EMCDDA DOCUMENTATION CENTRE
INFORMATION BULLETIN
PRESCRIPTION DRUGS INFORMATION BULLETIN
1 February 2016
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GREY LITERATURE
SAMHSA Prescription Drug Abuse Weekly Update
Issue 158
January 28, 2016
http://www.dsgonline.com/PAW/2016/2016_01_28/paw_2016_01_28.html
JOURNAL ARTICLES
Treatment / Prevention
Management of patients with issues related to opioid safety, efficacy and/or misuse: a case series from an integrated, interdisciplinary clinic
Becker, W C; Merlin, J S; Manhapra, A; Edens, E L
Addiction Science and Clinical Practice, 2016, 11, 3
Background:
Patients, providers, communities and health systems have struggled to achieve balance between access to opioid treatment for chronic pain and its potential harmful consequences: especially misuse, addiction and overdose. We developed an interdisciplinary clinic embedded within primary care (the Opioid Reassessment Clinic—ORC) with the goal of improving the quality of care of patients with co-occurring chronic pain and issues related to opioid safety, efficacy and/or misuse.
Case descriptions:
We present three cases referred to the ORC that highlight complex clinical scenarios related to assessment and treatment of patients with chronic pain and issues related to opioid safety, efficacy and misuse.
Discussion and evaluation:
In the context of the three cases, with respect to assessment, we discuss: making the diagnosis of opioid use disorder; allowing the patient space to endorse lack of efficacy; identification of co-occurring hazardous alcohol use; and recognizing barriers to multimodal pain care. With respect to treatment, we discuss: making a change in treatment with which the patient may not agree; effectiveness of buprenorphine/naloxone for the treatment of chronic pain; responding to low efficacy; and making continued opioid therapy contingent on engagement with substance abuse treatment.
Conclusions:
The core components of our approach—biopsychosocial assessment and multimodal treatment planning with an emphasis on promoting functional goals and safety using clear communication and a patient-centered stance—should guide providers in the management of similar clinical scenarios. More evidence is needed to definitively guide specific interventions and points of clinical equipoise.
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Role of community pharmacists in the detection of potentially inappropriate benzodiazepines prescriptions for insomnia
Urru SA, Pasina L, Minghetti P, Giua C
International Journal of Clinical Pharmacy
37(6):1004-8, 2015
Background:
The appropriate management of chronic insomnia is crucial and prescribing of hypnotic drugs is common. Regular and prolonged use of hypnotics should be avoided because of the risk of tolerance to effects, dependence and an increased risk of adverse events. In 2012, updated Beers criteria for potentially inappropriate medication in older adults suggested to avoid all benzodiazepines in older adults to treat insomnia. In addition, successful discontinuation may result in improvements on cognitive and psychomotor function, particularly in older people.
Objective:
To investigate the appropriateness of benzodiazepines prescription for insomnia and explore the role that community pharmacists can have in identifying signals of potential inappropriate drug prescriptions.
Setting:
Community pharmacies in Italy.
Method:
This is an observational study conducted in 8 community pharmacies. Each pharmacist was asked to interview a sample of patients with the prescriptions of at least one benzodiazepine and to complete a minimum data set collecting information about socio-demographic characteristics, drug indication, duration of drug prescription, number of hypnotic-drugs, previous attempt to drug-discontinuation, preference of patients about benzodiazepine withdrawal and modality of drug tapering. Main outcome measure Indications, treatment duration, dosage and drug discontinuation attempts and modalities.
Results:
A total of 181 participants were interviewed. About half of respondents (n = 81) reported to be treated for insomnia and 62 % were elderly (mean age 68, range 27-93). Fifty-two patients (64 %) were on long term treatment (>3 years) while for thirteen patients (16 %) duration of treatment was comprised between 1 and 3 years. Thirty-three patients were in favour of benzodiazepine-discontinuation but in all cases discontinuation was unsuccessful.
Conclusion:
Use of community pharmacy survey data allowed us to obtain information about incorrect management of insomnia and inappropriate benzodiazepines prescriptions. Stricter adherence to evidence-based guidelines is essential for a rational use of hypnotic and sedatives.
Denial of prescription analgesia among people who inject drugs in a Canadian setting
Voon P, Callon C, Nguyen P, Dobrer S, Montaner JS, Wood E, Kerr T
Drug and Alcohol Review
34(2):221-228, 2015
Introduction and Aims:
Despite the high prevalence of pain among people who inject drugs (PWIDs), clinicians may be reluctant to prescribe opioid-based analgesia to those with a history of drug use or addiction. We sought to examine the prevalence and correlates of PWIDs reporting being denied of prescription analgesia (PA). We also explored reported reasons for and actions taken after being denied PA.
Design and Methods:
Using data from two prospective cohort studies of PWIDs, multivariate logistic regression was used to identify the prevalence and correlates of reporting being denied PA. Descriptive statistics were used to characterise reasons for denials and subsequent actions.
Results:
Approximately two-thirds (66.5%) of our sample of 462 active PWIDs reported having ever been denied PA. We found that reporting being denied PA was significantly and positively associated with having ever been enrolled in methadone maintenance treatment (adjusted odds ratio 1.76, 95% confidence interval 1.11-2.80) and daily cocaine injection (adjusted odds ratio 2.38, 95% confidence interval 1.00-5.66). The most commonly reported reason for being denied PA was being accused of drug seeking (44.0%). Commonly reported actions taken after being denied PA included buying the requested medication off the street (40.1%) or obtaining heroin to treat pain (32.9%).
Discussion and Conclusions:
These findings highlight the challenges of addressing perceived pain and the need for strategies to prevent high-risk methods of self-managing pain, such as obtaining diverted medications or illicit substances for pain. Such strategies may include integrated pain management guidelines within methadone maintenance treatment and other substance use treatment programs.
Attitudes and self-reported practices of hand surgeons regarding prescription opioid use
Menendez ME, Mellema JJ, Ring D
Hand
10(4):789-95, 2015
Background:
Opioids are routinely prescribed after hand surgery, but there is limited research about surgeon variation in prescription patterns and attitudes toward the use of these drugs. We sought to examine hand surgeons' attitudes, beliefs, and self-reported practices regarding the use of opioids.
Methods:
An invitation to an online cross-sectional survey was sent to 3225 hand surgeons across the USA via email, of whom 502 (16%) responded. We used previously published data to compare hand surgeons' concerns about potential adverse opioid-related events with those of primary care physicians.
Results:
Most hand surgeons (76%) reported prescription opioid abuse to be a big or moderate problem in their communities, and 89% felt that opioids are overused to treat pain. Nearly all (94%) were very or moderately confident about their clinical skills regarding opioid prescribing, but only 40% reported always or often asking about a history of opioid abuse or dependence before scheduling surgery. Most (75%) were very or moderately comfortable refilling opioid prescriptions following fracture surgery, while only 13% were comfortable doing so after minor elective surgery. Nearly half (49%) reported being less likely to prescribe opioids compared to 1year ago, and 67% believed that the best approach to reduce postoperative opioid use is to discuss pain management and expectations with the patient before surgery. Compared to primary care physicians, hand surgeons were less likely to be concerned about potential adverse patient (e.g., opioid-related addiction [67 vs. 84%], death [37 vs. 70%], sedation [57 vs. 71%]) and prescriber (e.g., malpractice claim [22 vs. 46%], prosecution [15 vs. 45%], censure by state medical boards [16 vs. 44%]) outcomes.
Conclusion:
Hand surgeons have become aware of the extent and public health implications of the prescription opioid epidemic, and many are taking an active role by reducing their reliance on these drugs. Additional research using pharmacy data is needed to confirm the extent to which hand surgeons' reliance on prescription opioids is actually decreasing.
Public Health / Policy / Legislation / Law Enforcement
Nonmedical use of attention-deficit/hyperactivity disorder medication among secondary school students in the Netherlands
Koster ES, de Haan L, Bouvy ML, Heerdink ER
Journal of Child and Adolescent Psychopharmacology
25(8):649-52, 2015
Objective:
No studies in Europe have assessed the extent of nonmedical attention-deficit/hyperactivitiy disorder (ADHD) medication use among adolescents, while also, in Europe, prescribing of these medicines has increased. Our objective was to study the prevalence and motives for nonmedical ADHD medication use among secondary school students in the Netherlands.
Methods:
Adolescent students 10-19 years of age from six secondary schools were invited to complete an online survey on use of ADHD medication, tobacco, alcohol, and drugs. Nonmedical ADHD medication use was defined as self-reported use without a prescription during the previous 12 months.
Results:
Survey data were available for 777 students (15% response rate). The overall proportion of students self-reporting nonmedical ADHD medication use was 1.2% (n = 9), which represented almost 20% of the adolescents who reported ADHD medication use (n = 49). Most adolescents reported self-medication or enhancing study performance as motives for ADHD medication use.
Conclusions:
The proportion of the study sample reporting nonmedical ADHD medication use in our study is lower compared with that in previous research conducted in the United States and Canada; however, on a population-based level, there might be a considerable proportion of recreational users.
Association between childhood residential mobility and non-medical use of prescription drugs among American youth
Stabler ME, Gurka KK, Lander LR
Maternal and Child Health Journal
19(12):2646-53, 2016
Introduction:
Prescription drug abuse is a public health epidemic, resulting in 15,000 deaths annually. Disruption of childhood residence has been shown to increase drug-seeking behavior among adolescents; however, little research has explored its association specifically with non-medical use of prescription drugs (NMUPD). The objective of the study was to measure the association between residential mobility and NMUPD.
Methods:
The 2010 National Survey on Drug Use and Health data were analyzed for 15,745 participants aged 12-17years. NMUPD was defined as self-report of any non-medical use (i.e., taking a prescription drug that was not prescribed to them or consumption for recreational purposes) of tranquilizers, pain relievers, sedatives, or stimulants. Logistic regression for survey data was used to estimate the association between residential mobility and NMUPD, adjusting for potential confounders.
Results:
After controlling for demographic, intrapersonal, interpersonal, and community factors, adolescents with low mobility (1-2 moves in the past 5years) and residential instability (≥3 moves) were 16% (OR 1.16, 95% CI 1.01, 1.33) and 25% (OR 1.25, 95% CI 1.00, 1.56) more likely to report NMUPD compared to non-mobile adolescents (0 moves). Low-mobile adolescents were 18% (OR 1.18, 95% CI 1.01, 1.38) more likely to abuse pain relievers, specifically. No relationship was found between moving and tranquilizer, stimulant, or sedative use.
Discussion:
Increasing childhood residential mobility is associated with NMUPD; therefore, efforts to prevent NMUPD should target mobile adolescents. Further examination of the psychological effects of moving and its association with pain reliever abuse is indicated.
Opioid prescribing after nonfatal overdose and association with repeated overdose: a cohort study
Marc R. Larochelle; Jane M. Liebschutz; Fang Zhang; Dennis Ross-Degnan; and J. Frank Wharam
Annals of Internal Medicine
164(1):1-9, 2016
Background:
Nonfatal opioid overdose is an opportunity to identify and treat substance use disorders, but treatment patterns after the overdose are unknown.
Objective:
To determine prescribed opioid dosage after an opioid overdose and its association with repeated overdose.
Design:
Retrospective cohort study.
Setting:
A large U.S. health insurer.
Participants:
2848 commercially insured patients aged 18 to 64 years who had a nonfatal opioid overdose during long-term opioid therapy for noncancer pain between May 2000 and December 2012.
Measurements:
Nonfatal opioid overdose was identified using International Classification of Diseases, Ninth Revision, Clinical Modification, codes from emergency department or inpatient claims. The primary outcome was daily morphine-equivalent dosage (MED) of opioids dispensed from 60 days before to up to 730 days after the index overdose. We categorized dosages as large (≥100 mg MED), moderate (50 to <100 mg MED), low (<50 mg MED), or none (0 mg MED). Secondary outcomes included time to repeated overdose stratified by daily dosage as a time-varying covariate.
Results:
Over a median follow-up of 299 days, opioids were dispensed to 91% of patients after an overdose. Seven percent of patients (n=212) had a repeated opioid overdose. At 2 years, the cumulative incidence of repeated overdose was 17% (95% CI, 14% to 20%) for patients receiving high dosages of opioids after the index overdose, 15% (CI, 10% to 21%) for those receiving moderate dosages, 9% (CI, 6% to 14%) for those receiving low dosages, and 8% (CI, 6% to 11%) for those receiving no opioids.
Limitation:
The cohort was limited to commercially insured adults.
Conclusion:
Almost all patients continue to receive prescription opioids after an overdose. Opioid discontinuation after overdose is associated with lower risk for repeated overdose.
A detailed exploration into the association of prescribed opioid dosage and overdose deaths among patients with chronic pain
Bohnert, Amy S. B. ; Logan, Joseph E. ; Ganoczy, Dara ; Dowell, Deborah
Medical Care
January 22, 2016
doi: 10.1097/MLR.0000000000000505
Background:
High opioid dosage has been associated with overdose, and clinical guidelines have cautioned against escalating dosages above 100 morphine-equivalent mg (MEM) based on the potential harm and the absence of evidence of benefit from high dosages. However, this 100 MEM threshold was chosen somewhat arbitrarily.
Objective:
To examine the association of prescribed opioid dosage as a continuous measure in relation to risk of unintentional opioid overdose to identify the range of dosages associated with risk of overdose at a detailed level.
Methods:
In this nested case-control study with risk-set sampling of controls, cases (opioid overdose decedents) and controls were identified from a population of patients of the Veterans Health Administration who were prescribed opioids and who have a chronic pain diagnosis. Unintentional fatal opioid analgesic overdose was measured from National Death Index records and prescribed opioid dosage from pharmacy records.
Results:
The average prescribed opioid dosage was higher (P<0.001) for cases (mean=98.1 MEM, SD=112.7; median=60, interquartile range, 30-120), than controls (mean=47.7 MEM, SD=65.2; median=25, interquartile range, 15-45). In a ROC analysis, dosage was a moderately good "predictor" of opioid overdose death, indicating that, on average, overdose cases had a prescribed opioid dosage higher than 71% of controls.