Merging statewide data in a public/university collaboration to address opioid use disorder and overdose.

OBJECTIVE: Describe methods to compile a unified database from disparate state agency datasets linking person-level data on controlled substance prescribing, overdose, and treatment for opioid use disorder in Connecticut. METHODS: A multidisciplinary team of university, state and federal agency experts planned steps to build the data analytic system: stakeholder engagement, articulation of metrics, funding to establish the system, determination of needed data, accessing data and merging, and matching patient-level data. RESULTS: Stakeholder meetings occurred over a 6-month period driving selection of metrics and funding was obtained through a grant from the Food and Drug Administration. Through multi-stakeholder collaborations and memoranda of understanding, we identified relevant data sources, merged them and matched individuals across the merged dataset. The dataset contains information on sociodemographics, treatments and outcomes. Step-by-step processes are presented for dissemination. CONCLUSIONS: Creation of a unified database linking multiple sources in a timely and ongoing fashion may assist other states to monitor the public health impact of controlled substances, identify and implement interventions, and assess their effectiveness.

Concomitant use of buprenorphine for medication-assisted treatment of opioid use disorder and benzodiazepines: Using the prescription behavior surveillance system.

BACKGROUND: Despite clinical guidelines discouraging the practice, it is well-documented that the concomitant use of benzodiazepines and opioid analgesics occurs regularly. Information on concomitant use of buprenorphine for medication-assisted treatment (MAT) of opioid use disorder (OUD) and benzodiazepines, however, is limited. Thus, we aimed to describe real-world drug dispensing patterns for the concomitant use of buprenorphine products approved for MAT and benzodiazepines. METHODS: We examined concomitant use of buprenorphine for MAT and benzodiazepines using the 2013 Prescription Behavior Surveillance System data from eight states. For prescription-level analysis, we estimated the proportion of concomitant buprenorphine and benzodiazepine prescriptions and the proportions of concomitant prescriptions prescribed by the same provider (co-prescribing) and dispensed by the same pharmacy (co-dispensing) for each state. For patient-level analysis, we calculated the proportion of patients with ≥1 buprenorphine therapy episode overlapping with a benzodiazepine episode, i.e., concomitant users, and the proportion of concomitant users who experienced co-prescribing or co-dispensing. RESULTS: In 2013, 1,925,072 prescriptions of buprenorphine products for MAT were dispensed to 190,907 patients in eight states. Approximately 1 in 8 buprenorphine prescriptions was used concomitantly with ≥1 benzodiazepine prescription(s). Co-prescribing proportions ranged from 22.2 to 64.6% across states, while co-dispensing proportions ranged from 54.7 to 91.0%. Approximately 17.7% of patients had >1 buprenorphine episode overlapping a benzodiazepine episode for ≥7 cumulative days' supply. Among these patients, 33.1-65.2% experienced co-prescribing, and 65.1-93.3% experienced co-dispensing. CONCLUSIONS: The concomitant use of buprenorphine for MAT and benzodiazepines occurs frequently, with variations by state in co-prescribing and co-dispensing.

Measures to quantify the abuse of prescription opioids: a review of data sources and metrics.

PURPOSE: The abuse and nonmedical use of prescription opioids and its subsequent consequences are an important public health concern. This phenomenon has paralleled the increase in the therapeutic use of opioids for pain management. There is thus a need to measure prescription opioid abuse to understand trends over time and to compare abuse of one product to another. The purpose of this review is to provide an overview of the strengths and weaknesses of frequently used numerators and denominators in "abuse ratios" (ARs). METHODS: For this review, we critically evaluated the various measures to quantify drug availability and the available data sources to measure prescription opioid abuse. RESULTS: There are currently no commonly adopted metrics for measuring either the prevalence of opioid abuse, or abuse relative to drug availability. Because the settings, manifestations, and severity of abuse can vary from one person to the next, no one measure of abuse, abuse-related outcome, or drug exposure is ideal. Each measure of abuse captures a specific facet of abuse, but not the whole spectrum. Reliable estimation of population-adjusted or utilization-adjusted rates of abuse can be accomplished with a prescription opioid AR. This metric estimates the prevalence of abuse in a given population or abuse relative to how much drug is available, and, in certain cases, can be used to compare abuse among various opioid drugs. AR measurements in the literature vary in the inclusion of specific measures of abuse and availability, and there is little consensus in the field regarding which measures allow for the most appropriate approximation of the extent of abuse, and for comparisons among opioids. Crude numbers of outcomes related to abuse (e.g., emergency department visits, treatment admissions, and overdoses) cannot be properly understood without context as these may overestimate or underestimate the true scope and severity of prescription opioid abuse. They can, however, serve as numerators in properly constructed ARs. The denominator of the AR provides the necessary context by accounting for populations at risk or drug availability (e.g., prescriptions or tablets dispensed, unique recipients of dispensed drug, total patient days of therapy, or kilograms sold), and each comes with its own set of assumptions to consider. CONCLUSIONS: Moving forward, it is important that there be a common understanding in the scientific community regarding how to select appropriate measures to serve as numerators and denominators in AR calculations, and how to interpret the resultant findings. There is no single best measure of abuse for use as a numerator in an AR, and each must be chosen and interpreted in the context of what it measures. For public health considerations, one must always look at both absolute numbers and adjusted numbers. When conducting multiple analyses using different measures of exposure as denominators, differences in ARs are not unexpected, but one should explore why there are differences and assess the appropriateness of each of the denominators.

Use of parenteral iron products and serious anaphylactic-type reactions.

Controversy exists about the safety of the parenteral iron dextran products, Dexferrum and INFeD, which have been associated with rare, serious anaphylactic-type reactions. In the United States, their product labels carry boxed warnings of this adverse event; some have called for the withdrawal from marketing of the higher molecular weight Dexferrum. Between 2002 and 2007, sales of Dexferrum, INFeD, and iron gluconate Ferrlecit declined 32.5%, 21%, and 4.8%, respectively, while sales of iron sucrose Venofer increased 160%. Voluntary reports submitted to the Food and Drug Administration show anaphylactic reactions and symptoms for the four parenteral iron products. Because of underreporting, possible differential reporting, absence of iron dextran brand names, and incomplete use (denominator) data, incidence rates and relative risk estimates cannot be calculated. U.S. death certificate data show that for most years from 1979 through 2006, no more than 3 deaths per year were coded to "adverse events in therapeutic use of iron preparations;" brand names were not consistently recorded. Emergency department data show small numbers of visits for treatment of allergic reactions with intravenous iron preparations. The data presented herein show that allergic reactions are possible with all four parenteral iron products, and it is difficult to determine which product has the largest risk based on sales data, voluntarily submitted adverse event reports, death certificates, ED visits, and observational studies performed to date. To help differentiate risk among the parenteral iron products, the brand name of the product always should be provided on medical records, death certificates, and adverse drug reaction reports.

The PACARDO research project: youthful drug involvement in Central America and the Dominican Republic.

OBJECTIVE: To estimate the occurrence and school-level clustering of drug involvement among school-attending adolescent youths in each of seven countries in Latin America, drawing upon evidence from the PACARDO research project, a multinational collaborative epidemiological research study. METHODS: During 1999-2000, anonymous self-administered questionnaires on drug involvement and related behaviors were administered to a cross-sectional, nationally representative sample that included a total of 12,797 students in the following seven countries: Costa Rica (n = 1,702), the Dominican Republic (n = 2,023), El Salvador (n = 1,628), Guatemala (n = 2,530), Honduras (n = 1,752), Nicaragua (n = , 419), and Panama (n = 1,743). (The PACARDO name concatenates PA for Panamá, CA for Centroamérica, and RDO for República Dominicana). Estimates for exposure opportunity and actual use of alcohol, tobacco, inhalants, marijuana, cocaine (crack/coca paste), amphetamines and methamphetamines, tranquilizers, ecstasy, and heroin were assessed via responses about questions on age of first chance to try each drug, and first use. Logistic regression models accounting for the complex survey design were used to estimate the associations of interest. RESULTS: Cumulative occurrence estimates for alcohol, tobacco, inhalants, marijuana, and illegal drug use for the overall sample were, respectively: 52%, 29%, 5%, 4%, and 5%. In comparison to females, males were more likely to use alcohol, tobacco, inhalants, marijuana, and illegal drugs; the odds ratio estimates were 1.3, 2.1, 1.6, 4.1, and 3.2, respectively. School-level clustering was noted in all countries for alcohol and tobacco use; it was also noted in Costa Rica, El Salvador, Guatemala, and Panama for illegal drug use. CONCLUSIONS: This report sheds new light on adolescent drug experiences in Panama, the five Spanish-heritage countries of Central America, and the Dominican Republic, and presents the first estimates of school-level clustering of youthful drug involvement in these seven countries. Placed in relation to school survey findings from North America and Europe, these estimates indicate lower levels of drug involvement in these seven countries of the Americas. For example, in the United States of America 70% of surveyed youths had tried alcohol and 59% had smoked tobacco. By comparison, in these seven countries, only 51% have tried alcohol and only 29% have smoked tobacco. Future research will help to clarify explanations for the observed variations across different countries of the world. In the meantime, strengthening of school-based and other prevention efforts in the seven-country PACARDO area may help these countries slow the spread of youthful drug involvement, reduce school-level clustering, and avoid the periodic epidemics of illegal drug use that have been experienced in North America.

The adolescent behavioral repertoire as a context for drug exposure: behavioral autarcesis at play.

AIMS: The aim of this study is to investigate suspected behavioral autarcesis. Autarcesis refers to a mechanism of non-specific shielding from or immunity to infection or disease. Here, suspecting that some facets of the adolescent behavioral repertoire (ABR) might shield youths from early drug involvement, we studied recent-onset occurrence of first chances to try a drug and first actual drug use, expressed as a function of five observed ABR dimensions: religious, socializing, sports-related, gender socialization, and home-based activities. DESIGN AND PARTICIPANTS: Nationally representative samples of school-attending youths were drawn in Panama, the five Spanish heritage countries of Central America and the Dominican Republic (n = 12797). MEASUREMENTS: Drug involvement and ABR were assessed via anonymous self-administered questionnaires. FINDINGS: A religious activity dimension and a separate sports dimension were associated inversely with recent onset of adolescent drug experiences, and a socializing activity dimension was related to an increased occurrence of these experiences. For example, for each unit increase of the religious activity dimension of the ABR, there was an associated reduced occurrence of the first chance to try tobacco (OR = 0.75, 95% CI: 0.63-0.90, P = 0.002). Adolescents at higher levels of sports activities and home-based activities were less likely to experience recent-onset actual use of marijuana (OR = 0.45, 95% CI: 0.30-0.67, P < 0.001; OR = 0.56, 95% CI: 0.32-0.99, P = 0.048, respectively). CONCLUSIONS: The study evidence lends some support for behavioral autarcesis. Manipulation of selected ABR dimensions might help prevent or reduce adolescent drug involvement, enhancing autarcesis as a protective mechanism.

Religiosity and the earliest stages of adolescent drug involvement in seven countries of Latin America.

To investigate the role of religiosity in the earliest stages of drug involvement, the authors studied recent-onset occurrence of first chances to try a drug and first actual drug use, expressed as a function of religious practice behaviors, levels of religious devotion, and religious affiliation. Based upon standardized questionnaire assessments of nationally representative samples of school-attending youths drawn in Panama, the five Spanish heritage countries of Central America, and the Dominican Republic (n = 12,797), the 1999-2000 study estimates indicate that higher levels of religious practice are inversely associated with the earliest stages of tobacco and cannabis experiences (i.e., the first chance to try and the first actual use) but not so for alcohol. To illustrate, for each unit increase in levels of religious practice behaviors, there was an associated reduced occurrence of the first chance to try tobacco (odds ratio = 0.76, 95% confidence interval: 0.62, 0.94). Occurrence of first actual use of tobacco and cannabis was not associated with levels of religious practice behaviors among youths exposed to the opportunity to try these drugs. As such, these behaviors apparently have not strengthened resistance. Rather, autarcesis may be at work, functioning to shield youths from drug exposure opportunities.

The PACARDO research project: youthful drug involvement in Central America and the Dominican Republic

OBJETIVO: Estimar el grado en que el consumo de drogas se produce y muestra una concentración en el nivel escolar entre adolescentes que asisten a la escuela en siete países de América Latina. Los datos presentados provienen del proyecto de investigación PACARDO, estudio epidemiológico conjunto multinacional. MÉTODOS: En el período de 1999­2000, se aplicaron cuestionarios anónimos autoadministrados sobre el consumo de drogas y conductas afines a una muestra transversal, representativa de la población nacional, que se compuso de un total de 12 797 estudiantes en los siguientes siete países: Costa Rica (n> 1 702), El Salvador (n> 1 628), Guatemala (n> 2 530), Honduras (n> 1 752), Nicaragua (n> 1 419), República Dominicana (n> 2 023) y Panamá (n> 1 743). (El nombre de PACARDO combina la PA de Panamá, la CA de Centroamérica y la RDO de República Dominicana). Se calcularon las oportunidades de exposición y el consumo de alcohol, tabaco, sustancias inhaladas, marijuana, cocaína (crack/pasta de cocaína), anfetaminas y metaanfetaminas, tranquilizantes, éxtasis y heroína sobre la base de las respuestas dadas a preguntas acerca de la edad en que se tuvo la oportunidad de probar cada una de las drogas, y en que se probó cada una de ellas, por primera vez. Para estimar las asociaciones de interés se aplicaron modelos de regresión logística con arreglo a la complejidad de la encuesta. RESULTADOS: Las siguientes fueron las frecuencias estimadas acumulativas del consumo de alcohol, tabaco, sustancias inhaladas, marijuana y drogas, respectivamente, en toda la muestra: 52%, 29%, 5%, 4% y 5%. Comparados con las mujeres, los varones fueron más propensos a consumir alcohol, tabaco, sustancias inhaladas, marijuana y drogas; las razones de posibilidades estimadas fueron, respectivamente, 1,3; 2,1; 1,6; 4,1 y 3,2. En todos los países se observó una concentración del consumo de alcohol y tabaco en el nivel escolar; el consumo ilegal de drogas también mostró una concentración escolar en Costa Rica, El Salvador, Guatemala y Panamá. CONCLUSIONES: Este informe arroja nueva luz sobre las experiencias de los adolescentes con la droga en Panamá, en los cinco países centroamericanos de tradición española, y en la República Dominicana. En él se presentan las primeras estimaciones del grado en que se concentra en las escuelas el consumo de drogas entre la juventud de estos siete países. Cuando se examinan a la luz de los resultados de encuestas escolares...

The adolescent behavioral repertoire: its latent structure in the PACARDO region of Latin America.

In this study, the authors probed the latent structure of the adolescent behavioral repertoire (ABR) and estimated its sociodemographic correlates. The authors drew a nationally representative sample of 12,797 school-attending youth from the 7 countries in the PACARDO region of Latin America: Panama, Guatemala, El Salvador, Honduras, Nicaragua, Costa Rica, and the Dominican Republic. On the basis of the Behavioral Repertoire Self Report scale (Johanson, Duffy, and Anthony, 1996), the authors identified 5 primary dimensions, including religious behaviors, socializing, sports, home-based activities, and gender socialization activities. The authors found that the levels of involvement in these dimensions of the ABR varied across sociodemographic characteristics. The observed multidimensional structure of the ABR sets the stage for future research on adolescent health in relation to these behaviors and activities.