G. Caleb Alexander

The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction

Public health authorities have described, with growing alarm, an unprecedented increase in morbidity and mortality associated with use of opioid pain relievers (OPRs). Efforts to address the opioid crisis have focused mainly on reducing nonmedical OPR use. Too often overlooked, however, is the need for preventing and treating opioid addiction, which occurs in both medical and nonmedical OPR users. Overprescribing of OPRs has led to a sharp increase in the prevalence of opioid addiction, which in turn has been associated with a rise in overdose deaths and heroin use. A multifaceted public health approach that utilizes primary, secondary, and tertiary opioid addiction prevention strategies is required to effectively reduce opioid-related morbidity and mortality. We describe the scope of this public health crisis, its historical context, contributing factors, and lines of evidence indicating the role of addiction in exacerbating morbidity and mortality, and we provide a framework for interventions to address the epidemic of opioid addiction.

Knowledge and Early Adoption of the HPV Vaccine Among Girls and Young Women: Results of a National Survey

PURPOSE In 2006, universal human papillomavirus (HPV) vaccination of females ages 9 to 26 years became a formal recommendation, yet little is known about knowledge and adoption of this vaccine. METHODS A cross-sectional survey of females aged 13 to 26 years was drawn from a nationally representative panel, and developed and maintained by Knowledge Networks, Inc. (Menlo Park, CA). Outcome measures included: (a) knowledge about HPV and the HPV vaccine, (b) barriers to vaccine adoption, and (c) prevalence and correlates of early vaccine receipt. RESULTS Overall, 1,011 of 2,143 subjects (47%) completed the survey. Thirty percent of 13- to 17-year-olds and 9% of 18- to 26-year-olds reported receipt of at least one HPV injection. Knowledge about HPV varied; however, 5% or fewer subjects believed that the HPV vaccine precluded the need for regular cervical cancer screening or safe-sex practices. Adjusting for healthcare utilization and sources of information, vaccine receipt was more likely among 13- to 17-year-olds who reported a recent healthcare visit (adjusted odds ratio [AOR] 7.31, confidence interval [CI] 2.00-26.8) and reported discussing the HPV vaccine (AOR 4.50, CI 1.02-19.90) with a healthcare provider; and more likely among 18- to 26-year-olds who reported discussing the HPV vaccine (AOR 3.08, CI 1.21-7.80) with family or a healthcare provider (AOR 11.92, CI 2.62-54.27). CONCLUSIONS Few girls and young women believe that the HPV vaccine is protective beyond the true impact of the vaccine. Despite moderate uptake, many females at risk of acquiring HPV have not yet received the vaccine. These findings suggest the important role of both healthcare providers and parents in HPV vaccine adoption.

National Trends in Oral Anticoagulant Use in the United States, 2007 to 2011

Background—Little is known regarding the adoption of direct thrombin inhibitors in clinical practice. We examine trends in oral anticoagulation for the prevention of thromboembolism in the United States. Methods and Results—We used the IMS Health National Disease and Therapeutic Index, a nationally representative audit of office-based providers, to quantify patterns of oral anticoagulant use among all subjects and stratified by clinical indication. We quantified oral anticoagulant expenditures using the IMS Health National Prescription Audit. Between 2007 and 2011, warfarin treatment visits declined from ≈2.1 million (M) quarterly visits to ≈1.6M visits. Dabigatran use increased from 0.062M quarterly visits (2010Q4) to 0.363M visits (2011Q4), reflecting its increasing share of oral anticoagulant visits from 3.1% to 18.9%. In contrast to warfarin, the majority of dabigatran visits have been for atrial fibrillation, though this proportion decreased from 92% (2010Q4) to 63% (2011Q4), with concomitant increases in dabigatran’s off-label use. Among atrial fibrillation visits, warfarin use decreased from 55.8% visits (2010Q4) to 44.4% (2011Q4), whereas dabigatran use increased from 4.0% to 16.9%. Of atrial fibrillation visits, the fraction not treated with any oral anticoagulants has remained unchanged at ≈40%. Expenditures related to dabigatran increased rapidly from

National Trends in Treatment of Type 2 Diabetes Mellitus, 1994-2007

16M in 2010Q4 to

Comparative risk of gastrointestinal bleeding with dabigatran, rivaroxaban, and warfarin: population based cohort study.

166M in 2011Q4, exceeding expenditures on warfarin (

National Trends in Ambulatory Oral Anticoagulant Use

144M) in 2011Q4. Conclusions—Dabigatran has been rapidly adopted into ambulatory practice in the United States, primarily for treatment of atrial fibrillation, but increasingly for off-label indications. We did not find evidence that it has increased overall atrial fibrillation treatment rates.

Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010.

BACKGROUND Diabetes mellitus is common, costly, and increasingly prevalent. Despite innovations in therapy, little is known about patterns and costs of drug treatment. METHODS We used the National Disease and Therapeutic Index to analyze medications prescribed between 1994 and 2007 for all US office visits among patients 35 years and older with type 2 diabetes. We used the National Prescription Audit to assess medication costs between 2001 and 2007. RESULTS The estimated number of patient visits for treated diabetes increased from 25 million (95% confidence interval [CI], 23 million to 27 million) in 1994 to 36 million (95% CI, 34 million to 38 million) by 2007. The mean number of diabetes medications per treated patient increased from 1.14 (95% CI, 1.06-1.22) in 1994 to 1.63 (1.54-1.72) in 2007. Monotherapy declined from 82% (95% CI, 75%-89%) of visits during which a treatment was used in 1994 to 47% (43%-51%) in 2007. Insulin use decreased from 38% of treatment visits in 1994 to a nadir of 25% in 2000 and then increased to 28% in 2007. Sulfonylurea use decreased from 67% of treatment visits in 1994 to 34% in 2007. By 2007, biguanides (54% of treatment visits) and glitazones (thiazolidinediones) (28%) were leading therapeutic classes. Increasing use of glitazones, newer insulins, sitagliptin phosphate, and exenatide largely accounted for recent increases in the mean cost per prescription (

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

56 in 2001 to

Impact of FDA Black Box Advisory on Antipsychotic Medication Use

76 in 2007) and aggregate drug expenditures (

Impact of FDA drug risk communications on health care utilization and health behaviors: A systematic review

6.7 billion in 2001 to