Chronic Overlapping Pain Conditions and Long-Term Opioid Treatment

OBJECTIVES: One in 5 people in the United States lives with chronic pain. Many patients with chronic pain experience a subset of specific co-occurring pain conditions that may share a common pain mechanism and that have been designated as chronic overlapping pain conditions (COPCs). Little is known about chronic opioid prescribing patterns among patients with COPCs in primary care settings, especially among socioeconomically vulnerable patients. This study aims to evaluate opioid prescribing among patients with COPCs in US community health centers and to identify individual COPCs and their combinations that are associated with long-term opioid treatment (LOT). STUDY DESIGN: Retrospective cohort study. METHODS: We conducted analyses of more than 1 million patients 18 years and older based on electronic health record data from 449 US community health centers across 17 states between January 1, 2009, and December 31, 2018. Logistic regression models were used to assess the relationship between COPCs and LOT. RESULTS: Individuals with COPCs were prescribed LOT 4 times more often than individuals without a COPC (16.9% vs 4.0%). The presence of chronic low back pain, migraine headache, fibromyalgia, or irritable bowel syndrome combined with any of the other COPCs increased the odds of LOT prescribing compared with the presence of a single COPC. CONCLUSIONS: Although LOT prescribing has declined over time, it remains relatively high among patients with certain COPCs and for those with multiple COPCs. These study findings suggest target populations for future interventions to manage chronic pain among socioeconomically vulnerable patients

Efficacy and Tolerability of Pharmacotherapies to Aid Smoking Cessation in Adolescents

Abstract Adolescent smoking remains a public health problem. Despite concerns regarding adolescent nicotine dependence, few well-designed smoking cessation studies have been conducted with teen smokers. This is particularly true regarding pharmacological treatments for nicotine dependence. Currently, pharmacological aids are not recommended for treating adolescent nicotine dependence, as efficacy has not been shown in this population. This review includes studies that have examined the efficacy of pharmacotherapy for smoking abstinence and/or reduction in cigarette consumption among adolescent smokers who want to quit smoking, lab-based adolescent studies that have examined the effectiveness of these medications in reducing cravings and/or withdrawal symptoms, and/or studies that have assessed the tolerability of medications for smoking cessation in adolescent smokers. This review provides information on the pharmacologic action of each medication, the efficacy of each medication for adolescent smoking cessation, the tolerability of each medication based on reported adverse events, and compliance with the medication protocols. Thirteen relevant articles were identified and included in the review. Nicotine patch, nicotine gum, nicotine nasal spray, bupropion, and varenicline have been studied in adolescent smokers. The adverse events reported in the studies on pharmacology for adolescent smoking suggest that the side effect profiles for nicotine replacement therapy, bupropion, and varenicline are similar to those reported in adult studies. There is some evidence of efficacy of nicotine patch and bupropion at end of treatment (efficacy of varenicline has not been assessed), but none of the medications included in this review were efficacious in promoting long-term smoking cessation among adolescent smokers. It is noted that many of the study protocols did not follow the recommended dose or length of pharmacotherapy for adults, rendering it difficult to determine the true efficacy of medication for adolescent smoking cessation. Future efficacy studies are warranted before recommending pharmacotherapy for adolescent smoking cessation. Adolescent Smoking and Pharmacotherapy Adolescent smoking remains a high priority public health concern. The U.S. Department of Health and Human Services has retained the goal of reducing adolescent smoking rates in the Healthy People 2020 initiative. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Considering that over 80% of adult smokers begin smoking prior to age of 18, Relatively few well-designed smoking cessation studies have been conducted with teen smokers. This is particularly true regarding pharmacological treatments for nicotine dependence. To date, nicotine replacement, bupropion (Zyban), and varenicline have been approved as therapies for adult smokers and the recommended treatment for adult nicotine dependence is a combination of psychotherapy and pharmacotherapy. Methods Study Identification and Inclusion Searches were conducted through the PubMed and PsycINFO online databases (through May 2011) and were limited to "English Language" and "Human." The following keywords were used in the initial search "smoking cessation", "adolescent OR teen" and then limited by the separate use of the following terms: "bupropion", "Zyban", "nicotine replacement therapy", "varenicline", "Chantix", "nicotine patch", "nicotine gum", "nicotine nasal spray", and "pharmacotherapy." Only studies that targeted adolescent smokers for recruitment and enrollment were included. In addition, studies referenced in relevant review articles, metaanalyses, and all selected articles were examined. The searches yielded 14 relevant studies that included pharmacotherapy for adolescent nicotine dependence. One study was excluded from the review because the focus was on reduction of smoking among adolescents that did not want to quit and did not include data on adverse events. Nicotine replacement therapy This review focuses on nicotine replacement therapy (NRT) that has been evaluated for smoking cessation among adolescent smokers (nicotine patch, gum, and spray); however, there are other nicotine replacement products approved for smoking cessation, including a nicotine inhaler, a nicotine lozenge and, in some countries outside of the United States, a nicotine sublingual tablet. Nicotine replacement therapy (NRT) replaces the nicotine delivered while smoking to reduce craving and withdrawal symptoms and is available in different forms and dosages depending on the number of cigarettes smoked. Open-label studies- The earliest study to use NRT with adolescent smokers was conducted by Smith and colleagues in 1996. No adverse events were associated with discontinuation of patch therapy. Hurt et al. conducted a larger open-label study (n = 101) that coupled six weeks of 15 mg/ 16-hour NP therapy with an optional brief individual counseling session at the first clinic visit. Randomized clinical trials (RCT)- The first randomized, double-blind, placebocontrolled study of NRT was conducted by Hanson et al. in 2003. [16] Initial dose and titration schedules were based on the teens' level of cigarette consumption. Participants (n = 100) received 10 weeks of NP therapy and cognitive-behavioral therapy and a contingency management procedure. There were no significant differences between groups in biologically verified, 7-day point prevalence abstinence at end of treatment (Week 10) (28.0% NP vs. 24.0% placebo), 30-day point prevalence abstinence (20.0% NP vs. 18.0% placebo), or continuous abstinence from the quit date. Compared to the placebo patch group, the active NP group experienced a significantly lower craving score and overall withdrawal symptom score. Participants in the placebo patch group reported more headaches than those in the active NP group (75.6% vs. 56.3%, respectively). None reported dropping out as a result of an adverse event and no significant differences in dropout rates or medication compliance were observed across the treatment groups. A community-based, double-blind pilot RCT was conducted by Roddy and colleagues with 98 regular smokers (defined as > 1 cigarette per day or < 1 cigarette per day but reported past or anticipated withdrawal). Moolchan and colleagues Finally, Rubinstein et al. conducted a pilot randomized trial of nicotine nasal spray (NNS) in 40 adolescent smokers. Summary of efficacy See Safety/tolerability None of the studies reported any severe or life-threatening side effects. The adverse events reported by adolescents for NRT were similar to those reported by adult smokers. Of the NRT studies, only three reported discontinuation of study medication during treatment due to an adverse event. Special considerations for use in adolescent smokers Controversy remains over the use of NRT in adolescents. Studies with animals indicate that nicotine can elicit neuronal damage and long-term changes in synaptic function, suggesting that there could be long-term adverse consequences of nicotine exposure in adolescence. Bupropion Bupropion was initially marketed as an atypical antidepressant and was approved in 1997, under the name Zyban, as the first non-nicotine medication to aid in smoking cessation for adults. Bupropion inhibits the reuptake of dopamine and norepinephrine in the central nervous system Randomized clinical trials (RCT)-Four RCTs have assessed the efficacy of bupropion for smoking cessation with adolescents. In the only study to examine bupropion SR in combination with NP therapy, Killen and colleagues randomized adolescent smokers (n = 211) to receive eight weeks of NP therapy and nine weeks of either 150 mg/day bupropion SR or placebo pills. Finally, Gray and colleagues examined the efficacy of 300 mg/day bupropion SR and contingency management (CM). Summary of efficacy See None of the studies with 300 mg/day bupropion SR were longer than six weeks in duration. The full dose was well tolerated by adolescent smokers and resulted in higher end of treatment abstinence than 150 mg/day bupropion SR in the only adolescent multi-dose study. However, similar to the few multi-dose studies in adults, the higher dose did not produce a better outcome at follow-up. Paediatr Drugs. Author manuscript; available in PMC 2012 April 4. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Given that none of the studies that have examined the use of bupropion SR for adolescent nicotine dependence followed the dosage recommendations for adult smokers, a future study that adheres to these guidelines is warranted. Safety/tolerability The most common adverse events reported by adolescent smokers were similar to those reported by their adult counterparts Although bupropion SR was generally well tolerated by adolescent smokers, hospitalizations occurred on three occasions. One was due to the intentional ingestion of Jimson weed in combination with bupropion SR, resulting in an anticholinergic crisis. Compliance rates Three of the five studies provided compliance data, but the methods used to assess compliance varied across the three studies. Special considerations for use in adolescent smokers Zyban contains the same active ingredient as the antidepressant medications Wellbutrin, Wellbutrin SR, and Wellbutrin XL. In 2004, the FDA directed manufacturers to add a "black box" to the health professional label of all antidepressants warning that antidepressants increased the risk compared to placebo of suicidal thinking and suicidal behavior in NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript children, adolescents, and young adults in short-term studies of major depressive disorder and other psychiatric disorders. In the RCTs with bupropion SR for smoking cessation in adolescent smokers, two adverse events were deemed to be intentional suicide attempts. Varenicline In 2006, the United States FDA approved varenicline as a prescription-only pharmacological aid for adult smoking cessation. It is also an approved smoking cessation aid in some countries outside of the U.S. Varenicline is a selective nicotinic acetylcholine receptor partial antagonist that binds to the α 4 β 2 receptor subtype, thereby reducing the reinforcing effects of nicotine. Due to its mixed agonist-antagonist properties, varenicline is effective at relieving craving and withdrawal during abstinence and blocking the reinforcing effects of smoking. Literature on varenicline in adolescent smokers One RCT examined the pharmacokinetics, safety and tolerability of varenicline in adolescent smokers

Development and implementation of a prescription opioid registry across diverse health systems

Objective: Develop and implement a prescription opioid registry in 10 diverse health systems across the US and describe trends in prescribed opioids between 2012 and 2018. Materials and Methods: Using electronic health record and claims data, we identified patients who had an outpatient fill for any prescription opioid, and/or an opioid use disorder diagnosis, between January 1, 2012 and December 31, 2018. The registry contains distributed files of prescription opioids, benzodiazepines and other select medications, opioid antagonists, clinical diagnoses, procedures, health services utilization, and health plan membership. Rates of outpatient opioid fills over the study period, standardized to health system demographic distributions, are described by age, gender, and race/ethnicity among members without cancer. Results: The registry includes 6 249 710 patients and over 40 million outpatient opioid fills. For the combined registry population, opioid fills declined from a high of 0.718 per member-year in 2013 to 0.478 in 2018, and morphine milligram equivalents (MMEs) per fill declined from 985 MMEs per fill in 2012 to 758 MMEs in 2018. MMEs per member declined from 692 MMEs per member in 2012 to 362 MMEs per member in 2018. Conclusion: This study established a population-based opioid registry across 10 diverse health systems that can be used to address questions related to opioid use. Initial analyses showed large reductions in overall opioid use per member among the combined health systems. The registry will be used in future studies to answer a broad range of other critical public health issues relating to prescription opioid use

Disparities in Smoking Cessation Assistance n US Primary Care Clinics

Objectives. To examine associations between patient factors and smoking cessation assistance in US safety-net clinics.Objectives. To examine associations between patient factors and smoking cessation assistance in US safety-net clinics. Methods. Using electronic health record data from the OCHIN network, we identified adults with at least 1 primary care visit to a study clinic (n = 143 clinics in 12 states) with at least 1 documented “current smoker” status during 2014 to 2016 (n = 136 314; 29.8%). We estimated odds ratios (ORs) of smoking cessation assistance receipt (none [reference], counseling, medication, or both) by patient covariates. Results. For all cessation assistance categories, odds of assistance were higher among women, those with more visits, those assessed and ready to quit, and patients with asthma or chronic obstructive pulmonary disease and hyperlipidemia. Odds of receiving both counseling and medication were lower among uninsured patients (OR = 0.56; 95% confidence interval [CI] = 0.48, 0.64), those of a race/ethnicity other than non-Hispanic White (OR range = 0.65–0.82), and those with diabetes (OR = 0.85; 95% CI = 0.79, 0.92), and higher among older patients and those with a comorbidity, with few exceptions. Conclusions. Disparities in smoking cessation assistance receipt exist in safety-net settings, in particular by health insurance coverage and across race/ethnicity, even after control for other socioeconomic and demographic factors

A Qualitative Examination of Tobacco Use and Smoking Cessation Among Gender Minority Adults

BackgroundDespite the elevated prevalence of smoking among gender minority adults, little is known about the factors that influence their tobacco use and cessation.PurposeWe identified and examined factors that influence tobacco use and cessation for gender minority adults, using a conceptual framework based on the Model of Gender Affirmation and Gender Minority Stress Model.MethodsNineteen qualitative, semi-structured in-depth interviews were conducted with gender minority adults who smoke or no longer smoke and were recruited from the Portland, OR metropolitan area. Interviews were audio-recorded, professionally transcribed, and analyzed utilizing thematic analysis.ResultsFour main themes were generated. Gender minority adults smoke to cope with general and gender minority-specific stressors. Smoking was described as a social behavior that was influenced and sustained by community and interpersonal relationships. Smoking cessation was motivated by health concerns (both general and gender minority-specific) and moderated by conducive life circumstances. Recommendations for tobacco cessation interventions highlighted the importance and role of social support. Participants expressed a strong desire for gender minority-specific tobacco cessation programs. There are unique and complex factors that contribute to the higher prevalence of smoking observed among gender minority adults.ConclusionsTobacco cessation interventions are urgently needed for this population and should be tailored to address the unique factors that impact tobacco use and cessation among gender minority people to increase the likelihood of success

Prescription Opioid Use Patterns, Use Disorder Diagnoses, and Addiction Treatment Receipt after the 2014 Medicaid Expansion in Oregon

Background/Aims: Evidence suggests Medicaid beneficiaries in the USA are prescribed opioids more frequently than are people who are privately‐insured, but little is known about opioid prescribing patterns among Medicaid enrollees who gained coverage via the Affordable Care Act Medicaid expansions. This study compared the prevalence of receipt of opioid prescriptions and opioid‐use‐disorder (OUD), along with time from OUD diagnosis to medication‐assisted treatment (MAT) receipt between Oregon residents who had been continuously insured by Medicaid, were newly insured after Medicaid expansion in 2014, or returned to Medicaid coverage after expansion. Design: Cross‐sectional study using inverse‐propensity weights to adjust for differences among insurance groups. Setting: Oregon. Participants: 225,295 Oregon Medicaid adult beneficiaries insured 2014‐2015 and either: 1) newly enrolled, 2) returning in 2014 after a \u3e 12‐month gap, or 3) continuously insured between 2013 and 2015. We excluded patients in hospice care or with cancer diagnoses. Measurements: Any opioid dispensed, chronic (≥90‐day) and high dose (≥ 90 daily morphine milligram equivalence) opioid use, documented OUD diagnosis, and MAT receipt. Findings: Compared with the continuously insured, newly and returning insured enrollees were less likely to be dispensed opioids [newly: 42.3%, 95% confidence interval (95%CI) 42.0‐42.7%; returning: 49.3%, 95%CI 48.8‐49.7%; continuously: 52.5%, 95%CI 52.0‐53.0%], use opioids chronically (newly: 12.8%, 95%CI 12.4‐13.1%; returning: 11.9%, 95%CI 11.5‐12.3%, continuously: 15.8%, 95%CI 15.4‐16.2%), have OUD diagnoses (newly: 3.6%, 95%CI 3.4‐3.7%; returning: 3.9%, 95%CI 3.8‐4.1%, continuously: 4.7%, 95%CI 4.5‐4.9%), and receive MAT after OUD diagnosis [Hazard Ratio newly: 0.57, 95%CI 0.53‐0.61; Hazard Ratio returning: 0.60, 95%CI 0.56‐0.65 (REF: continuously)]. Conclusions: Residents of Oregon, USA who enrolled or re‐enrolled in Medicaid health insurance after expansion of coverage in 2014 as a result of the Affordable Care Act were less likely than those already covered to receive opioids, use them chronically, or receive medication‐assisted treatment for opioid use disorder

Asthma/COPD Disparities in Diagnosis and Basic Care Utilization Among Low-Income Primary Care Patients

Obstructive pulmonary disease outcomes in the United States differ between Latinos and non-Hispanic whites. There is little objective data about diagnosis prevalence and primary care visit frequency in these disease processes. We used electronic health record data to perform a retrospective cohort analysis of 34,849 low-income patients seen at Oregon community health centers between 2009 and 2013 to assess joint racial/ethnic and insurance disparities in diagnosis and visit rates between Latino and non-Hispanic white patients. The overall study prevalence of obstructive lung disease was 18%. Latinos had lower odds of obstructive lung disease diagnosis (OR 0.37, 95% CI 0.30–0.44). Among those diagnosed prior to 2009, the uninsured (regardless of race/ethnicity) had lower visit rates during 2009–2013 than the insured. This study identified racial/ethnic disparities in the diagnosis of obstructive pulmonary disease between Latinos and non-Hispanic Whites, confirming trends observed in survey research but controlling for important confounders. Health insurance was associated with basic care utilization, suggesting that lack of health insurance could lessen the quality of care for obstructive pulmonary disease in Latino and non-Hispanic white patients

Associations between Psychiatric Disorders and Cannabis-Related Disorders Documented in Electronic Health Records

Data from a large network of community health centers connected via a single electronic health record (EHR) system examined associations between psychiatric disorders and documentation of a cannabis-related disorder among patients with reported cannabis use. Participants were adults who had at least one ambulatory visit at a clinic in three states between 1/1/2012 and 12/31/2016 and had either 1) a documented cannabis-related disorder indicated by an ICD-9/10 code on the problem list or encounter list or 2) documentation of cannabis use in the EHR social history section. Clinics included 101,405 patients with either cannabis use recorded in the social history of the EHR (n = 71,660) or a cannabis-related disorder documented in the encounter or problem list (n = 29,745). GEE logistic regression modeling estimated adjusted odds ratios (aOR). Odds of patients having cannabis-related disorder recorded on the encounter or problem list were higher for individuals with depression (aOR = 1.08, 95% CI: 1.04–1.13), anxiety (aOR = 1.16, CI: 1.11–1.21) and bipolar disorder (aOR = 1.16, CI: 1.10–1.23). A diagnosis of schizophrenia increased the odds of a cannabis-related disorder by 62% (aOR = 1.62, CI: 1.48– 1.78). Primary care providers should routinely screen for and document cannabis-related disorders and psychiatric disorders

Associations between psychiatric disorders and cannabis related disorders documented in electronic health records

Data from a large network of community health centers connected via a single electronic health record (EHR) system examined associations between psychiatric disorders and documentation of a cannabis-related disorder among patients with reported cannabis use. Participants were adults who had at least one ambulatory visit at a clinic in three states between 1/1/2012 and 12/31/2016 and had either 1) a documented cannabis-related disorder indicated by an ICD-9/10 code on the problem list or encounter list or 2) documentation of cannabis use in the EHR social history section. Clinics included 101,405 patients with either cannabis use recorded in the social history of the EHR (n = 71,660) or a cannabis-related disorder documented in the encounter or problem list (n = 29,745). GEE logistic regression modeling estimated adjusted odds ratios (aOR). Odds of patients having cannabis-related disorder recorded on the encounter or problem list were higher for individuals with depression (aOR = 1.08, 95% CI: 1.04–1.13), anxiety (aOR = 1.16, CI: 1.11–1.21) and bipolar disorder (aOR = 1.16, CI: 1.10–1.23). A diagnosis of schizophrenia increased the odds of a cannabis-related disorder by 62% (aOR = 1.62, CI: 1.48– 1.78). Primary care providers should routinely screen for and document cannabis-related disorders and psychiatric disorders