1. Home
  2. prescriptions

prescriptions

Mobile Telemedicine for Buprenorphine Treatment in Rural Populations With Opioid Use Disorder

Author/s: 
Weintraub, E., Seneviratne, C., Anane, J.

Importance
The demand for medications for opioid use disorder (MOUD) in rural US counties far outweighs their availability. Novel approaches to extend treatment capacity include telemedicine (TM) and mobile treatment on demand; however, their combined use has not been reported or evaluated.

Objective
To evaluate the use of a TM mobile treatment unit (TM-MTU) to improve access to MOUD for individuals living in an underserved rural area.

Design, Setting, and Participants
This quality improvement study evaluated data collected from adult outpatients with a diagnosis of OUD enrolled in the TM-MTU initiative from February 2019 (program inception) to June 2020. Program staff traveled to rural areas in a modified recreational vehicle equipped with medical, videoconferencing, and data collection devices. Patients were virtually connected with physicians based more than 70 miles (112 km) away. Data analysis was performed from June to October 2020.

Intervention
Patients received buprenorphine prescriptions after initial teleconsultation and follow-up visits from a study physician specialized in addiction psychiatry and medicine.

Main Outcomes and Measures
The primary outcome was 3-month treatment retention, and the secondary outcome was opioid-positive urine screens. Exploratory outcomes included use of other drugs and patients’ travel distance to treatment.

Results
A total of 118 patients were enrolled in treatment, of whom 94 were seen for follow-up treatment predominantly (at least 2 of 3 visits [>50%]) on the TM-MTU; only those 94 patients’ data are considered in all analyses. The mean (SD) age of patients was 36.53 (9.78) years, 59 (62.77%) were men, 71 (75.53%) identified as White, and 90 (95.74%) were of non-Hispanic ethnicity. Fifty-five patients (58.51%) were retained in treatment by 3 months (90 days) after baseline. Opioid use was reduced by 32.84% at 3 months, compared with baseline, and was negatively associated with treatment duration (F = 12.69; P = .001). In addition, compared with the nearest brick-and-mortar treatment location, TM-MTU treatment was a mean of 6.52 miles (range, 0.10-58.70 miles) (10.43 km; range, 0.16-93.92 km) and a mean of 10 minutes (range, 1-49 minutes) closer for patients.

Conclusions and Relevance
These data demonstrate the feasibility of combining TM with mobile treatment, with outcomes (retention and opioid use) similar to those obtained from office-based TM MOUD programs. By implementing a traveling virtual platform, this clinical paradigm not only helps fill the void of rural MOUD practitioners but also facilitates access to underserved populations who are less likely to reach traditional medical settings, with critical relevance in the context of the COVID-19 pandemic.

Trajectories of Opioid Use Following First Opioid Prescription in Opioid-Naive Youths and Young Adults

Author/s: 
Wilson, J.D., Zbebe, K.Z., Kraemer, K., Liebschutz, J., Merlin, J., Miller, E., D., Donohue, J.

Importance: Although prescription opioids are the most common way adolescents and young adults initiate opioid use, many studies examine population-level risks following the first opioid prescription. There is currently a lack of understanding regarding how patterns of opioid prescribing following the first opioid exposure may be associated with long-term risks.

Objective: To identify distinct patterns of opioid prescribing following the first prescription using group-based trajectory modeling and examine the patient-, clinician-, and prescription-level factors that may be associated with trajectory membership during the first year.

Design, setting, and participants: This cohort study examined Pennsylvania Medicaid enrollees' claims data from 2010 through 2016. Participants were aged 10 to 21 years at time of first opioid prescription. Data analysis was performed in March 2020.

Main outcomes and measures: This study used group-based trajectory modeling and defined trajectory status by opioid fill.

Results: Among the 189 477 youths who received an initial opioid prescription, 107 562 were female (56.8%), 81 915 were non-Latinx White (59.6%), and the median age was 16.9 (interquartile range [IQR], 14.6-18.8) years. During the subsequent year, 47 477 (25.1%) received at least one additional prescription. Among the models considered, the 2-group trajectory model had the best fit. Of those in the high-risk trajectory, 65.3% (n = 901) filled opioid prescriptions at month 12, in contrast to 13.1% (n = 6031) in the low-risk trajectory. Median age among the high-risk trajectory was 19.0 years (IQR, 17.1-20.0 years) compared with the low-risk trajectory (17.8 years [IQR, 15.8-19.4 years]). The high-risk trajectory received more potent prescriptions compared with the low-risk trajectory (median dosage of the index month for high-risk trajectory group: 10.0 MME/d [IQR, 5.0-21.2 MME/d] vs the low-risk trajectory group: 4.7 MME/d [IQR, 2.5-7.8 MME/d]; P < .001). The trajectories showed persistent differences with more youths in the high-risk trajectory going on to receive a diagnosis of opioid use disorder (30.0%; n = 412) compared with the low-risk group (10.1%; n = 4638) (P < .001).

Conclusions and relevance: This study's results identified 2 trajectories associated with elevated risk for persistent opioid receipt within 12 months following first opioid prescription. The high-risk trajectory was characterized by older age at time of first prescription, and longer and more potent first prescriptions. These findings suggest even short and low-dose opioid prescriptions can be associated with risks of persistent use for youths.

Keywords 
opioids Native Peoples youth Young Adults Opioid Prescription Opioid Use RISEOK

Challenges and Approaches to Population Management of Long-Term Opioid Therapy Patients

Author/s: 
Stephens, Kari A., Ike, Brooke, Baldwin, Laura-Mae, Packer, Christine, Parchman, Michael

Purpose: Primary care is challenged with safely prescribing opioids for patients with chronic noncancer pain (CNCP), specifically to address risks for overdose, opioid use disorder, and death. We identify sociotechnical challenges, approaches, and recommendations in primary care to effectively track and monitor patients on long-term opioid therapy, a key component for supporting adoption of opioid prescribing guidelines.

Methods: We examined qualitative data (field notes and postintervention interview and focus group transcripts) from 6 rural and rural-serving primary care organizations with 20 clinic locations enrolled in a study evaluating a practice redesign program to improve opioid medication management for CNCP patients. Two independent researchers used content analysis to categorize data into key themes to develop an understanding of sociotechnical factors critical to creating and implementing an approach to tracking and monitoring of patients on long-term opioid therapy in primary care practices.

Results: Four factors were critical to developing a tracking and monitoring system. For each we describe common challenges and approaches used by the clinics to overcome then. The first factor, buy-in and participation, was essential for accomplishing the other 3. The other factors occurred sequentially: 1) cohort identification-finding the right patients, 2) data collection and extraction-tracking the right data, and 3) data use-monitoring patients and adjusting care processes.

Conclusions: We identified common challenges and approaches to tracking and monitoring patients using long-term opioid therapy for CNCP in primary care. Based on these findings we provide recommendations to build capacity for tracking and monitoring for organizations that are engaged in improving safe opioid-prescribing practices for CNCP in primary care.

Keywords 
Capacity Building Chronic Disease chronic pain Disease Management Drug Overdose 2019-nCOV 1,4-DMAA primary health care RISEOK

Adolescent Opioid Misuse Attributable to Adverse Childhood Experiences

Author/s: 
Swedo, E.A., Sumner, S.A., Fijter, S., Werhan, L., Norris, K., Beauregard, J.L., Montgomery, M.P., Rose, E.B., Hillis, S. D., Massetti, G.M.

Objectives

To estimate the proportion of opioid misuse attributable to adverse childhood experiences (ACEs) among adolescents.

Study design

A cross-sectional survey was administered to 10,546 7th‒12th grade students in northeastern Ohio in Spring 2018. Study measures included self-reported lifetime exposure to 10 ACEs and past 30 day use of nonmedical prescription opioid or heroin. Using generalized estimating equations, we evaluated associations between recent opioid misuse, individual ACEs, and cumulative number of ACEs. We calculated population attributable fractions (PAF) to determine the proportion of adolescents’ recent opioid misuse attributable to ACEs.

Results

Nearly one in 50 adolescents reported opioid misuse within 30 days (1.9%); ∼60% of youth experienced ≥1 ACE; 10.2% experienced ≥5 ACEs. Cumulative ACE exposure demonstrated a significant graded relationship with opioid misuse. Compared with youth with zero ACEs, youth with 1 ACE (adjusted odds ratio [AOR]: 1.9, 95% confidence interval [CI]: 0.9‒3.9), 2 ACEs (AOR: 3.8, CI: 1.9‒7.9), 3 ACEs (AOR: 3.7, CI: 2.2‒6.5), 4 ACEs (AOR: 5.8, CI: 3.1‒11.2), and ≥5 ACEs (AOR: 15.3, CI: 8.8‒26.6) had higher odds of recent opioid misuse. The population attributable fraction of recent opioid misuse associated with experiencing ≥1 ACE was 71.6% (CI: 59.8–83.5).

Conclusions

There was a significant graded relationship between number of ACEs and recent opioid misuse among adolescents. Over 70% of recent adolescent opioid misuse in our study population was attributable to ACEs. Efforts to decrease opioid misuse could include programmatic, policy, and clinical practice interventions to prevent and mitigate the negative effects of ACEs.

Keywords 
adverse childhood experience

Aspirin in the Treatment and Prevention of Migraine Headaches: Possible Additional Clinical Options for Primary Healthcare Providers

Author/s: 
Biglione, B., Gitin, A., Gorelick, P., Hennekens, C.

Migraine headaches are among the most common and potentially debilitating disorders encountered by primary healthcare providers. In the treatment of acute migraine as well as prevention of recurrent attacks there are prescription drugs of proven benefit. For those without health insurance or high co-pays, however, they may be neither available nor affordable and, for all patients, they may be either poorly tolerated or contraindicated.

The totality of evidence, which includes data from randomized trials, suggests that high-dose aspirin, in doses from 900 to 1300 milligrams, taken at the onset of symptoms, is an effective and safe treatment option for acute migraine headaches. In addition, the totality of evidence, including some, but not all, randomized trials, suggests the possibility that daily aspirin in doses from 81 to 325 milligrams, may be an effective and safe treatment option for the prevention of recurrent migraine headaches.

The relatively favorable side effect profile of aspirin and extremely low costs compared with other prescription drug therapies may provide additional options for primary healthcare providers treating acute as well as recurrent migraine headaches.

Keywords 
migraine treatment headache

Don't Get Burned! Legal Issues Associated with Medical Marijuana

Author/s: 
Loomis, Cori H.

In Conclusion

  • Evaluate carefully whether recommending medical marijuana is something you want to do and the risks and requirements associated with it.
  • Prepare and use appropriate informed consent forms and treatment agreements.
  • Notify your medical liability insurance carrier.
  • Check with your employer or facilities at which you have privleges.
Keywords 
cannabis medical marijuana legal issues
Subscribe to prescriptions