and diversion. Results have the potential to inform policymakers, clinicians, consumers and researchers alike.

The epidemiologic association between opioid prescribing, non-medical use, and emergency department visits.

INTRODUCTION: Since the 1990s prescriptions for and the non-medical use of opioids have increased. This study examines associations between opioid prescribing, non-medical use, and emergency department (ED) visits. METHODS: Data were abstracted from four federally sponsored, nationally representative, annual surveys (National Hospital Ambulatory Medical Care Survey, National Ambulatory Medical Care Survey, National Survey on Drug Use and Health, and Drug Abuse Warning Network). RESULTS: For hydrocodone and oxycodone, associations between prescribing and non-medical use, and prescribing and ED visits were statistically significant (p-values < 0.04) and strongly associated (correlation coefficient range 0.73 to 0.87). Male gender, White race, and age > or = 35 were all statistically significant (p-values < 0.0001) predictors of receiving a hydrocodone or oxycodone-containing prescription. CONCLUSION: The increased number of prescriptions written for hydrocodone and oxycodone between 1995 and 2004 was associated with similar increases in non-medical use and the number of ED visits during this time period.

The availability of web sites offering to sell opioid medications without prescriptions.

OBJECTIVE: This study was designed to determine the availability of web sites offering to sell opioid medications without prescriptions. METHOD: Forty-seven Internet searches were conducted with a variety of opioid medication terms, including "codeine," "no prescription Vicodin," and "OxyContin." Two independent raters examined the links generated in each search and resolved any coding disagreements. The resulting links were coded as "no prescription web sites" (NPWs) if they offered to sell opioid medications without prescriptions. RESULTS: In searches with terms such as "no prescription codeine" and "Vicodin," over 50% of the links obtained were coded as "NPWs." The proportion of links yielding NPWs was greater when the phrase "no prescription" was added to the opioid term. More than 300 opioid NPWs were identified and entered into a database. CONCLUSIONS: Three national drug-use monitoring studies have cited significant increases in prescription opioid use over the past 5 years, particularly among young people. The emergence of NPWs introduces a new vector for unregulated access to opioids. Research is needed to determine the effect of NPWs on prescription opioid use initiation, misuse, and dependence.