A recent history of opioid use in the US: Three decades of change.

BACKGROUND: The opioid epidemic in the United States is a problem that has developed over decades. While clinical, regulatory, and legislative changes have been implemented to combat this issue, changes will not be immediate. Moreover, the changes that have been carried out may have unintended negative consequences such as increased use of illicit opioids (e.g., heroin and synthetics) and challenges in effective and appropriate pain management. OBJECTIVES: This review focuses on the last three decades and presents key changes the United States has seen in the use of opioids. Conclusions/Importance: There have been numerous policy changes and programs aimed at decreasing opioid use and abuse in the United States; however, it will take a major shift in the mindset of clinicians, the general public, and policy makers to alleviate this epidemic.

Exposure Calls to U. S. Poison Centers Involving Electronic Cigarettes and Conventional Cigarettes-September 2010-December 2014.

INTRODUCTION: E-cigarette use is increasing, and the long-term impact on public health is unclear. We described the acute adverse health effects from e-cigarette exposures reported to U.S. poison centers. METHODS: We compared monthly counts and demographic, exposure, and health effects data of calls about e-cigarettes and conventional cigarettes made to poison centers from September 2010 through December 2014. RESULTS: Monthly e-cigarette calls increased from 1 in September 2010, peaked at 401 in April 2014, and declined to 295 in December 2014. Monthly conventional cigarette calls during the same period ranged from 302 to 514. E-cigarette calls were more likely than conventional cigarette calls to report adverse health effects, including vomiting, eye irritation, and nausea. Five e-cigarette calls reported major health effects, such as respiratory failure, and there were two deaths associated with e-cigarette calls. CONCLUSION: E-cigarette calls to U.S. poison centers increased over the study period, and were more likely than conventional cigarettes to report adverse health effects. It is important for health care providers and the public to be aware of potential acute health effects from e-cigarettes. Developing strategies to monitor and prevent poisonings from these novel devices is critical.

Prescription-acquired acetaminophen use and the risk of asthma in adults: a case-control study.

BACKGROUND: Studies have examined the association between acetaminophen use and asthma; however, their interpretation is limited by several methodologic issues. OBJECTIVE: To investigate the association between recent and chronic prescription-acquired acetaminophen use and asthma. METHODS: This retrospective case-control study used a 10% random sample of the IMS LifeLink commercial claims data from 1997 to 2009. Cases had to have at least 1 incident claim of asthma; 3:1 controls matched on age, sex, and region were randomly chosen. Acetaminophen exposure, dose, and duration were measured in the 7- and 30-day (recent) and the 1-year (chronic) look-back periods. Multivariable conditional logistic regression was used to estimate the risk of asthma associated with acetaminophen use adjusted for comorbidities, other drugs increasing asthma risk, and health system factors. RESULTS: There were 28,892 cases and 86,676 controls, with mean age of 42.8 years; 37.7% were males, and 22.6% of cases and 18.2% of controls had acetaminophen exposure in the pre-index year, with mean cumulative doses of 78.7 g and 59.8 g, respectively. There was no significant association between recent prescription acetaminophen exposure and asthma (7 days: OR 1.02, p = 0.74; 30 days: OR 0.97, p = 0.38). Cumulative prescription acetaminophen dose in the year prior increased asthma risk compared to acetaminophen nonusers (≤1 kg: OR 1.09, p < 0.001 and >1 kg: OR = 1.60, p = 0.02). Duration of prescription acetaminophen use greater than 30 days was associated with elevated asthma risk (OR 1.39, p < 0.001). CONCLUSIONS: Chronic prescription-acquired acetaminophen use was associated with an increased risk of asthma, while recent use was not. However, over-the-counter acetaminophen use was not captured in this study and further epidemiologic research with complete acetaminophen exposure ascertainment and research on pathophysiologic mechanisms is needed to confirm these relationships.

Acute and chronic acetaminophen use and renal disease: a case-control study using pharmacy and medical claims.

BACKGROUND: Studies have examined the association between acetaminophen (APAP) use and renal disease; however, their interpretation is limited by a number of methodological issues. OBJECTIVE: To study the association between acute and chronic prescription-acquired APAP use and renal disease. METHODS: This was a retrospective case-control study of medical and pharmacy claims of a 10% random sample of the enrollees from the IMS LifeLink Health Plans commercial claims dataset for dates of service from January 1, 1997, through December 31, 2009. Subjects were continuously enrolled and aged 18 years or older. Cases had at least 1 incident claim of renal disease defined by ICD-9-CM codes in the primary diagnosis field. Controls were randomly selected from individuals without evidence of renal disease, liver disease, or asthma in medical claims and matched to cases in a 3-to-1 ratio based on 3 variables (age, gender, and geographic region). APAP exposure, dosage, and duration of use were measured in the 7 and 30 days (acute) and in the 1-year (chronic) look-back periods. Multivariable conditional logistic regression was used to estimate the risk of APAP exposure adjusted for comorbidities, use of other nephrotoxic drugs, and health system factors. RESULTS: There were 4,724 cases and 14,172 controls with a mean (SD) age of 60.8 (17.8) years, and 52.6% were males; 10.9% of cases and 4.2% of controls had APAP exposure in the 30 days pre-index with mean potential maximum daily dosages of 3,846.5 mg and 3,190.8 mg, respectively. Acute APAP exposure was significantly associated with renal disease, and the risk decreased with longer look-back periods (7 days: adjusted odds ratio [OR] = 1.93, 95% CI = 1.61-2.30); 30 days: OR = 1.71, 95% CI = 1.48-1.97). Cumulative APAP dosage greater than 1 kg and APAP use for longer than 30 days in the pre-index year were not significantly associated with an increased risk of renal disease (both P values = 0.900). CONCLUSIONS: Acute prescription-acquired APAP use was associated with renal disease, while chronic use was not. Because this study assessed APAP use in pharmacy claims, further research accounting for over-the-counter APAP use is warranted before the safety of chronic APAP consumption can be firmly established.

Effect of scheduling tramadol as a controlled substance on poison center exposures to tramadol.

BACKGROUND: There is limited information on the effect of scheduling a drug as a controlled substance with comparable data from both a pre-scheduling and post-scheduling time period. OBJECTIVE: To investigate the temporal changes on poisoning cases involving tramadol in 4 states: 2 states where it has been scheduled and 2 where it is not scheduled. METHODS: Databases were searched for all cases involving tramadol reported from 2003 through 2009 at 6 regional poison centers that served Arkansas, Kentucky, Ohio, and West Virginia. To allow for comparison based on population, state population estimates were obtained from the US Census Bureau. RESULTS: Over the 7-year study period, the number of tramadol cases increased from 401 per year to 1009 cases per year. The mean annual increase in tramadol cases for all 4 states ranged from 8.8% to 14.1%. Post-scheduling in Arkansas and Kentucky, there was a mean decrease in cases of 4% and 31%, respectively. During this same period, the comparison states of West Virginia and Ohio showed a continued increase of 14% and 23%, respectively. The mean annual increase in tramadol cases per 100,000 population for all 4 states ranged from 16% to 31%. Post-scheduling of tramadol, there was an annual decrease in tramadol human exposures of 5% to 31% in Arkansas and Kentucky, respectively. During this same period, West Virginia and Ohio showed a continued annual increase of 14%. CONCLUSIONS: The decrease in the number of cases of tramadol exposure following its addition to the schedule of controlled substances in Kentucky and Arkansas suggests that adding a drug to the schedule of controlled substances may result in a decrease in poisoning exposures related to that drug.

Dextromethorphan.

Dextromethorphan is reviewed in its role as an emerging drug of abuse, and the effects of dextromethorphan, along with those of co-ingredients in OTC formulations, are discussed. The Drug Abuse and Warning Network (DAWN) national data in the United States are examined in the context of data from other poison control centers, and possible national trends are postulated. Implications for dextromethorphan as an emerging drug of abuse are explored. Data from the Arkansas Poison Control Center (APCC) show emerging trends in the abuse of dextromethorphan, particularly in this rural area of the United States.

Do poison center guidelines adversely affect patient outcomes as triage referral values increase?

BACKGROUND: The purpose of this study was to determine whether patient outcomes were adversely affected as healthcare referral values increased for two common poisonings: acute, unintentional acetaminophen (APAP) poisonings and acute, unintentional iron (Fe) poisonings. We hypothesized that symptom rates would increase with high referral values. METHODS: Qualifying 1997 exposures were separated by substance (APAP or Fe) and then further stratified into three healthcare referral value ranges. Symptomatic and asymptomatic patients were totaled for each stratum. Expected vs. observed distributions of symptomatic and asymptomatic patients across triage referral strata for a given substance and treatment location were compared using chi-square test for independence. The Wilcoxon-Mann-Whitney test was used to compare the distribution of patients across referral strata for home vs. healthcare facility locations for a specific substance. RESULTS: There were no statistically significant differences in the distribution of symptomatic patients within referral value strata for APAP or for Fe. There was also no difference in distribution of symptomatic patients across strata when comparing home vs. healthcare facility for APAP and Fe. CONCLUSION: Referral values as high as 201 mg/kg for APAP and 61 mg/kg for Fe do not appear to adversely affect patient outcomes.