Characterising incident opioid use among incident users of prescription sedative hypnotics: A national cohort study.

OBJECTIVE: To evaluate co-prescribing of sedatives hypnotics and opioids. DESIGN: Retrospective study evaluating the association of patient characteristics and comorbidities with coprescribing. SETTING AND PARTICIPANTS: Using the national Merative MarketScan Database between 2005 and 2018, we identified patients who received an incident sedative prescription with or without subsequent, incident opioid prescriptions within a year of the sedative prescription in the USA. OUTCOME MEASURES: Coprescription of sedative-hypnotics and opioids. RESULTS: A total of 2 632 622 patients (mean (SD) age, 43.2 (12.34) years; 1 297 356 (62.5%) female) received incident prescriptions for sedatives over the course of the study period. The largest proportion of sedative prescribing included benzodiazepines (71.1%); however, z-drugs (19.9%) and barbiturates (9%) were also common. About 557 845 (21.2%) patients with incident sedatives also received incident opioid prescriptions. About 59.2% of these coprescribed patients received opioids coprescription on the same day. Multivariate logistic regression findings showed that individuals with a comorbidity index score of 1, 2 or ≥3 (aOR 1.19 (95% CI 1.17 to 1.21), 1.17 (95% C 1.14 to 1.19) and 1.25 (95% C 1.2 to 1.31)) and substance use disorder (1.21 (95% C 1.19 to 1.23)) were more likely to be coprescribed opioids and sedatives. The likelihood of receiving both opioid and sedative prescriptions was lower for female patients (aOR 0.93; 95% CI 0.92 to 0.94), and those receiving a barbiturate (aOR 0.3; 95% CI 0.29 to 0.31) or z-drugs (aOR 0.67; 95% CI 0.66 to 0.68) prescriptions at the index date. CONCLUSIONS: Coprescription of sedatives with opioids was associated with the presence of comorbidities and substance use disorder, gender and types of sedatives prescribed at the index date. Additionally, more than half of the coprescribing occurred on the same day which warrants further evaluation of current prescribing and dispensing best practice guidelines.

Protocol for the development of a consensus practice guideline To address clinical and regulatory barriers to buprenorphine dispensing in community pharmacy.

BACKGROUND: Less than half of community pharmacies in the United States stock buprenorphine products indicated for the treatment of opioid use disorder. This lack of access to buprenorphine in community pharmacies is a significant barrier to care. To address this issue, this protocol outlines a comprehensive approach to develop a practice guideline aimed at improving access to safe and effective opioid use disorder treatment in community pharmacies. METHODS: The guideline development process will proceed in three phases, following a technique closely aligned with the Institute of Medicine's guidance on guideline development. The first phase will involve conducting qualitative interviews with pharmacists in three states to identify their beliefs toward buprenorphine dispensing. As limitations on buprenorphine supply are related to constraints at all levels of the drug supply and regulatory system, the second phase, we will recruit representatives from regulatory agencies, pharmacy organizations, the Drug Enforcement Administration, pharmaceutical wholesalers as well as addiction medicine physicians and psychiatric pharmacists to develop consensus recommendations through a modified Delphi design. This will be followed by a public comment period and external expert review of the recommendations led by the National Association of Boards of Pharmacy. Finally, in the third phase, a national, mixed media dissemination campaign will be led by the National Community Pharmacists Association (NCPA) to convey recommendations to practicing pharmacists. DISCUSSION: The guideline development process aims to incorporate the perspectives of multiple stakeholders and emphasize the importance of addressing the regulatory and pharmacy-specific aspects of care in addition to clinical evidence and guidance. The development of this guideline will provide targeted, multidisciplinary guidance for pharmacists, improving access to safe and effective opioid use disorder treatment in the community setting. PREREGISTRATION: This protocol was registered with the Open Science Framework in March of 2023. Registration may be found at: https://doi.org/10.17605/OSF.IO/6S9DY .

Leveraging prescription monitoring program data to evaluate the implementation of buprenorphine telehealth flexibilities: An interrupted time series analysis in Texas.

Background: In March 2020, policy changes by the Substance Abuse and Mental Health Services Administration and the Drug Enforcement Administration aimed to maintain access to office-based opioid treatment services by easing telehealth buprenorphine prescribing restrictions. However, the effectiveness of these changes remains largely unmeasured. The objective of this study was to measure the effectiveness of COVID-19-related telehealth flexibilities in an all-payer cohort from the Texas Prescription Monitoring Program. Methods: Using Texas Prescription Monitoring Program data, we identified oral buprenorphine and buprenorphine/naloxone prescriptions dispensed in Texas between September 1, 2019, and September 26, 2020. Weekly counts of prescriptions, prescribing physicians, and dispensing pharmacies were analyzed. An autoregressive integrated moving average (ARIMA) model estimated changes in prescription volume between pre-implementation (September 1, 2019 - February 15, 2020) and post-implementation (April 12, 2020 - September 26, 2020) periods. Results: Pre-flexibility, an average of 8898 (SD: 342) buprenorphine prescriptions were dispensed to 7829 (SD: 326) patients weekly. This declined to 8360 (SD: 247) prescriptions and 7661 (SD: 229) patients post-flexibility. Adjusted for seasonality, this represented a statistically significant average decline of -257.27 (95% CI: -426.06, -88.49) patients and -647.01 (95% CI: -856.67, -437.36) prescriptions per week. Discussion: Our results suggest a modest decline in buprenorphine dispensing volume early in the COVID-19 pandemic. While difficult to assess its significance, it can be assumed that telehealth flexibilities mitigated a potentially larger decline. Future research should explore system and individual-level barriers to telehealth utilization.

Trajectories and Predictors for the Development of Clinically Significant Weight Gain in Children and Adolescents Prescribed Second-Generation Antipsychotics.

Background: As many as 60% of pediatric patients taking second-generation antipsychotics (SGA) experience weight gain (antipsychotic-induced weight gain). However, the subgroup that experienced substantial weight increase was poorly understood. This study aimed to identify the development and predictors of clinically significant weight gain (CSWG) among pediatric SGA recipients. Methods: A retrospective analysis of the 2016 to 2021 IQVIA Ambulatory EMR-US database was conducted. The study cohort comprised SGA-naive patients ages 5 to 19, continuously prescribed SGA for ≥90 days. CSWG was defined as a weight gain in BMI z-score >0.5. The development of CSWG was described using the group-based trajectory model approach, and multinomial logistic regression analysis was conducted to examine the risk factors associated with the CSWG trajectories. Results: Of the 16,262 SGA recipients who met the inclusion criteria, 4 distinctive CSWG trajectories were identified: (1) Rapid (14.6%), (2) Gradual (12.6%), (3) Transit (7%), and (4) no CSWG (65.8%). Factors associated with a higher likelihood of having rapid or gradual CSWG versus nonsignificant weight gain were being younger (OR [95% CI] = 12-17 vs. 5-11, Rapid, 0.727 [0.655-0.806]; Gradual, 0.776 [0.668-0.903]), male (Rapid, 1.131 [1.021-1.253]), non-Hispanic White (Black vs. White: Rapid, 0.833 [0.709-0.98]), with lower baseline BMI z-score (Rapid, 0.376 [0.361-0.392]; Gradual, 0.449 [0.424-0.476]), and receiving olanzapine as the initial SGA (Rapid, 1.38 [1.093-1.74]). The Area under the Receiver operating characteristic (ROC) Curve for the comparison of rapid and gradual CSWG with no CSWG trajectory were 0.83 and 0.80, respectively. Conclusions: SGA recipients experienced four distinctive CSWG trajectories (Rapid, Gradual, Transient, and No CSWG). The risk of CSWG could be predicted using patient characteristics at the SGA initiation. This insight highlights the importance of personalized monitoring and timely intervention strategies for at-risk individuals who experienced persistent CSWG in real practice.

Why the increase? Examining the rise in prescription medication expenditures in the United States between 2011 and 2020.

The objective of this cross-sectional analysis was to identify determinants of increasing medicine expenditures in the US between 2011 and 2020. Prescription medication expenditures from the 2011-2020 Medical Expenditures Panel Survey (MEPS) were used to calculate total annual medication expenditures by payer categories (Out-of-pocket, Medicare, Medicaid, TRICARE/Veterans Administration/CHAMPVA (TVAC), Other Government Sources, Private Insurance, and Other Sources). From here, expenditures were stratified by therapeutic category using Multum Lexicon Drug Class to examine trends in expenditures by therapeutic area. Linear regression was used to identify temporal trends in medication expenditures. From 2011 to 2020, total annual prescription medication expenditures rose from $341.49 to $473.12 billion per year with metabolic agents being the most costly category. Among the metabolic agents, antidiabetic agents were the most costly therapeutic area, with an increasing trend observed from $27.15 to $89.17 billion over the same period. Medicare, Medicaid, Private Insurance, TVAC, and Other Sources also saw an increasing trend in antidiabetic agent expenditure, while no trend was observed for Out-of-pocket and Other Government Sources. Insulin had the highest expenditure among antidiabetic agents. Further studies are warranted to explore specific factors contributing to the increasing trend.

Group-Based Trajectory Modeling to Identify Patterns of Antipsychotic-Associated Weight Gain Among Children and Adolescents.

PURPOSE/BACKGROUND: Antipsychotic-associated weight gain (AAWG) is a common adverse effect of second-generation antipsychotic (SGA) medications among children and adolescents. This study applied group-based trajectory modeling to identify latent trajectories of AAWG among children and adolescents and associated risk factors. PROCEDURES: This was a retrospective analysis of the IQVIA Ambulatory EMR-US database from 2016 to 2021. The cohort consisted of patients aged 6 to 19 years who were SGA naive and received at least 90 days of continuous SGA prescriptions. Group-based trajectory modeling was used to identify latent trajectories of AAWG development during a 24-month period since SGA initiation, and multinomial logistic regression analysis was conducted to examine the risk factors associated with the identified AAWG trajectories. FINDINGS/RESULTS: A total of 16,262 patients were included. Group-based trajectory modeling identified the following 4 distinctive AAWG trajectories: persistent severe weight gain (4.2%), persistent moderate weight gain (20.1%), minor weight change (69.6%), and gradual weight loss (6.1%). Compared with the minor weight change group, younger age (12-17 vs 5-11: odds ratio [OR], 0.634; 95% confidence interval [CI], 0.521-0.771), lower baseline body mass index z -score (OR, 0.216; 95% CI, 0.198-0.236), and receiving olanzapine as the initial SGA (olanzapine vs aripiprazole: OR, 1.686; 95% CI, 1.673-1.699) were more likely to follow severe weight gain trajectories. The area under the receiver operating characteristic curves for comparing severe weight gain versus minor weight change groups and moderate weight vs minor weight change groups in the multinomial regression model were 0.91 and 0.8, respectively. IMPLICATIONS/CONCLUSIONS: A quarter of pediatric SGA recipients experienced persistent weight gain during the SGA treatment. The risk of having persistent AAWG can be predicted using patient characteristics collected before SGA initiation and the initial SGA agent.

Regional Variation in Opioid-Related Emergency Medical Services Transfers During the COVID-19 Pandemic: An Interrupted Time Series Analysis.

BACKGROUND: The COVID-19 pandemic has impacted public infrastructure and healthcare utilization. However, regional variation in opioid-related harm secondary to COVID-19 remains poorly understood. This study aimed to measure the regional variation in the association between stay-at-home orders (SAHOs) and nonfatal opioid-related emergency medical services (EMS) transfers in the United States. METHODS: In this interrupted time series design, counts of nonfatal opioid overdoses were identified in each week between July 29, 2019 and December 27, 2020 from the National Emergency Medical Services Information System Dataset. A longitudinal, interrupted time series model was used to compare the change in the number of nonfatal opioid overdose transfers between the pre-pandemic period (July 29, 2019-January 6, 2020) and the pandemic period (June 1, 2020-December 27, 2020). The time period between January 7, 2020 and May 31, 2020 was treated as a washout period to account for state-level variation in the timing of SAHO implementation. RESULTS: We identified 277 141 adult nonfatal opioid-related overdose EMS transfers in the United States across all census regions. After implementation of the SAHO, EMS transfers significantly increased in all regions, with an increase most notable in the Southern United States (2161, 95% CI: 1699-2623 transfers per week). In the post-SAHO period between June 1 and December 27, 2020, EMS transfers declined from this regional peak in the Southern, Midwestern, and Northeastern United States. No change in trend was observed in the Western United States. CONCLUSION: These findings underscore the importance of tailoring public health policies regionally. While most regions saw a modest decline in opioid-related EMS transfers after an initial increase, the COVID-19 pandemic led to notable increases in opioid-related EMS transfers nationwide. Future research should focus on identifying public health strategies to counteract the deleterious effects of the COVID-19 pandemic on opioid-related morbidity.

Productivity Loss Among Opioid and Benzodiazepine Users in the United States: A Medical Expenditure Panel Survey From 2010 to 2019.

OBJECTIVE: The aim of the study is to estimate the association between productivity losses and the use of prescription opioids and benzodiazepines among employed US adults with painful conditions. METHODS: Using Medical Expenditures Panel Survey (2010-2019), we used two-part (logistic regression and generalized linear model with zero-truncated negative binomial link) model to compare missed workdays due to illness or injury among employed adults with a painful condition. RESULTS: Of the eligible sample of 57,413 working US individuals, 14.65% were prescription opioid users, 2.95% were benzodiazepine users, and 1.59% were both opioid and benzodiazepine users. The predicted missed workdays were 5.75 (95% Confidence Limit [CL]: 5.58-5.92) days for benzodiazepine users, 13.06 (95% CL: 12.88-13.23) days among opioid users, and 15.18 (95% CL: 14.46-15.90) days for opioid and benzodiazepine concomitant users. CONCLUSIONS: Concomitant use of prescription opioids and benzodiazepines was significantly associated with having more missed workdays among employed adults with documented painful conditions.

Physician perspective on the implementation of risk mitigation strategies when prescribing opioid medications: a qualitative analysis.

OBJECTIVE: To understand the physician perspective on the barriers and facilitators of implementing nine different opioid risk mitigation strategies (RMS) when prescribing opioid medications. METHODS: We created and dispersed a cross-sectional online survey through the Qualtrics© data collection platform among a nationwide sample of physicians licensed to practice medicine in the United States who have prescribed an opioid medication within the past year. The responses were analyzed using a deductive thematic analysis approach based on the Consolidated Framework for Implementation Research (CFIR) to ensure a holistic approach to identifying the barriers and facilitators for each RMS assessed. In concordance with this method, the themes and codes for the thematic analysis were defined prior to the analysis. The five domains within the CFIR were used as themes and the 39 nested constructs were treated as the codes. Two members of the research team independently coded the transcripts and discussed points of disagreement until consensus was reached. All analyses were conducted in ATLAS.ti© V7. RESULTS: The completion rate for this survey was 85.1% with 273 participant responses eligible for analysis. Intercoder reliability was calculated to be 82%. Deductive thematic analysis yielded 2,077 descriptions of factors affecting implementation of the nine RMS. The most salient code across all RMS was Knowledge and Beliefs about the Intervention, which refers to individuals' attitudes towards and value placed on the intervention. Patient Needs and Resources, a code referring to the extent to which patient needs are known and prioritized by the organization, also emerged as a salient code. The physicians agreed that the patient perspective on the issue is vital to the uptake of each of the RMS. CONCLUSIONS: This deductive thematic analysis identified key points for actionable intervention across the nine RMS assessed and established the importance of patient concordance with physicians when deciding on a course of treatment.

Student-led podcasts to enhance literature evaluation skills.

BACKGROUND AND PURPOSE: Critical evaluation and understanding of primary literature is essential to pharmacy practice. This project evaluated student confidence and learning outcomes in a critical care elective course where podcasts were used as an active learning assignment for literature evaluation. EDUCATIONAL ACTIVITY AND SETTING: Third-year pharmacy students created a 15- to 20-min podcast episode that reviewed a landmark critical care trial. A pre/post survey was used to assess student perceptions of confidence in evaluating primary literature. A standardized rubric was used to assess literature evaluation skills in several domains. FINDINGS: Ninety-two third-year pharmacy students were enrolled in the critical care elective course, and 93% (86 of 92) completed the survey. Student perceptions of their ability to evaluate literature improved for all seven questions, including comfort in interpreting study methodology and applying findings of literature to patient care. Students scored proficient on most components of the standardized rubric, with ability to discuss results and conclusions being the lowest performing domain (78.2% fully proficient). After completing the activity, students felt more confident in interpreting results, applying findings, and orally presenting a journal article to peers. Most students felt the podcast activity helped them strengthen their literature evaluation skills and recommended this activity to a peer. SUMMARY: Third-year pharmacy students reported an improvement in confidence in the interpretation and application of primary literature after creating a podcast episode reviewing a critical care trial. Additional research with creation of podcasts or other audio/visual methods should be studied in the future.

Outpatient opioid prescribing by Alzheimer's diagnosis among older adults with pain in United States.

OBJECTIVE: To examine opioid prescribing practices for pain in older adults with and without Alzheimer's Disease and Related Dementias (ADRD). METHODS: This cross-sectional study used National Ambulatory Medical Care Survey data (2014-2016, and 2018). Adults aged ≥ 50 years with pain were analyzed. Prescribing of opioid and concomitant sedative prescriptions (including benzodiazepines, Z-drugs, and barbiturates) were identified by the Multum lexicon code. Multivariable logistic regression evaluated the risk of opioid prescribing or co-prescribing of opioid and sedative associated with ADRD in older adults with pain. RESULTS: There were 13,299 office visits in older adults with pain, representing 451.75 million visits. Opioid prescribing occurred in 27.19%; 30% involved co-prescribing of opioids and sedatives. ADRD was not associated with opioid prescribing or co-prescribing of opioid and sedative therapy. CONCLUSIONS: Opioid and sedatives are commonly prescribed in older adults with pain. Longitudinal studies need to understand the etiology and chronicity of opioid use in older patients, specifically with ADRD.

Patients prefer free drug disposal options delivered by pharmacists at the point of care: Results of a decision tree analysis of a national factorial vignette panel survey.

BACKGROUND: Unused opioid medication in the home increases risk of medication diversion, misuse, and unintended harm. The United States Federal Food and Drug Administration is currently considering the implementation of a risk evaluation and mitigation strategy (REMS) program that would require US pharmacists to provide drug disposal products with opioid prescriptions. Still, little is known about consumer preference for drug disposal method. The objective of this study was to identify product and program characteristics associated with consumer preference for at-home drug disposal products. METHODS: A 2x2x3x3 full-factorial design was employed to text-based vignettes representing opioid analgesic disposal scenarios. Each vignette varied on four characteristics: product cost (free vs paid), ease of use (a mail back envelope, bringing medication to a takeback site, and an at-home drug deactivation pouch), potential environmental impact (incineration), and point of access (pharmacy, community organization, and prescriber). Of the 36 possible vignettes, 12 were removed as they represented a non-realistic combination of vignette characteristics. The remaining 24 were administered to a panel of patients with controlled-substance use in the past six-months. Decision tree modeling and general linear mixed (GLM) models were used sequentially to identify product characteristics associated with patient drug preferences RESULTS: A total of 1,006 participants completed all vignette drug disposal scenarios. Regression tree analysis found that the most important predictor of use was cost followed by ease of access and product design. GLM showed that takeback programs offered at a pharmacy were the most preferred disposal option followed by at-home products (mailed envelope or deactivation system) dispensed with the prescription. CONCLUSION: Programs that provide disposal resources directly to the patient at no cost with their prescription are likely to optimize willingness to dispose. Findings support the FDA's plan for a REMS program requiring pharmacies to distribute mail-back envelopes to patients when dispensed opioids.

The impact of the mainstreaming addiction treatment act and associated legislative action on pharmacy practice.

The recent passage of the Mainstreaming Addiction Treatment (MAT) Act will expand access to treatment for opioid use disorder (OUD) by eliminating prescriber registration requirements introduced as part of the Drug Abuse Treatment Act (DATA) of 2000. Without the X-Waiver, and Drug Enforcement Administration (DEA) registered prescriber can now prescribe buprenorphine. Eliminating DATA-2000 registration is the first step in improving access to buprenorphine, but additional barriers, including unclear restrictions on wholesale buprenorphine supply and insurance coverage, remain. Recently, the DEA formally clarified that suspicious order monitoring programs were managed entirely by wholesalers and manufacturers and that DEA does not set suspicious order monitoring limits. In this commentary, we address the somewhat conflicting implications of the MAT Act and recent DEA guidance on buprenorphine dispensing in community pharmacies. We also discuss innovative practice models that leverage pharmacists' cognitive skills to manage pharmacotherapy for persons with OUD. Recent policy changes and emerging evidence suggest that pharmacists are better positioned than ever to provide low-barrier access to treatment for OUD and to show their value in this practice area by actively engaging patients with prescribed buprenorphine.

Parents' intention to have their child vaccinated at a community pharmacy: A national cross-sectional survey.

BACKGROUND: During the coronavirus disease 2019 pandemic, pediatric vaccination rates for routine childhood vaccines have been declining. To boost pediatric immunizations, pharmacists in the United States may order and administer age-appropriate vaccines to children of 3 years of age and older without a prescription. OBJECTIVE: The objective of this study was to examine parents' intention to have their young children between 3 and 10 years of age vaccinated in a community pharmacy setting. METHODS: A survey instrument was designed based on the health belief model (HBM). The cross-sectional survey was administered online via Qualtrics Panels to parents in the United States with at least 1 child between the ages of 3 and 10 years. Confirmatory factor analysis was used to estimate the correlation between each of the HBM constructs and a 3-item scale measuring parents' intention to have their children between the ages of 3 and 10 vaccinated in a community pharmacy. RESULTS: There were 416 usable responses collected for an effective response rate of 25.95%. Most participants were white (79.09%) and female (51.44%), and many had a graduate degree (48.32%). More than half of parents (69.7%) indicated they would be willing to have their child vaccinated in a community pharmacy. Intention to have their child vaccinated in a pharmacy was most strongly corrected with health benefit beliefs (ψ 0.79 [95% CI 0.75-0.83]), (ψ 0.86 [95% CI 0.83-0.89])cues to action, and perceived convenience.(ψ 0.71 [95% CI 0.66-0.76]). CONCLUSION: Many parents have high intention to vaccinate their young children in community pharmacies. Parents should be educated and informed about services that community pharmacies offer. Stakeholders need to engage in interventions targeted at promoting health benefits of getting vaccinations at a pharmacy and strong recommendations from health care providers.

Comparing Two Databases to Identify Access to Buprenorphine Treatment for Opioid Use Disorder.

OBJECTIVE: The objective of this study is to assess the differences in buprenorphine prescribers from a county level in the state of Texas by comparing the Substance Abuse and Mental Health Services Administration (SAMHSA) Buprenorphine Practitioner Locator to the Drug Enforcement Administration's (DEA) Controlled Substance Act (CSA) database. METHODS: County-level counts of buprenorphine prescribers were calculated from both the publicly available SAMHSA buprenorphine practitioner locator list and the DEA CSA database. These were then used to estimate the number of providers per 100,000 residents in each county. Regional variation in access to buprenorphine was compared descriptively across the state using poverty data from the US Census and county-level demography from the Texas Demographic Center. RESULTS: This study found 68.8% more X-waivered providers on the DEA CSA database (n = 2,622) with at least one provider reported in 125 of 144 counties in the state (49.2%) compared to the SAMHSA Buprenorphine Practitioner Locator (n = 1,553) with at least one provider reported in 103 counties (40.5%). CONCLUSIONS: The lack of a complete public registry of buprenorphine prescribers can inhibit the ability of patients to identify a convenient treatment. More work is needed to quantify the gap between treatment capacity and treatment need.

Association of cash payment with intensity of opioid prescriptions.

BACKGROUND: It is difficult to track use and outcomes in patients who pay cash for their prescriptions at the pharmacy. In Texas, 14% of all opioid prescriptions are paid with cash, often by uninsured patients and pharmacy shoppers. OBJECTIVE: To evaluate the association of cash payment with intensity of opioid prescriptions. METHODS: Using a prescription drug monitoring program and the U.S. Census data for the 2019 calendar year, this cross-sectional descriptive study analyzed more than 4 million opioid prescriptions in Texas residents aged 18-64 years. The payment type was coded as insurance if the prescription was paid in whole or in part by a health plan and as cash otherwise. Daily morphine milligram equivalent (MME) dose was used to compare the intensity of opioid prescriptions. The association of uninsured rates with mean daily MME and the number of opioid prescriptions paid with cash per 100,000 persons were assessed at a county level. RESULTS: Cash payment was associated with 30% higher mean daily MME (59 vs. 45; P < 0.001) than insurance payment. This difference was driven by the prescriptions for patients aged 25-34 years and from the highest decile of prescribers based on the percentage of opioid prescriptions paid by cash. For instance, cash payment was associated with 82% higher mean daily MME (91 vs. 50; P < 0.001) when patients aged 25-34 years obtained their prescriptions from the highest decile of prescribers. At a county level, uninsured rates were not associated with mean daily MMEs or the number of opioid prescriptions paid with cash. CONCLUSION: Cash payment was associated with a higher intensity of opioid prescriptions, mirroring the rates of drug overdose deaths across the patient age groups. Further research and policy actions need to address unmet pain management needs in uninsured patients and potential pharmacy shopping with cash payment and fraudulent identifications.

Investigation of racial differences in survival from non-small cell lung cancer with immunotherapy use: A Texas study.

Background: The use of immunotherapy is associated with improved survival among patients with Non-Small Cell Lung Cancer (NSCLC) and has gained widespread use in its management. However, there is limited information on whether the survival benefits associated with immunotherapy differ among races and ethnicities. Objective: This study aimed to investigate racial differences in survival amongst patients with NSCLC who received immunotherapy as the first-line treatment in Texas. Methods: Patients with NSCLC who received immunotherapy between October 2015 to December 2018 were identified from the Texas Cancer Registry (TCR). Disease-specific survival was evaluated and compared among patients across racial/ethnic categories using the Kaplan-Meier survival analysis, log-rank test, and a multivariable Cox proportional hazard regression model following an inverse probability treatment weighting (IPTW) propensity score analysis. Results: A total of 1453 patients were included in the analysis. Median survival (in months) was longest among Asians (34, 95% CI: 15-Not Estimable), followed by African Americans (AAs) (23, 95% CI: 15-34), Hispanics (22, 95% CI: 16-26), and Whites (19, 95% CI: 17-22). The adjusted regression estimates had no statistically significant differences in survival among AAs (aHR = 0.97; 95% CI = 0.78-1.20; P =0.77) and Hispanics (aHR = 0.96; 95% CI = 0.77-1.19, P =0.73) when compared to White patients. Asians on the other hand, had 40% reduction in mortality risk compared to Whites (aHR = 0.60; 95% CI = 0.39-0.94, P = 0.03). Conclusions: Our study indicated that African Americans and Hispanics do not have poorer survival compared to White patients when receiving immunotherapy as first-line treatment. Asians however had longer survival compared to Whites. Our findings suggest that existing racial disparity in NSCLC survival might be mitigated with the use of immunotherapy and should be considered in providing care to these minority groups.

Switching pharmacies leads to gaps in medication possession in individuals treated with buprenorphine.

BACKGROUND: Not all pharmacies stock and dispense buprenorphine, potentially complicating continuous access to care for patients with opioid use disorder (OUD). This may become problematic if a patient's primary pharmacy can no longer provide buprenorphine, and the patient cannot locate a new pharmacy. OBJECTIVES: To identify how often patients treated with buprenorphine for OUD switch pharmacies and to estimate the association between switching pharmacies and a clinically significant gap in therapy of 7 days or longer. METHODS: A retrospective repeated measures longitudinal cohort design was used. Patients initiating treatment with a buprenorphine product indicated for OUD were identified from the 2016-2018 Texas Prescription Monitoring Program. The predictor of interest-switching pharmacies-was defined by comparing the dispensaries used between subsequent prescriptions. The outcome of interest was defined as a gap in medication possession of 7 days or longer on the basis of the National Quality Forum's definition of continuity of pharmacotherapy for OUD. A generalized estimating equation approach was used to estimate a repeated measures logistic regression measuring the association between switching pharmacies and a gap in therapy. RESULTS: Of 13,375 eligible patients, 29.6% switched pharmacies at least once during treatment, and 51.6% of these did so more than once. The median time to initial switch was 30 days (interquartile range: 13-66 days). When patients switched pharmacies, they were significantly more likely to have a gap in therapy of between 7 and 29 days (adjusted odds ratio 1.67 [95% CI 1.57-1.78]). CONCLUSION: Patients receiving buprenorphine switch pharmacies early and frequently in treatment, which leads to clinically significant gaps in therapy. Although qualitative explanatory work is needed to understand why patients switch pharmacies so often, pharmacists and prescribers must ensure that patients have reliable access to a convenient source of buprenorphine to prevent gaps in therapy.

Clinical decision making involving prescription drug monitoring programs: A factorial, vignette-based study among student pharmacists.

OBJECTIVES: Prescription drug monitoring programs (PDMPs) are state-maintained databases that providers may reference when deciding to prescribe or dispense controlled substances. As more states begin to mandate PDMP use at the point of care, it is imperative to assess how pharmacists use PDMP information when determining whether to fill a controlled substance prescription (CSP). The objective of this study was to evaluate which factors affected fourth-year student pharmacists' decision to fill an opioid prescription, their level of confidence in their decision making, and familiarity with the PDMP. METHODS: We used a 24 factorial design to present a series of text-based vignettes to fourth-year student pharmacists. Each participant received 8 vignettes (5 randomly selected, 3 fixed), representing a hypothetical hydrocodone-acetaminophen combination prescription with varying levels of the following dichotomous factors: doctor shopping, dosage, pharmacy shopping, and concurrent benzodiazepine prescription. Participants were asked to decide whether or not they would fill each of the hypothetical prescriptions they received. A multilevel model was used to measure the association between each of the vignette factors, age, race, sex, experience with PDMP, and the decision to refuse to fill a prescription. Each vignette response served as an independent observation. RESULTS: A total of 87 participants yielded 696 vignette responses. Participants were significantly more likely to refuse to fill prescriptions with doctor shopping (adjusted odds ratio [aOR] 19.86 [95% CI 10.78-36.58]), pharmacy shopping (6.78 [4.13-11.12]), dosage (1.83 [1.16-2.90]), or if the student pharmacist was of female sex (1.73 [1.02-2.93]). Concomitant benzodiazepine use was not associated with a no-fill decision (1.45 [0.92-2.27]). CONCLUSION: This study reveals that student pharmacists' decision to fill a prescription is dependent on both prescription characteristics and a patient's CSP history. The importance of PDMP history cannot be downplayed and suggests that PDMP use may be effective in informing patient care decisions. Still, the variability in filling decision highlights the need to teach a formulaic approach to CSP dispensing in colleges of pharmacy.

Factors associated with the use of the prescription monitoring program by prescribers and pharmacists in Texas.

PURPOSE: To describe Texas Prescription Monitoring Program (PMP) use and identify predictors of PMP query for opioid and benzodiazepine prescriptions by prescribers and pharmacists. METHODS: Dispensation and query records from the Texas PMP for opioid and benzodiazepine medications dispensed between October 1, 2016 and December 31, 2018 were linked using common patient identifiers. Autoregressive linear regression was used to assess trends in utilization. Hierarchical logistic models were specified to identify factors associated with provider and pharmacist query of opioid and benzodiazepine prescriptions. RESULTS: Despite a significant increase in the total number of pharmacists (ß = 169.85, p < 0.0001) and prescribers (ß = 301.59, p < 0.0001) who used the PMP every month, the ratio of active to registered pharmacists (ß = -0.0001, p = 0.75) and prescribers (ß = -0.0015, p = 0.10) did not change. Pharmacists and prescribers were significantly more likely to query opioid and benzodiazepine prescriptions of 14 days or more, and those issued to patients new to their practice. Pharmacists were most likely to query opioid prescriptions for oxycodone (aOR = 4.51, 95%CI = 4.42-4.60) and prescribers were most likely to query prescriptions for buprenorphine (aOR = 2.24, 95%CI = 2.15-2.35) compared to codeine. CONCLUSION: Changes in PMP utilization between October 2016 and December 2018 were driven by increasing registration, not increasing frequency of use among registered users. Use of the PMP is inconsistent and dependent upon patient characteristics thus limiting the utility of the PMP as a decision support tool. These results support the need for policy mandating PMP use in Texas and provide a useful baseline and framework to evaluate the effectiveness of mandate implementation.