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      Potentially Inappropriate Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011–2015

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          Abstract

          <div class="section"> <a class="named-anchor" id="d4592157e269"> <!-- named anchor --> </a> <h5 class="section-title" id="d4592157e270">Background</h5> <p id="Par1">Potentially inappropriate prescribing (PIP) may contribute to opioid overdose.</p> </div><div class="section"> <a class="named-anchor" id="d4592157e274"> <!-- named anchor --> </a> <h5 class="section-title" id="d4592157e275">Objective</h5> <p id="Par2">To examine the association between PIP and adverse events.</p> </div><div class="section"> <a class="named-anchor" id="d4592157e279"> <!-- named anchor --> </a> <h5 class="section-title" id="d4592157e280">Design</h5> <p id="Par3">Cohort study.</p> </div><div class="section"> <a class="named-anchor" id="d4592157e284"> <!-- named anchor --> </a> <h5 class="section-title" id="d4592157e285">Participants</h5> <p id="Par4">Three million seventy-eight thousand thirty-four individuals age ≥ 18, without disseminated cancer, who received prescription opioids between 2011 and 2015. </p> </div><div class="section"> <a class="named-anchor" id="d4592157e289"> <!-- named anchor --> </a> <h5 class="section-title" id="d4592157e290">Main Measures</h5> <p id="Par5">We defined PIP as (a) morphine equivalent dose ≥ 100 mg/day in ≥ 3 months; (b) overlapping opioid and benzodiazepine prescriptions in ≥ 3 months; (c) ≥ 4 opioid prescribers in any quarter; (d) ≥ 4 opioid-dispensing pharmacies in any quarter; (e) cash purchase of prescription opioids on ≥ 3 occasions; and (f) receipt of opioids in 3 consecutive months without a documented pain diagnosis. We used Cox proportional hazards models to identify PIP practices associated with non-fatal opioid overdose, fatal opioid overdose, and all-cause mortality, controlling for covariates. </p> </div><div class="section"> <a class="named-anchor" id="d4592157e294"> <!-- named anchor --> </a> <h5 class="section-title" id="d4592157e295">Key Results</h5> <p id="Par6">All six types of PIP were associated with higher adjusted hazard for all-cause mortality, four of six with non-fatal overdose, and five of six with fatal overdose. Lacking a documented pain diagnosis was associated with non-fatal overdose (adjusted hazard ratio [AHR] 2.21, 95% confidence interval [CI] 2.02–2.41), as was high-dose opioids (AHR 1.68, 95% CI 1.59–1.76). Co-prescription of benzodiazepines was associated with fatal overdose (AHR 4.23, 95% CI 3.85–4.65). High-dose opioids were associated with all-cause mortality (AHR 2.18, 95% CI 2.14–2.23), as was lacking a documented pain diagnosis (AHR 2.05, 95% CI 2.01–2.09). Compared to those who received opioids without PIP, the hazard for fatal opioid overdose with one, two, three, and ≥ four PIP subtypes were 4.24, 7.05, 10.28, and 12.99 (test of linear trend, <i>p</i> &lt; 0.001). </p> </div><div class="section"> <a class="named-anchor" id="d4592157e302"> <!-- named anchor --> </a> <h5 class="section-title" id="d4592157e303">Conclusions</h5> <p id="Par7">PIP was associated with higher hazard for all-cause mortality, fatal overdose, and non-fatal overdose. Our study implies the possibility of creating a risk score incorporating multiple PIP subtypes, which could be displayed to prescribers in real time. </p> </div><div class="section"> <a class="named-anchor" id="d4592157e307"> <!-- named anchor --> </a> <h5 class="section-title" id="d4592157e308">Electronic supplementary material</h5> <p id="d4592157e310">The online version of this article (10.1007/s11606-018-4532-5) contains supplementary material, which is available to authorized users. </p> </div>

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          Patterns of abuse among unintentional pharmaceutical overdose fatalities.

          Aron Hall (2008)
          Use and abuse of prescription narcotic analgesics have increased dramatically in the United States since 1990. The effect of this pharmacoepidemic has been most pronounced in rural states, including West Virginia, which experienced the nation's largest increase in drug overdose mortality rates during 1999-2004. To evaluate the risk characteristics of persons dying of unintentional pharmaceutical overdose in West Virginia, the types of drugs involved, and the role of drug abuse in the deaths. Population-based, observational study using data from medical examiner, prescription drug monitoring program, and opiate treatment program records. The study population was all state residents who died of unintentional pharmaceutical overdoses in West Virginia in 2006. Rates and rate ratios for selected demographic variables. Prevalence of specific drugs among decedents and proportion that had been prescribed to decedents. Associations between demographics and substance abuse indicators and evidence of pharmaceutical diversion, defined as a death involving a prescription drug without a documented prescription and having received prescriptions for controlled substances from 5 or more clinicians during the year prior to death (ie, doctor shopping). Of 295 decedents, 198 (67.1%) were men and 271 (91.9%) were aged 18 through 54 years. Pharmaceutical diversion was associated with 186 (63.1%) deaths, while 63 (21.4%) were accompanied by evidence of doctor shopping. Prevalence of diversion was greatest among decedents aged 18 through 24 years and decreased across each successive age group. Having prescriptions for a controlled substance from 5 or more clinicians in the year prior to death was more common among women (30 [30.9%]) and decedents aged 35 through 44 years (23 [30.7%]) compared with men (33 [16.7%]) and other age groups (40 [18.2%]). Substance abuse indicators were identified in 279 decedents (94.6%), with nonmedical routes of exposure and illicit contributory drugs particularly prevalent among drug diverters. Multiple contributory substances were implicated in 234 deaths (79.3%). Opioid analgesics were taken by 275 decedents (93.2%), of whom only 122 (44.4%) had ever been prescribed these drugs. The majority of overdose deaths in West Virginia in 2006 were associated with nonmedical use and diversion of pharmaceuticals, primarily opioid analgesics.
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            Painting a truer picture of US socioeconomic and racial/ethnic health inequalities: the Public Health Disparities Geocoding Project.

            We describe a method to facilitate routine monitoring of socioeconomic health disparities in the United States. We analyzed geocoded public health surveillance data including events from birth to death (c. 1990) linked to 1990 census tract (CT) poverty data for Massachusetts and Rhode Island. For virtually all outcomes, risk increased with CT poverty, and when we adjusted for CT poverty racial/ethnic disparities were substantially reduced. For half the outcomes, more than 50% of cases would not have occurred if population rates equaled those of persons in the least impoverished CTs. In the early 1990s, persons in the least impoverished CT were the only group meeting Healthy People 2000 objectives a decade ahead. Geocoding and use of the CT poverty measure permit routine monitoring of US socioeconomic inequalities in health, using a common and accessible metric.
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              New Data on Opioid Use and Prescribing in the United States

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                Author and article information

                Journal
                Journal of General Internal Medicine
                J GEN INTERN MED
                Springer Nature
                0884-8734
                1525-1497
                June 14 2018
                Article
                10.1007/s11606-018-4532-5
                6109008
                29948815
                e990b0d3-e3cd-4c42-8b56-8ab84045c67c
                © 2018

                http://www.springer.com/tdm

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