Christopher M. Jones

Marijuana use and use disorders in adults in the USA, 2002–14: analysis of annual cross-sectional surveys

BACKGROUNDnThe study of marijuana use disorders is urgently needed because of increasing marijuana legalisation in multiple jurisdictions, the effect of marijuana use on future risk of psychiatric disorders, and deleterious effects of marijuana exposure. Thus, understanding trends of marijuana use and use disorders and examining factors that might drive these trends (eg, perceptions of harms from marijuana use) is essential.nnnMETHODSnWe analysed data from US civilians aged 18 years or older who participated in annual, cross-sectional US National Surveys on Drug Use and Health from 2002 to 2014. The sample in each US state was designed to be approximately equally distributed between participants aged 12-17 years, 18-25 years, and 26 years or older. For each survey year, we estimated prevalence of marijuana use and use disorders, initiation of marijuana use, daily or near daily use, perception of great or no risk of harm from smoking marijuana, perception of state legalisation of medical marijuana use, and mean number of days of marijuana use in the previous year. Descriptive analyses, multivariable logistic regressions, and zero-truncated negative binomial regressions were applied.nnnFINDINGSn596u2008500 adults participated in the 2002-14 surveys. Marijuana use increased from 10·4% (95% CI 9·97-10·82) to 13·3% (12·84-13·70) in adults in the USA from 2002 to 2014 (β=0·0252, p<0·0001), and the prevalence of perceiving great risk of harm from smoking marijuana once or twice a week decreased from 50·4% (49·60-51·25) to 33·3% (32·64-33·96; β=-0·0625, p<0·0001). Changes in marijuana use and risk perception generally began in 2006-07. After adjusting for all covariates, changes in risk perceptions were associated with changes in prevalence of marijuana use, as seen in the lower prevalence of marijuana use each year during 2006-14 than in 2002 when perceiving risk of harm from smoking marijuana was included in models. However, marijuana use disorders in adults remained stable at about 1·5% between 2002 and 2014 (β=-0·0042, p=0·22).nnnINTERPRETATIONnPrevalence and frequency of marijuana use increased in adults in the USA starting in approximately 2007 and showing significantly higher results in multivariable models during 2011-14 (compared with 2002). The associations between increases in marijuana use and decreases in perceiving great risk of harm from smoking marijuana suggest the need for education regarding the risk of smoking marijuana and prevention messages.nnnFUNDINGnNone.

Trends in the Concomitant Prescribing of Opioids and Benzodiazepines, 2002−2014

INTRODUCTIONnAlthough many clinical guidelines caution against the combined use of opioids and benzodiazepines, overdose deaths and emergency department visits involving the co-ingestion of these drugs are increasing.nnnMETHODSnIn this ecologic time series study, the IMS Health Total Patient Tracker was used to describe nationally projected trends of patients receiving opioids and benzodiazepines in the U.S. outpatient retail setting between January 2002 and December 2014. The IMS Health Data Extract Tool was used to examine trends in the concomitant prescribing of these two medication classes among 177 million individuals receiving opioids during this period. The annual proportion of opioid recipients who were prescribed benzodiazepines concomitantly was calculated and stratified by gender, age, duration of opioid use, immediate-release versus extended-release/long-acting opioids, and benzodiazepine molecule. The proportion of patients with concomitancy receiving opioids and benzodiazepines from the same prescriber was also analyzed. Analyses were conducted from April to June 2015.nnnRESULTSnThe nationally projected number of patients receiving opioids and benzodiazepines increased by 8% and 31%, respectively, from 2002 to 2014. During this period, the annual proportion of opioid recipients dispensed a benzodiazepine concomitantly increased from 6.8% to 9.6%, which corresponded to a relative increase of 41%. Approximately half of these patients received both prescriptions from the same prescriber on the same day. Concomitancy was more common in patients receiving opioids for ≥90 days, women, and the elderly.nnnCONCLUSIONSnConcomitant prescribing of opioids and benzodiazepines is increasing and may play a growing role in adverse patient outcomes related to these medications.

Use of Marijuana for Medical Purposes Among Adults in the United States

Use of Marijuana for Medical Purposes Among Adults in the United States By 2014, 23 states and the District of Columbia had legalized medical marijuana use, suggesting a need for information about national rates of marijuana use for medical purposes.1 Although 17% of past-year marijuana users reported use for medical purposes in states with medical marijuana legalization,2 physic ians might recommend medical marijuana use to patients regardless of their residing states.3 Therefore, we examined differences between medical and nonmedical marijuana users across all US states.

Increases in prescription opioid injection abuse among treatment admissions in the United States, 2004–2013

BACKGROUNDnThe 2015 HIV outbreak in Indiana associated with prescription opioid injection coupled with rising rates of hepatitis C, especially in areas with long-standing opioid abuse, have raised concerns about prescription opioid injection. However, research on this topic is limited. We assessed trends in treatment admissions reporting injection, smoking, and inhalation abuse of prescription opioids and examined characteristics associated with non-oral routes of prescription opioid abuse in the U.S.nnnMETHODSnPrescription opioid abuse treatment admissions in the 2004-2013 Treatment Episode Data Set were used to calculate counts and percentages of prescription opioid treatment admissions reporting oral, injection, or smoking/inhalation abuse overall, by sex, age, and race/ethnicity. Multivariable multinomial logistic regression was used to identify demographic and substance use characteristics associated with injection or smoking/inhalation abuse.nnnRESULTSnFrom 2004-2013, oral abuse decreased from 73.1% to 58.9%; injection abuse increased from 11.7% to 18.1%; and smoking/inhalation abuse increased from 15.3% of admissions to 23.0%. Among treatment admissions, the following were associated with injection abuse: male sex, 18-54 year-olds, non-Hispanic whites, non-Hispanic other, homeless or dependent living, less than full-time work, living in the Midwest or South, ≥1 prior treatment episodes, younger age of first opioid use, and reporting use of cocaine/crack, marijuana, heroin, or methamphetamine.nnnCONCLUSIONSnThe proportion of treatment admissions reporting prescription opioid injection and smoking/inhalation abuse increased significantly in the U.S. between 2004 and 2013. Expanding prevention efforts as well as access to medication-assisted treatment and risk reduction services for people who inject drugs is urgently needed.

Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas — United States

Problem/Condition Drug overdoses are a leading cause of injury death in the United States, resulting in approximately 52,000 deaths in 2015. Understanding differences in illicit drug use, illicit drug use disorders, and overall drug overdose deaths in metropolitan and nonmetropolitan areas is important for informing public health programs, interventions, and policies. Reporting Period Illicit drug use and drug use disorders during 2003–2014, and drug overdose deaths during 1999–2015. Description of Data The National Survey of Drug Use and Health (NSDUH) collects information through face-to-face household interviews about the use of illicit drugs, alcohol, and tobacco among the U.S. noninstitutionalized civilian population aged ≥12 years. Respondents include residents of households and noninstitutional group quarters (e.g., shelters, rooming houses, dormitories, migratory workers’ camps, and halfway houses) and civilians living on military bases. NSDUH variables include sex, age, race/ethnicity, residence (metropolitan/nonmetropolitan), annual household income, self-reported drug use, and drug use disorders. National Vital Statistics System Mortality (NVSS-M) data for U.S. residents include information from death certificates filed in the 50 states and the District of Columbia. Cases were selected with an underlying cause of death based on the ICD-10 codes for drug overdoses (X40–X44, X60–X64, X85, and Y10–Y14). NVSS-M variables include decedent characteristics (sex, age, and race/ethnicity) and information on intent (unintentional, suicide, homicide, or undetermined), location of death (medical facility, in a home, or other [including nursing homes, hospices, unknown, and other locations]) and county of residence (metropolitan/nonmetropolitan). Metropolitan/nonmetropolitan status is assigned independently in each data system. NSDUH uses a three-category system: Core Based Statistical Area (CBSA) of ≥1 million persons; CBSA of <1 million persons; and not a CBSA, which for simplicity were labeled large metropolitan, small metropolitan, and nonmetropolitan. Deaths from NVSS-M are categorized by the county of residence of the decedent using CDC’s National Center for Health Statistics 2013 Urban-Rural Classification Scheme, collapsed into two categories (metropolitan and nonmetropolitan). Results Although both metropolitan and nonmetropolitan areas experienced significant increases from 2003–2005 to 2012–2014 in self-reported past-month use of illicit drugs, the prevalence was highest for the large metropolitan areas compared with small metropolitan or nonmetropolitan areas throughout the study period. Notably, past-month use of illicit drugs declined over the study period for the youngest respondents (aged 12–17 years). The prevalence of past-year illicit drug use disorders among persons using illicit drugs in the past year varied by metropolitan/nonmetropolitan status and changed over time. Across both metropolitan and nonmetropolitan areas, the prevalence of past-year illicit drug use disorders declined during 2003–2014. In 2015, approximately six times as many drug overdose deaths occurred in metropolitan areas than occurred in nonmetropolitan areas (metropolitan: 45,059; nonmetropolitan: 7,345). Drug overdose death rates (per 100,000 population) for metropolitan areas were higher than in nonmetropolitan areas in 1999 (6.4 versus 4.0), however, the rates converged in 2004, and by 2015, the nonmetropolitan rate (17.0) was slightly higher than the metropolitan rate (16.2). Interpretation Drug use and subsequent overdoses continue to be a critical and complicated public health challenge across metropolitan/nonmetropolitan areas. The decline in illicit drug use by youth and the lower prevalence of illicit drug use disorders in rural areas during 2012–2014 are encouraging signs. However, the increasing rate of drug overdose deaths in rural areas, which surpassed rates in urban areas, is cause for concern. Public Health Actions Understanding the differences between metropolitan and nonmetropolitan areas in drug use, drug use disorders, and drug overdose deaths can help public health professionals to identify, monitor, and prioritize responses. Consideration of where persons live and where they die from overdose could enhance specific overdose prevention interventions, such as training on naloxone administration or rescue breathing. Educating prescribers on CDC’s guideline for prescribing opioids for chronic pain (Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep 2016;66[No. RR-1]) and facilitating better access to medication-assisted treatment with methadone, buprenorphine, or naltrexone could benefit communities with high opioid use disorder rates.

Promising roles for pharmacists in addressing the U.S. opioid crisis

Overdoses of prescription or illicit opioids claimed the lives of 116 Americans each day in 2016, and the crisis continues to escalate. As healthcare systems evolve to address the crisis, the potential of pharmacists to make a positive difference is significant. In addition to utilizing available prescription drug monitoring programs to help prevent diversion of opioids, practicing pharmacists can be alert for signs of opioid misuse by patients (e.g., multiple prescriptions from different physicians) as well as inappropriate prescribing or hazardous drug combinations that physicians may not be aware of (e.g., opioid analgesics combined with benzodiazepines). They can also supply patients with information on risks of opioids, proper storage and disposal of medications, and the harms (and illegality) of sharing medications with other people. Increasingly, pharmacies are sites of distribution of the opioid antagonist naloxone, which has been shown to save lives when made available to opioid users and their families or other potential bystanders to an overdose; and pharmacists can provide guidance about its use and even legal protections for bystanders to an overdose that customers may not be aware of. Pharmacists can also recommend addiction treatment to patients and be a resource for information on addiction treatment options in the community. As addiction treatment becomes more integrated with general healthcare, pharmacies are also increasingly dispensing medications like buprenorphine and, in the future, possibly methadone. Pharmacists in private research labs and at universities are helping to develop the next generation of addiction treatments and safer, non-addictive pain medications; they can also play a role in implementation research to enhance the delivery of addiction interventions and medications in pharmacy settings. Meanwhile, pharmacists in educational settings can promote improved education about the neurobiology and management of pain and its links to opioid misuse and addiction.

Prescription Drug Coverage for Treatment of Low Back Pain Among US Medicaid, Medicare Advantage, and Commercial Insurers

Key Points Question Among US insurers, what are the coverage policies for pharmacologic treatments for low back pain? Findings In this cross-sectional study of 62 products used to treat low back pain examined across 50 Medicaid, Medicare Advantage, and commercial insurance plans, utilization management strategies were common for nonopioids and opioids alike. Key informant interviews with plan executives underscored the frequent absence of comprehensive strategies to improve chronic pain treatment and to better integrate pharmacologic and nonpharmacologic opioid alternatives. Meaning Our findings underscore important opportunities among insurers to redesign coverage policies to improve pain management and reduce opioid-related injuries and deaths.

Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas-United States

Drug overdoses are a leading cause of injury death in the United States, resulting in approximately 52,000 deaths in 2015. Understanding differences in illicit drug use, illicit drug use disorders, and overall drug overdose deaths in metropolitan and nonmetropolitan areas is important for informing public health programs, interventions, and policies.

Changes in the medical management of patients on opioid analgesics following a diagnosis of substance abuse.

When providers recognize that patients are abusing prescription drugs, review of the drugs they are prescribed and attempts to treat the substance use disorder are warranted. However, little is known about whether prescribing patterns change following such a diagnosis.

Physician Dispensing of Oxycodone and Other Commonly Used Opioids, 2000–2015, United States

ObjectivenAn average of 91 people in the United States die every day from an opioid-related overdose (including prescription opioids and heroin). The direct dispensing of opioids from health care practitioner offices has been linked to opioid-related harms. The objective of this study is to describe the changing nature of the volume of this type of prescribing at the state level.nnnMethodsnThis descriptive study examines the distribution of opioids by practitioners using 1999-2015 Automation of Reports and Consolidated Orders System data. Analyses were restricted to opioids distributed to practitioners. Amount distributed (morphine milligram equivalents [MMEs]) and number of practitioners are presented.nnnResultsnPatterns of distribution to practitioners and the number of practitioners varied markedly by state and changed dramatically over time. Comparing 1999 with 2015, the MME distributed to dispensing practitioners decreased in 16 states and increased in 35. Most notable was the change in Florida, which saw a peak of 8.94 MMEs per 100,000 persons in 2010 (the highest distribution in all states in all years) and a low of 0.08 in 2013.nnnDiscussionnThis study presents the first state estimates of office-based dispensing of opioids. Increases in direct dispensing in recent years may indicate a need to monitor this practice and consider whether changes are needed. Using controlled substances data to identify high prescribers and dispensers of opioids, as well as examining overall state trends, is a foundational activity to informing the response to potentially high-risk clinical practices.