Joanne Salas

Prescription Opioid Duration, Dose, and Increased Risk of Depression in 3 Large Patient Populations

PURPOSE Recent results suggests the risk of a new onset of depression increases with longer duration of opioid analgesic use. It is unclear whether new-onset depression related to opioid analgesic use is a function of the dose prescribed or the duration of use or both. METHODS Using a retrospective cohort design, we collected patient data from 2000 to 2012 from the Veterans Health Administration (VHA), and from 2003 to 2012 from both Baylor Scott & White Health (BSWH) and the Henry Ford Health System (HFHS). Patients (70,997 VHA patients, 13,777 BSWH patients, and 22,981 HFHS patients) were new opioid users, aged 18 to 80 years, without a diagnosis of depression at baseline. Opioid analgesic use duration was defined as 1 to 30, 31 to 90, and more than 90 days, and morphine equivalent dose (MED) was defined as 1 to 50 mg/d, 51 to 100 mg/d, and greater than 100 mg/d of analgesic. Pain and other potential confounders were controlled for by inverse probability of treatment–weighted propensity scores. RESULTS New-onset depression after opioid analgesic use occurred in 12% of the VHA sample, 9% of the BSWH sample, and 11% of the HFHS sample. Compared with 1- to 30-day users, new-onset depression increased in those with longer opioid analgesic use. Risk of new-onset depression with 31 to 90 days of opioid analgesic use ranged from hazard ratio [HR] = 1.18 (95% CI, 1.10–1.25) in VHA to HR = 1.33 (95% CI, 1.16–1.52) in HFHS; in opioid analgesic use of more than 90 days, it ranged from HR = 1.35 (95% CI, 1.26–1.44) in VHA to HR = 2.05 (95% CI, 1.75–2.40) in HFHS. Dose was not significantly associated with a new onset of depression. CONCLUSIONS Opioid-related new onset of depression is associated with longer duration of use but not dose. Patients and practitioners should be aware that opioid analgesic use of longer than 30 days imposes risk of new-onset depression. Opioid analgesic use, not just pain, should be considered a potential source when patients report depressed mood.

Change in opioid dose and change in depression in a longitudinal primary care patient cohort

Abstract Depression is associated with receipt of higher doses of prescription opioids. It is not known whether the reverse association exists in that an increased opioid dose is associated with increased depression. Questionnaires were administered to 355 patients with chronic low back pain at baseline and 1-year and 2-year follow-up. Depression, pain, anxiety, health-related quality of life, and social support or stress were obtained by survey. Opioid type and dose and comorbid conditions were derived from chart abstraction. Random intercept, generalized linear mixed models were computed to estimate the association between change in opioid morphine equivalent dose (MED) thresholds (0, 1-50, >50 mg) and probability of depression over time. Second, we computed the association between change in depression and odds of an increasing MED over time. After adjusting for covariates, an increase to >50 mg MED from nonuse increased a participants probability of depression over time (odds ratio [OR] = 2.65; 95% confidence interval [CI], 1.17-5.98). An increase to 1 to 50 mg MED did not increase an individuals probability of depression over time (OR = 1.08; 95% CI, 0.65-1.79). In unadjusted analysis, developing depression was associated with a 2.13 (95% CI, 1.36-3.36) increased odds of a higher MED. This association decreased after adjusting for all covariates (OR = 1.65; 95% CI, 0.97-2.81). Post hoc analysis revealed that depression was significantly associated with a 10.1-mg MED increase in fully adjusted models. Change to a higher MED leads to an increased risk of depression, and developing depression increases the likelihood of a higher MED. We speculate that treating depression or lowering MED may mitigate a bidirectional association and ultimately improve pain management.

DIFFERENCES BETWEEN WOMEN AT HIGHER AND LOWER RISK FOR AN UNINTENDED PREGNANCY

CONTEXT Little is known about the preconception health status of women that are at risk for an unintended pregnancy. OBJECTIVE We hypothesized that women at high risk for an unintended pregnancy would engage in less healthy behaviors and would have fewer health care encounters than women at lower risk. DESIGN Using the Behavioral Risk Factor Surveillance System (2002 and 2004 datasets), we examined health factors of 18- to 44-year-old, fertile women who were not intending a pregnancy, grouped into high-risk (n=16,113) or low-risk (n=39,426) groups. Women were designated as high risk for an unintended pregnancy based on their non-use of birth control, and women were designated as low-risk for an unintended pregnancy based on their use of birth control. RESULTS Controlling for variables that mask or exacerbate relationships between risk factors and outcomes was an important component of this study. After controlling for the effects of demographic characteristics, we found that high-risk women remained 1.23 times more likely to be obese (confidence interval [CI], 1.12-1.34) and 1.2 times more likely to smoke (CI, 1.11-1.31), both significant findings. We also found high-risk women to be 27% less likely to exercise (CI, 0.67-0.79), 62% less likely to receive a Pap test (CI, 0.31-0.46), 19% less likely to have HIV testing (CI, 0.75-0.87), and 44% less likely to have received sexually transmitted diseases counseling (CI, 0.50-0.63) compared with low-risk women. Interestingly, high-risk women were 27% less likely to use any alcohol (CI, 0.67-0.79) and 11% less likely to binge drink (CI, 0.80-0.99) compared with women at low-risk for an unintended pregnancy. CONCLUSIONS Nearly one third of women at risk for an unintended pregnancy are not using any contraceptive method (29%), and these high-risk women also have higher proportions of unhealthy behaviors and significantly lower clinical health encounters than women using any form of birth control (low-risk women).

Exploring Pregnancy‐Related Changes in Alcohol Consumption Between Black and White Women

BACKGROUND Although epidemiological data indicate that White women are more likely to drink and binge drink before pregnancy, fetal alcohol syndrome (FAS) is more common in the Black population than among Whites in the United States. Differences in drinking cessation between Black and White women who become pregnant may help explain the disparity in FAS rates. METHODS The study sample was comprised of 280,126 non-Hispanic Black and White women, ages 18 to 44, from the Behavioral Risk Factor Surveillance System (BRFSS) 2001 to 2005 data sets. Predictors of reduction in alcohol consumption (in drinks per month) and binge drinking (>4 drinks on one occasion) by pregnant and non-pregnant women were identified with logistic regression. The effect of interactions of pregnancy status with age, education, and Black or White race on drinks per month and binge occasions were explored using analysis of variance (ANOVA). RESULTS Pregnant White women averaged 79.5% fewer drinks per month than non-pregnant White women (F = 1250.1, p < 0.001), and 85.4% fewer binge drinking occasions (F = 376, p < 0.001). Pregnant Black women averaged 58.2% fewer drinks per month than non-pregnant Black women (F = 31.8, p < 0.001) and 64.0% fewer binge occasions (F = 13.8, p < 0.001). Compared to Black women, White women appear to make a 38% greater reduction in drinks per month, and a 33% greater reduction in binge occasions. CONCLUSIONS Non-Hispanic White women appear more likely to reduce drinks per month and binge drinking occasions than non-Hispanic Black women during pregnancy. These findings may help explain disparities in FAS in the United States, though this cross-sectional sample does not permit claims of causation. To better describe the impact of differential drinking reduction on FAS rates, future studies of longitudinal data should be done.

Antidepressant medication use and glycaemic control in co-morbid type 2 diabetes and depression

OBJECTIVE Depression is prevalent in diabetes and is associated with increased risks of hyperglycaemia, morbidity and mortality. The effect of antidepressant medication (ADM) on glycaemic control is uncertain owing to a paucity of relevant data. We sought to determine whether the use of ADM is associated with glycaemic control in depressed patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A retrospective cohort study (n = 1399) was conducted using electronic medical record registry data of ambulatory primary care visits from 2008 to 2013. Depression and type 2 diabetes were identified from ICD-9-CM codes; ADM use was determined from prescription orders; and glycaemic control was determined from measures of glycated haemoglobin (A1c). Good glycaemic control was defined as A1c < 7.0% (53 mmol/mol). Generalized estimating equations were used to determine the effect of depression and ADM use on glycaemic control. RESULTS Good glycaemic control was achieved by 50.9% of depressed subjects receiving ADM versus 34.6% of depressed subjects without ADM. After adjusting for covariates, depressed patients receiving ADM were twice as likely as those not receiving ADM to achieve good glycaemic control (odds ratio = 1.95; 95% confidence interval: 1.02-3.71). CONCLUSIONS In this retrospective cohort study of a large sample of primary care patients with type 2 diabetes, ADM use was associated with improved glycaemic control.

The Association of Sleep Duration and Depressive Symptoms in Rural Communities of Missouri, Tennessee, and Arkansas

PURPOSE To determine the association between sleep duration and depressive symptoms in a rural setting. METHODS We conducted a cross-sectional study using data from Wave 3 of the Walk the Ozarks to Wellness Project including 12 rural communities in Missouri, Arkansas, and Tennessee (N = 1,204). Sleep duration was defined based on average weeknight and weekend hours per day: short (<7), optimal (7-8), and long (>8). The primary outcome was self-reported elevated depressive symptoms. Multivariable logistic regression was used to estimate adjusted prevalence odds ratios (aPOR) and 95% confidence intervals (95% CI). FINDINGS Elevated depressive symptoms were common in this rural population (17%). Depressive symptoms were more prevalent among subjects with short (26.1%) and long (24%) sleep duration compared to those with optimal (11.8%) sleep duration. After adjusting for age, gender, race, education, employment status, income, and BMI, short sleep duration was associated with increased odds of elevated depressive symptoms (aPOR = 2.12, 95% CI: 1.49, 3.01), compared to optimal sleep duration. Conversely, the association between long sleep duration and depressive symptoms was not statistically significant after covariate adjustment. Similar findings were observed when we excluded individuals with insomnia symptoms for analysis. CONCLUSIONS This study suggests that short sleep duration (<7 hours per night) and depressive symptoms are common among rural populations. Short sleep duration is positively associated with elevated depressive symptoms. The economic and health care burden of depression may be more overwhelming among rural populations, necessitating the need to target modifiable behaviors such as sleep habits to improve mental health.

Exploring Health by Reproductive Status: An Epidemiological Analysis of Preconception Health

BACKGROUND Recently published preconception health guidelines promote maternal health, yet adherence to those guidelines has not been documented. We hypothesized that pregnant women engaged in a healthier lifestyle than nonpregnant women, although this may vary by pregnancy intention and birth control method. METHODS We performed secondary analysis of cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS) (2002 and 2004 datasets). The data are collected in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam through a telephone survey of 350,000 adults annually. Subjects were a representative sample of noninstitutionalized, 18-44-year-old, fertile women (n = 66,152). Based on pregnancy risk, women were grouped into one of five categories: pregnant, intending pregnancy (IP), unintended pregnancy high risk (HR), moderate risk (MR), and low risk (LR). Logistic regression was used to estimate adjusted prevalence odds ratios (aPOR) and 95% confidence intervals (CI) for behavioral characteristics using pregnant women as the referent group. RESULTS IP, HR, MR, and LR women were more likely to drink any alcohol (aPOR 10.85, aPOR 8.39, aPOR 11.90, aPOR 11.98, respectively), binge drink (aPOR 7.07, aPOR 6.24, aPOR 7.27, aPOR 7.17, respectively), heavy drink (aPOR 6.90, aPOR 5.67, aPOR 7.48, aPOR 5.89, respectively), and smoke (aPOR 2.89, aPOR 2.69, aPOR 2.40, aPOR 2.09, respectively). Interestingly, IP, HR, MR, and LR women were more likely to engage in leisure activity (aPOR 1.37, aPOR 1.19, aPOR 1.57, aPOR 1.17, respectively). HR, MR, and LR women were less likely to consume folic acid (aPOR 0.14, aPOR 0.21, aPOR 0.29, respectively), whereas women intending a pregnancy were equally likely to consume folic acid (aPOR 0.77 CI 0.30, 2.0), although the response rate for folic acid was low. CONCLUSIONS Preconceptional health goals are not being met. Pregnancy risk, as delineated by contraceptive use, can inform interventions designed to prevent adversely exposed pregnancies.

Cholesterol Treatment and Changes in Guidelines in an Academic Medical Practice

BACKGROUND National guidelines are intended to influence physician cholesterol treatment practices, yet few studies have documented the effect of new guidelines on actual prescribing behaviors and impacts on patient eligibility for treatment. We describe current cholesterol treatment in an academic practice of Family and Internal Medicine physicians as well the effect of a change in cholesterol treatment guidelines from 2001 Adult Treatment Panel III (ATPIII) to 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. METHODS Medical records were extracted from primary care patients aged 40-75 years with at least one outpatient visit from January 1, 2012 to July 31, 2013; patients were included if they had records of cholesterol testing, blood pressure measurement, sex, race, and smoking status. Patients were classified into ATPIII and ACC/AHA categories based on clinical variables (eg, diabetes, hypertension, atherosclerotic cardiovascular disease), Framingham Risk Score, and 10-year atherosclerotic cardiovascular disease risk. RESULTS There were 4536 patients included in the analysis. Of these, 71% met ATPIII goals and 56% met ACC/AHA guidelines, a 15% decrease. Forty-three percent of high-risk patients met their low-density lipoprotein goals and 46% were on statins. Overall, 32% of patients would need to be started on a statin, 12% require an increased dose, and 6% could stop statins. Of patients considered low risk by ATPIII guidelines, 271 would be eligible for treatment by ACC/AHA guidelines, whereas 129 patients were shifted from intermediate risk to low risk with the change in guidelines. CONCLUSIONS The ACC/AHA guidelines expand the number of patients recommended to receive statins, particularly among patients who were previously thought to be at moderate risk, and would increase the intensity of treatment for many patients at high risk. Significant numbers of patients at risk for cardiovascular events were not receiving guideline-based treatment. New cholesterol guidelines may make treatment decisions easier.

Surveillance of Preconception Health Indicators in Behavioral Risk Factor Surveillance System: Emerging Trends in the 21st Century

OBJECTIVES This article assesses emerging trends in the 21st century, if any, in preconception health indicators among women of reproductive age. METHODS This is a secondary analysis of cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS), 2003-2010. Subjects were a sample of noninstitutionalized, 18-44-year-old, nonpregnant, women in the United States (n=547,177) grouped into two categories, 2003-2006 (n=275,630) and 2007-2010 (n=271,547). Overall crude and adjusted prevalence odds ratios were calculated for preconception indicators before 2006 and after 2006. RESULTS Significant improvements were found for any and heavy alcohol use, smoking, social and emotional support, moderate/vigorous physical activity, and having had an influenza shot in the last year. In contrast, binge drinking, having a medical condition (i.e., diabetes, high blood pressure, asthma, or obesity), and self-reported health significantly worsened. No change was found for mental distress, HIV testing, and having a routine checkup. CONCLUSIONS As the 21st century unfolds, emerging trends suggest that we need to focus on educating women, providers, and public health advocates about improved health before pregnancy, especially for women with chronic conditions and those who binge drink alcohol.

New-onset depression following stable, slow, and rapid rate of prescription opioid dose escalation

Abstract Recent studies suggest that longer durations of opioid use, independent of maximum morphine equivalent dose (MED) achieved, is associated with increased risk of new-onset depression (NOD). Conversely, other studies, not accounting for duration, found that higher MED increased probability of depressive symptoms. To determine whether rate of MED increase is associated with NOD, a retrospective cohort analysis of Veterans Health Administration data (2000-2012) was conducted. Eligible patients were new, chronic (>90 days) opioid users, aged 18 to 80, and without depression diagnoses for 2 years before start of follow-up (n = 7051). Mixed regression models of MED across follow-up defined 4 rate of dose change categories: stable, decrease, slow increase, and rapid increase. Cox proportional hazard models assessed the relationship of rate of dose change and NOD, controlling for pain, duration of use, maximum MED, and other confounders using inverse probability of treatment-weighted propensity scores. Incidence rate for NOD was 14.1/1000PY (person-years) in stable rate, 13.0/1000PY in decreasing, 19.3/1000PY in slow increasing, and 27.5/1000PY in rapid increasing dose. Compared with stable rate, risk of NOD increased incrementally for slow (hazard ratio = 1.22; 95% confidence interval: 1.05-1.42) and rapid (hazard ratio = 1.58; 95% confidence interval: 1.30-1.93) rate of dose increase. Faster rates of MED escalation contribute to NOD, independent of maximum dose, pain, and total opioid duration. Dose escalation may be a proxy for loss of control or undetected abuse known to be associated with depression. Clinicians should avoid rapid dose increase when possible and discuss risk of depression with patients if dose increase is warranted for pain.