Joseph O. Merrill

Opioid Prescriptions for Chronic Pain and Overdose: A Cohort Study

BACKGROUND Long-term opioid therapy for chronic noncancer pain is becoming increasingly common in community practice. Concomitant with this change in practice, rates of fatal opioid overdose have increased. The extent to which overdose risks are elevated among patients receiving medically prescribed long-term opioid therapy is unknown. OBJECTIVE To estimate rates of opioid overdose and their association with an average prescribed daily opioid dose among patients receiving medically prescribed, long-term opioid therapy. DESIGN Cox proportional hazards models were used to estimate overdose risk as a function of average daily opioid dose (morphine equivalents) received at the time of overdose. SETTING HMO. PATIENTS 9940 persons who received 3 or more opioid prescriptions within 90 days for chronic noncancer pain between 1997 and 2005. MEASUREMENTS Average daily opioid dose over the previous 90 days from automated pharmacy data. Primary outcomes--nonfatal and fatal overdoses--were identified through diagnostic codes from inpatient and outpatient care and death certificates and were confirmed by medical record review. RESULTS 51 opioid-related overdoses were identified, including 6 deaths. Compared with patients receiving 1 to 20 mg/d of opioids (0.2% annual overdose rate), patients receiving 50 to 99 mg/d had a 3.7-fold increase in overdose risk (95% CI, 1.5 to 9.5) and a 0.7% annual overdose rate. Patients receiving 100 mg/d or more had an 8.9-fold increase in overdose risk (CI, 4.0 to 19.7) and a 1.8% annual overdose rate. LIMITATIONS Increased overdose risk among patients receiving higher dose regimens may be due to confounding by patient differences and by use of opioids in ways not intended by prescribing physicians. The small number of overdoses in the study cohort is also a limitation. CONCLUSION Patients receiving higher doses of prescribed opioids are at increased risk for overdose, which underscores the need for close supervision of these patients. PRIMARY FUNDING SOURCE National Institute of Drug Abuse.

Self-Report Measures of Antiretroviral Therapy Adherence: A Review with Recommendations for HIV Research and Clinical Management

A review of 77 studies employing self-report measures of antiretroviral adherence published 1/1996 through 8/2004 revealed great variety in adherence assessment item content, format, and response options. Recall periods ranged from 2 to 365 days (mode=7 days). The most common cutoff for optimal adherence was 100% (21/48 studies, or 44%). In 27 of 34 recall periods (79%), self-reported adherence was associated with adherence as assessed with other indirect measures. Data from 57 of 67 recall periods (84%) indicated self-reported adherence was significantly associated with HIV-1 RNA viral load; in 16 of 26 (62%), it was associated with CD4 count. Clearly, the field would benefit from item standardization and a priori definitions and operationalizations of adherence. We conclude that even brief self-report measures of antiretroviral adherence can be robust, and recommend items and strategies for HIV research and clinical management.

Trends in long-term opioid therapy for chronic non-cancer pain

To report trends and characteristics of long‐term opioid use for non‐cancer pain.

De Facto Long-term Opioid Therapy for Noncancer Pain

ObjectivesThis paper describes characteristics of opioid use episodes for noncancer pain and defines thresholds for de facto long-term opioid therapy. MethodsCONSORT (CONsortium to Study Opioid Risks and Trends) includes adult members of 2 health plans serving over 1% of the US population. Opioid use episodes beginning in the years 1997 to 2005 were classified as acute, episodic, long-term/lower dose, or long-term/higher dose. ResultsOn the basis of evaluation of the likelihood of opioid use continuing, long-term opioid therapy was defined by episodes lasting longer than 90 days with 10+ opioid prescriptions or 120+ days supply of opioids dispensed. Long-term/higher dose episodes (<1.5% of all opioid use episodes) were characterized by daily or near daily use, a mean duration of about 1000 days, and an average daily dose of about 55 mg. They accounted for more than half the total morphine equivalents dispensed from the years 1997 to 2006. Short-acting, non-Schedule II opioids (eg, hydrocodone with acetaminophen) were, by far, the most commonly prescribed medications for acute, episodic, and long-term episodes. Long-acting (sustained-release) opioids were the predominately prescribed medication in a minority of long-term episodes (6% to 12%). DiscussionLong-term opioid therapy was characterized by the diversity in medications prescribed, dosage levels, and frequency of use. The proposed threshold for long-term opioid therapy provides a checkpoint for physicians to review whether an explicit decision to sustain opioid therapy has been reached, and to ensure that a documented treatment plan and provisions for monitoring medication use and patient outcomes are in place.

Gender Differences in Chronic Medical, Psychiatric, and Substance-Dependence Disorders Among Jail Inmates

OBJECTIVES We investigated whether there were gender differences in chronic medical, psychiatric, and substance-dependence disorders among jail inmates and whether substance dependence mediated any gender differences found. METHODS We analyzed data from a nationally representative survey of 6982 US jail inmates. Weighted estimates of disease prevalence were calculated by gender for chronic medical disorders (cancer, hypertension, diabetes, arthritis, asthma, hepatitis, and cirrhosis), psychiatric disorders (depressive, bipolar, psychotic, posttraumatic stress, anxiety, and personality), and substance-dependence disorders. We conducted logistic regression to examine the relationship between gender and these disorders. RESULTS Compared with men, women had a significantly higher prevalence of all medical and psychiatric conditions (P < or = .01 for each) and drug dependence (P < .001), but women had a lower prevalence of alcohol dependence (P < .001). Gender differences persisted after adjustment for sociodemographic factors and substance dependence. CONCLUSIONS Women in jail had a higher burden of chronic medical disorders, psychiatric disorders, and drug dependence than men, including conditions found more commonly in men in the general population. Thus, there is a need for targeted attention to the chronic medical, psychiatric, and drug-treatment needs of women at risk for incarceration, both in jail and after release.

Trends in long-term opioid therapy for noncancer pain among persons with a history of depression

OBJECTIVE We report trends in long-term opioid use among patients with a history of depression from two large health plans. METHODS Using claims data, age- and gender-adjusted rates for long-term (>90 days) opioid use episodes were calculated for 1997-2005, comparing those with and without a depression diagnosis in the prior 2 years. Opioid use characteristics were calculated for those with a long-term episode in 2005. RESULTS Incident and prevalent long-term opioid use rates were three times higher in those with a history of depression. Prevalent long-term use per 1000 in patients with a history of depression increased from 69.8 to 125.9 at Group Health and from 84.3 to 117.5 at Kaiser Permanente of Northern California between 1997 and 2005. Those with a history of depression were more likely to receive a higher average daily dose, greater days supply, and Schedule II opioids than nondepressed persons. CONCLUSION Persons with a history of depression are more likely to receive long-term opioid therapy for noncancer pain than those without a history of depression. Results suggest that long-term opioid therapy for noncancer pain is being prescribed to a different population in clinical practice than the clinical trial populations where opioid efficacy has been established.

Age and Gender Trends in Long-Term Opioid Analgesic Use for Noncancer Pain

OBJECTIVES We describe age and gender trends in long-term use of prescribed opioids for chronic noncancer pain in 2 large health plans. METHODS Age- and gender-standardized incident (beginning in each year) and prevalent (ongoing) opioid use episodes were estimated with automated health care data from 1997 to 2005. Profiles of opioid use in 2005 by age and gender were also compared. RESULTS From 1997 to 2005, age-gender groups exhibited a total percentage increase ranging from 16% to 87% for incident long-term opioid use and from 61% to 135% for prevalent long-term opioid use. Women had higher opioid use than did men. Older women had the highest prevalence of long-term opioid use (8%-9% in 2005). Concurrent use of sedative-hypnotic drugs and opioids was common, particularly among women. CONCLUSIONS Risks and benefits of long-term opioid use are poorly understood, particularly among older adults. Increased surveillance of the safety of long-term opioid use is needed in community practice settings.

Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders

ABSTRACT Long‐term opioid therapy for non‐cancer pain has increased. Caution is advised in prescribing for persons with substance use disorders, but little is known about actual health plan practices. This paper reports trends and characteristics of long‐term opioid use in persons with non‐cancer pain and a substance abuse history. Using health plan data (1997–2005), the study compared age–sex‐standardized rates of incident, incident long‐term and prevalent long‐term prescription opioid use, and medication use profiles in those with and without substance use disorder histories. The CONsortium to Study Opioid Risks and Trends study included adult enrollees of two health plans, Kaiser Permanente of Northern California (KPNC) and Group Health Cooperative (GH) of Seattle, Washington. At KPNC (1999–2005), prevalence of long‐term use increased from 11.6% to 17.0% for those with substance use disorder histories and from 2.6% to 3.9% for those without substance use disorder histories. Respective GH rates (1997–2005), increased from 7.6% to 18.6% and from 2.7% to 4.2%. Among persons with an opioid disorder, KPNC rates increased from 44.1% to 51.1%, and GH rates increased from 15.7% to 52.4%. Long‐term opioid users with a prior substance abuse diagnosis received higher dosage levels, were more likely to use Schedule II and long‐acting opioids, and were more often frequent users of sedative‐hypnotic medications in addition to their opioid use. Since these patients are viewed as higher risk, the increased use of long‐term opioid therapy suggests the importance of improved understanding of the benefits and risks of opioid therapy among persons with a history of substance abuse, and the need for more careful screening for substance abuse history than is the usual practice.

Problems and concerns of patients receiving chronic opioid therapy for chronic non-cancer pain

&NA; The value of chronic opioid therapy (COT) for chronic non‐cancer pain (CNCP) patients is determined by a balance of poorly understood benefits and harms. Traditionally, this balance has been framed as the potential for improved pain control versus risks of iatrogenic addiction, drug diversion, and aberrant drug‐related behaviors. These potential harms are typically defined from the providers’ perspective. This paper seeks to clarify difficulties with the long‐term use of opioids for CNCP from the patients’ perspective. We used the Prescribed Opioids Difficulties Scale (PODS) to assess current problems and concerns attributed to opioid use by 1144 adults receiving COT. Subjects were grouped into low (56.9%), medium (25.6%) and high (17.5%) PODS scorers. Among patients with high PODS scores, 64% were clinically depressed and 78% experienced high levels of pain‐related interference with activities, compared to 28% depressed and 60% with high interference with activities among those with low PODS scores. High levels of opioid‐related problems and concerns were not explained by differences in pain intensity or persistence. Patients with medium to high PODS scores were often concerned about their ability to control their use of opioid medications, but prior substance abuse diagnoses and receiving excess days supply of opioids were much less common in these patients than depression and pain‐related interference with activities. These results suggest two types of potential harm from COT attributed by CNCP patients to opioids: psychosocial problems that are distinct from poor pain control and opioid control concerns that are distinct from opioid misuse or addiction.

“Hooked on” Prescription-Type Opiates Prior to Using Heroin: Results from a Survey of Syringe Exchange Clients

Abstract The availability and diversion of prescription-type opioids increased dramatically in the first decade of the twenty-first century. One possible consequence of increased prescription opioid use and accessibility is the associated rise in opioid dependence, potentially resulting in heroin addiction. This study aimed to determine how common initial dependence on prescription-type opioids is among heroin injectors; associations with demographic and drug-using characteristics were also examined. Interview data were collected at syringe exchanges in King County, Washington in 2009. Among the respondents who had used heroin in the prior four months, 39% reported being “hooked on” prescription-type opioids first. Regression analysis indicated that younger age, sedative use and no recent crack use were independently associated with self-report of being hooked on prescription-type opioids prior to using heroin. These data quantify the phenomenon of being hooked on prescription-type opioids prior to initiating heroin use. Further research is needed to characterize the epidemiology, etiology and trajectory of prescription-type opioid and heroin use in the context of continuing widespread availability of prescription-type opioids.