Differential patterns of opioid misuse between younger and older adults - a retrospective observational study using data from South Carolina's prescription drug monitoring program.

Background: Most research on opioid misuse focuses on younger adults, yet opioid-related mortality has risen fastest among older Americans over age 55.Objectives: To assess whether there are differential patterns of opioid misuse over time between younger and older adults and whether South Carolina's mandatory Prescription Drug Monitoring Program (PDMP) affected opioid misuse differentially between the two groups.Methods: We used South Carolina's Reporting and Identification Prescription Tracking System from 2010 to 2018 to calculate an opioid misuse score for 193,073 patients (sex unknown) using days' supply, morphine milligram equivalents (MME), and the numbers of unique prescribers and dispensaries. Multivariable regression was used to assess differential opioid misuse patterns by age group over time and in response to implementation of South Carolina's mandatory PDMP in 2017.Results: We found that between 2011 and 2018, older adults received 57% (p < .01) more in total MME and 25.4 days more (p < .01) in supply, but received prescriptions from fewer doctors (-0.063 doctors, p < 01) and pharmacies (-0.11 pharmacies, p < 01) per year versus younger adults. However, older adults had lower odds of receiving a high misuse score (OR 0.88, p < .01). After the 2017 legislation, misuse scores fell among younger adults (OR 0.79, p < .01) relative to 2011, but not among older adults.Conclusion: Older adults may misuse opioids differently compared to younger adults. Assessment of policies to reduce opioid misuse should take into account subgroup differences that may be masked at the population level.

Early transplantation maximizes survival in severe acute-on-chronic liver failure: Results of a Markov decision process model.

BACKGROUND & AIMS: Uncertainties exist surrounding the timing of liver transplantation (LT) among patients with acute-on-chronic liver failure grade 3 (ACLF-3), regarding whether to accept a marginal quality donor organ to allow for earlier LT or wait for either an optimal organ offer or improvement in the number of organ failures, in order to increase post-LT survival. METHODS: We created a Markov decision process model to determine the optimal timing of LT among patients with ACLF-3 within 7 days of listing, to maximize overall 1-year survival probability. RESULTS: We analyzed 6 groups of candidates with ACLF-3: patients age ≤60 or >60 years, patients with 3 organ failures alone or 4-6 organ failures, and hepatic or extrahepatic ACLF-3. Among all groups, LT yielded significantly greater overall survival probability vs. remaining on the waiting list for even 1 additional day (p <0.001), regardless of organ quality. Creation of 2-way sensitivity analyses, with variation in the probability of receiving an optimal organ and expected post-transplant mortality, indicated that overall survival is maximized by earlier LT, particularly among candidates >60 years old or with 4-6 organ failures. The probability of improvement from ACLF-3 to ACLF-2 does not influence these recommendations, as the likelihood of organ recovery was less than 10%. CONCLUSION: During the first week after listing for patients with ACLF-3, earlier LT in general is favored over waiting for an optimal quality donor organ or for recovery of organ failures, with the understanding that the analysis is limited to consideration of only these 3 variables. LAY SUMMARY: In the setting of grade 3 acute-on-chronic liver failure (ACLF-3), questions remain regarding the timing of transplantation in terms of whether to proceed with liver transplantation with a marginal donor organ or to wait for an optimal liver, and whether to transplant a patient with ACLF-3 or wait until improvement to ACLF-2. In this study, we used a Markov decision process model to demonstrate that earlier transplantation of patients listed with ACLF-3 maximizes overall survival, as opposed to waiting for an optimal donor organ or for improvement in the number of organ failures.