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Study Objective: To evaluate the association between potential emergency department (ED)-based modifiable risk factors and subsequent development of delirium among hospitalized older adults free of delirium at the time of ED stay., Methods: Observational cohort study of patients aged ≥75 years who screened negative for delirium in the ED, were subsequently admitted to the hospital, and had delirium screening performed within 48 h of admission. Potential ED-based risk factors for delirium included ED length of stay (LOS), administration of opioids, benzodiazepines, antipsychotics, or anticholinergics, and the placement of urinary catheter while in the ED. Odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CIs) were calculated., Results: Among 472 patients without delirium in the ED (mean age 84 years, 54.2% females), 33 (7.0%) patients developed delirium within 48 h of hospitalization. The ED LOS of those who developed delirium was similar to those who did not develop delirium (312.1 vs 325.6 min, MD -13.5 min, CI -56.1 to 29.0). Patients who received opioids in the ED were as likely to develop delirium as those who did not receive opioids (7.2% vs 6.9%: OR 1.04, CI 0.44 to 2.48). Patients who received benzodiazepines had a higher risk of incident delirium, the difference was clinically but not statistically significant (37.3% vs 6.5%, OR 5.35, CI 0.87 to 23.81). Intermittent urinary catheterization (OR 2.05, CI 1.00 to 4.22) and Foley placement (OR 3.69, CI 1.55 to 8.80) were associated with a higher risk of subsequent delirium. After adjusting for presence of dementia, only Foley placement in the ED remained significantly associated with development of in-hospital delirium (adjusted OR 3.16, CI 1.22 to 7.53)., Conclusion: ED LOS and ED opioid use were not associated with higher risk of incident delirium in this cohort. Urinary catheterization in the ED was associated with an increased risk of subsequent delirium. These findings can be used to design ED-based initiatives and increase delirium prevention efforts., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

BACKGROUND: Due to the US opioid epidemic, in March of 2016, the Centers for Disease Control and Prevention (CDC) published new guidelines for primary care providers on opioid prescribing for chronic pain. Payer coverage changes were also implemented to help modify opioid prescribing behavior. Whether these initiatives were associated with changes in opioid initiation patterns is unknown. OBJECTIVE: To assess the association between 3 of the 2016 CDC guidelines and 2 subsequent payer pharmacy coverage changes with changes in opioid initiation behavior across different provider specialties. METHODS: We conducted a real-world evidence study using claims data from OptumLabs Data Warehouse between January of 2014 and December of 2018. Subjects were continuously enrolled opioid naive patients, aged at least 18 years, who had at least 1 chronic pain diagnosis within 2 weeks before their first (first-time) opioid prescription. The study used multiple treatment period segmented regression analysis to evaluate the association, across different provider specialties, between the CDC guideline release and the payer pharmacy coverage changes with immediate change in level and overall change in the rate of first-time extended-release opioid prescriptions, firsttime opioid prescriptions at doses of at least 50 MME (morphine milligram equivalent) per day, and first-time opioid prescriptions with overlapping benzodiazepine prescription. RESULTS: The CDC guidelines were not associated with any change in the rate of first-time prescriptions of extended-release opioids. However, a January 2017 payer pharmacy coverage change was associated with a reduction over time in first-time extended-release opioid prescription rates by 22.15 in every 100,000 prescriptions (CI = -40.04 to -2.92, P = 0.013). The CDC guidelines were associated with an immediate decline in level of first-time opioid prescription at doses of at least 50 MME per day by 74.00 in every 10,000 prescriptions (CI = -124.86 to -23.13, P = 0.004) and an increased rate of decline over time by 13.64 in every 10,000 prescriptions (CI = -17.07 to -10.21, P < 0.001). These associations varied across provider types and specialties. The March 2018, payer coverage change was associated with an immediate reduction in level of first-time opioid prescriptions at doses of at least 50 MME per day across all specialties and an increased reduction over time among surgeons. The CDC guidelines were associated, respectively, with a reduction in the rate of overlapping first-time opioid prescriptions with benzodiazepines among family medicine, internal medicine, surgeons, emergency medicine providers, and providers with unknown specialty by 6.11, 5.10, 2.89, 11.43, and 9.11 in every 10,000 prescriptions monthly (CI = -9.48 to -2.73, -9.86 to -0.35, -5.40 to -0.38, -17.26 to -5.61 and -11.96 to -6.25, respectively, P < 0.001, P = 0.035, P = 0.024, P < 0.001 and P < 0.001). CONCLUSIONS: Some specialist providers also adopted the CDC guidelines, and the response to the guidelines differed across various provider specialties. Some CDC guidelines were associated with a reduction in high-risk first-time opioid prescriptions. Payer pharmacy coverage changes reinforced the guidelines both in situations where the CDC guidelines did and did not show any association. DISCLOSURE: This research was funded by Agency for Healthcare Research and Quality (R01 HS025164; PI: Karaca-Mandic). Karaca-Mandic reports grants from the American Cancer Society and Sempre Health, along with fees from Tactile Medical and Precision Health Economics, unrelated to this study. The other authors have nothing to disclose.

Objective: Understanding postsurgical prescribing patterns and their impact on persistent opioid use is important for establishing reasonable opioid prescribing protocols. We aimed to determine national variation in postoperative opioid prescription practices following elective lumbar spine surgery and their impact on short-term refill prescriptions., Methods: The OptumLabs Data Warehouse was queried from 2016 to 2017 for adults undergoing anterior lumbar fusion, posterior lumbar fusion, circumferential lumbar fusion, and lumbar decompression/discectomy for degenerative spine disease. Discharge opioid prescription fills were obtained and converted to morphine milligram equivalents (MMEs). Age- and sex-adjusted MMEs and frequency of discharge prescriptions >200 MMEs were determined for each U.S. census division and procedure type., Results: The study included 43,572 patients with 37,894 postdischarge opioid prescription fills. There was wide variation in mean filled MMEs across all census divisions (anterior lumbar fusion: 774-1147 MMEs; posterior lumbar fusion: 717-1280 MMEs; circumferential lumbar fusion: 817-1271 MMEs; lumbar decompression/discectomy: 619-787 MMEs). A significant proportion of cases were found to have filled discharge prescriptions >200 MMEs (posterior lumbar fusion: 78.6%-95%; anterior lumbar fusion: 87.5%-95.6%; circumferential lumbar fusion: 81.4%-96.5%; lumbar decompression/discectomy: 80.5%-91%). Multivariable logistic regression showed that female sex and inpatient surgery were associated with a top-quartile discharge prescription and a short-term second opioid prescription fill, while the opposite was noted for elderly and opioid-naïve patients (all P ≤ 0.05). Prescriptions with long-acting opioids were associated with higher odds of a second opioid prescription fill (reference: nontramadol short-acting opioid)., Conclusions: In analysis of filled opioid prescriptions, we observed a significant proportion of prescriptions >200 MMEs and wide regional variation in postdischarge opioid prescribing patterns following elective lumbar spine surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Experts cautioned that patients affected by the November 2010 withdrawal of the opioid analgesic propoxyphene might receive riskier prescriptions. To explore this, we compared drug receipts and outcomes among propoxyphene users before and aftermarket withdrawal., Study Design: Using OptumLabs data, we studied 3 populations: commercial, Medicare Advantage (MA) aged (age 65+ y) and MA disabled (age below 65 y) enrollees. The exposed enrollees received propoxyphene in the 3 months before market withdrawal (n=13,622); historical controls (unexposed) received propoxyphene 1 year earlier (n=9971). Regression models estimated daily milligrams morphine equivalent (MME), daily prescription acetaminophen dose, potentially toxic acetaminophen doses, nonopioid prescription analgesics receipt, emergency room visits, and diagnosed falls, motor vehicle accidents, and hip fractures., Principal Findings: Aged MA enrollees illustrate the experience of all 3 populations examined. Following the market withdrawal, propoxyphene users in the exposed cohort experienced an abrupt decline of 69% in average daily MME, compared with a 14% decline in the unexposed. Opioids were discontinued by 34% of the exposed cohort and 18% of the unexposed. Tramadol and hydrocodone were the most common opioids substituted for propoxyphene. The proportion of each group receiving ≥4 g of prescription acetaminophen per day decreased from 12% to 2% in the exposed group but increased from 6% to 8% among the unexposed. Adverse events were rare and not significantly different in exposed versus unexposed groups., Conclusions: After propoxyphene market withdrawal, many individuals experienced abrupt discontinuation of opioids. Policymakers might consider supporting appropriate treatment transitions and monitoring responses following drug withdrawals.

Importance: The Centers for Disease Control and Prevention guidelines in 2016 recommended avoiding concurrent use of opioids and benzodiazepines., Objective: To determine whether the release of the guidelines was associated with changes in coprescription of opioids and benzodiazepines., Design, Setting, and Participants: This retrospective cohort study used claims data obtained from a US national database of medical and pharmacy claims for 3 598 322 adult commercially insured patients and 1 299 142 Medicare Advantage (MA) beneficiaries with no recent history of cancer, sickle cell disease, or hospice care who ever used prescribed opioids during the study period, January 1, 2014, through March 31, 2018., Exposures: Overlapping opioid and benzodiazepine prescriptions filled., Main Outcomes and Measures: The extent (proportion of person-months with any overlapping days of prescription of opioids and benzodiazepines) and intensity (proportion of days with opioids prescribed where benzodiazepines were also available) of coprescription., Results: Of 4 897 464 patients (with 13.4 million person-months of opioid use), the total number of unique commercially insured individuals was 3 598 322 (1 974 731 women [54.9%]), and the total number of unique MA beneficiaries was 1 299 142 (770 256 women [59.3%]). Among 128 576 participants experiencing chronic pain episodes, more than one-half of person-months of long-term opioid use occurred in women (52.7% of person-months among those with commercial insurance and 62.4% of person-months among MA beneficiaries). The median (interquartile range) age of the participants was 51 (41-58) years for patients in the commercial insurance group and 70 (61-77) years for those in the MA group. The mean (SE) extent of coprescription was 23.0% (0.18%) for the commercial insurance group and 25.7% (0.18%) for the MA group. The extent of coprescription decreased in the targeted guideline population-individuals with long-term opioid use-after the guideline release (postguideline slope, -0.95 percentages point per year [95% CI, -1.44 to -0.46 percentage points per year] for the commercial insurance group and -1.06 percentage points per year [95% CI, -1.49 to -0.63 percentage points per year] for the MA group). Nontargeted short-term episodes of opioid use were associated with no change or small declines in trend (for the MA group, postguideline slope of 0.47 percentage point per year [95% CI, 0.35-0.59 percentage point per year]; for the commercial insurance group, postguideline slope of -0.05 percentage point per year [95% CI, -0.12 to 0.02 percentage point per year]). High coprescribing intensity was seen, with 79.3% (95% CI, 78.9%-79.6%) of opioid prescription days in the commercial insurance group and 83.9% (95% CI, 83.7%-84.2%) in the MA group overlapping with benzodiazepines. There was no change in the intensity of coprescribing. Intensity of coprescription was higher when the same clinician prescribed opioids and benzodiazepines., Conclusion and Relevance: This study observed a reduction in the extent but not intensity of coprescribing of benzodiazepines for patients with long-term opioid use.