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To evaluate the impact of a quality improvement bundle on opioid discharge prescribing following thyroidectomy and parathyroidectomy.This before-and-after study included patients undergoing thyroidectomy or parathyroidectomy at an academic medical center. The quality improvement bundle included a patient education flyer, electronic health record order sets with multimodal analgesia regimens, and provider education. The preimplementation cohort included patients treated from January 2018 to December 2019. The postimplementation cohort included patients treated from June 2021 to August 2021. The primary outcome was the proportion of patients who received new opioid discharge prescriptions.A total of 160 patients were included in the preimplementation cohort, and the first 80 patients treated after bundle implementation were included in the postimplementation cohort. Patients receiving new opioid discharge prescriptions decreased from 80% (128/160) in the preimplementation cohort to 35% (28/80) in the postimplementation cohort with an unadjusted absolute reduction of 45% (95% CI, 33%-57%;Implementation of a pain management quality improvement bundle reduced opioid discharge prescribing following thyroidectomy and parathyroidectomy.Unnecessary opioid prescriptions generate unused opioids in patients' homes that can lead to opioid misuse. We believe that this bundle reduced the risk for opioid misuse in our community.The study was registered at ClinicalTrials.gov (NCT04955444) before implementation.

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.

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.

Study objective To compare the effectiveness of oral fingolimod and conventional injectable disease-modifying agents (DMAs) using the composite endpoint of relapse or DMA treatment switch in patients with multiple sclerosis (MS). Design A retrospective longitudinal cohort study. Data source IBM MarketScan Commercial Claims and Encounters Database from 2010-2012. Patients Adults (≥18 years) with MS diagnosis (ICD-9-CM:340) who newly initiated DMAs. Intervention Oral fingolimod and conventional injectable DMAs (interferon beta and glatiramer acetate). Measurements Composite endpoint of time to relapse or DMA treatment switch. Main results The incident study cohort consisted of 1997 MS patients who initiated oral fingolimod (15.6%) or injectable (84.4%) DMAs. The proportion of patients who had a composite endpoint (relapse/DMA treatment switch) in oral fingolimod and injectable DMA users was found to be 16.72% and 27.16%, respectively. The Cox PH regression model with stabilized IPTW revealed that fingolimod is equally effective as conventional injectable DMAs in reducing the risk of experiencing the composite endpoint of relapse or DMA switch (adjusted hazard ratio [aHR]: 0.67, 95% CI: 0.43-1.03). Additional analysis among patients who were adherent also found no significant difference in the composite endpoint (aHR: 0.70, 95% CI 0.49-1.15) between oral fingolimod and injectable DMA users. Conclusions Oral fingolimod has similar effectiveness as conventional injectable DMAs in reducing the risk of experiencing the composite endpoint (relapse or DMA treatment switch). In addition, when assessed independently, oral fingolimod showed no difference in reducing the time to relapse or DMA treatment switch compared to injectable DMAs.

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 (β = 169.85, p

Background Healthcare access has changed drastically during the COVID-19 pandemic. Elective medical procedures, including routine office visits, were restricted raising concerns regarding opioid and benzodiazepine provider and prescription availability. Objective To examine how the cancelation of elective medical procedures due to COVID-19 impacted the dispensing of opioid and benzodiazepine prescriptions in Texas. Methods Interrupted time series analyses were preformed to examine changes in prescription trends for opioids and benzodiazepines before and after the restriction on elective medical procedures. Samples of patients who filled an opioid or benzodiazepine prescription from January 5, 2020 to May 12, 2020 were identified from the Texas Prescription Monitoring Program. Elective medical procedures were restricted starting March 23, 2020 indicating the beginning of the intervention period. Results Restricting elective procedures was associated with a significant decrease in the number of patients (β = −6029, 95%CI = −8810.40, −3246.72) and prescribers (β = −2784, 95%CI = −3671.09, −1896.19) filling and writing opioid prescriptions, respectively. Also, the number of patients filling benzodiazepine prescriptions decreased significantly (β = −1982, 95%CI = −3712.43, −252.14) as did the number of prescribers (β = −708.62, 95%CI = −1190.54, −226.71). Conclusion Restricting elective procedures resulted in a large care gap for patients taking opioid or benzodiazepine prescriptions.

Opioid use among metastatic breast cancer (MBC) patients has not been well-studied. This study examined the trends and patterns of opioid use among working-age, privately insured patients diagnosed with MBC. Using MarketScan data, we identified female patients diagnosed with MBC in 2006–2015. We determined the proportion of patients who filled a prescription for an opioid and calculated days’ supply and daily morphine milligram equivalents (MMEs) from 1 year prior to diagnosis till 1 year after. We assessed the trend in opioid use over the 10-year study period and examined opioid usage patterns after the diagnosis of MBC. Among 24,752 patients included, 11,579 (46.8%) had an opioid prescription within 1 year before diagnosis of MBC, and 20,416 (81.4%) had an opioid prescription within 1 year after diagnosis. The proportion of patients with opioid prescriptions after diagnosis was relatively stable from 2006 to 2015. However, both the median daily MME and median days’ supply decreased over time with most of the decline from the subgroup of patients with prior prescription opioid use. Most patients received an opioid prescription in the first month after diagnosis (57.3%), dropping to approximately 20% from 3 to 12 months after diagnosis. Also, the median days’ supply increased substantially during the year after diagnosis for patients who received opioids (from 7 to 19). Most women with MBC require opioid analgesia within the first month after diagnosis. Judicious, long-term management of pain after diagnosis of MBC will continue to be necessary for many patients.

Background Oral fingolimod is convenient to use than injectable disease modifying agents (DMAs) in patients with multiple sclerosis (MS). However, the existing literature regarding the comparative adherence trajectories between oral fingolimod and injectable DMAs is limited. Objective To compare the adherence trajectories between oral DMA, fingolimod, and injectable DMAs in patients with MS. Methods A retrospective longitudinal study was conducted using adults (≥18 years) with MS (ICD-9-CM: 340 and a DMA prescription) from the IBM MarketScan Commercial Claims and Encounters Database between 2010 and 2012. Patients were grouped into oral fingolimod or injectable DMA users based on the index DMA among patients with MS. The annual DMA adherence trajectories, based on the proportion of days covered (PDC), were examined using group-based trajectory modeling (GBTM) during the one-year follow-up period after treatment initiation. Multivariable multinomial logistic regression using stabilized inverse probability treatment weights (IPTW) was performed to assess the association between the DMA route of administration (Oral vs Injectable) and the adherence trajectory groups. The balance of covariates between oral and injectable DMAs before and after IPTW was checked against a standardized difference threshold of 0.25. Results The study cohort consisted of 1,700 MS patients who were initiated with oral (15.8%) or injectable (84.2%) DMAs between 2010 and 2012. The adherence rates (PDC≥0.8) in oral fingolimod and injectable DMA users were found to be 64.7% and 50.8%, respectively. The GBTM grouped individuals in the study cohort into three adherence trajectories - rapid discontinuers (23.5%), complete adherers (49.9%), and slow decliners (26.6%). The multinomial logistic regression model with stabilized IPTW revealed that oral fingolimod users had higher odds to be a complete adherer (adjusted odds ratio [AOR]: 2.78, 95% CI: 1.85-4.16) or a slow discontinuer (AOR: 2.62, 95% CI: 1.70-4.05) than injectable DMA users. Conclusions Oral DMA fingolimod was associated with better adherence than injectable DMAs across group-based trajectories. Further research is warranted to evaluate the adherence trajectories with newer oral DMAs introduced in the last decade for MS.

Introduction This study examined the patterns of prolonged opioid use and the factors associated with higher risk of prolonged opioid use among opioid-naive working-age patients with early-stage breast cancer. Methods Using MarketScan data, the study identified 23,440 opioid-naive patients who received surgery for breast cancer between January 2000 and December 2014 and filled at least one opioid prescription attributable to surgery. Prolonged opioid use was defined as one or more prescriptions for opioids within 90 to 180 days after surgery and defined extra-prolonged opioid use as one or more opioid prescriptions between 181 and 365 days after surgery. Multivariable logistic regressions were performed to ascertain factors associated with prolonged and extra-prolonged use of opioids. Findings Of the 23,440 patients, 4,233 (18%) had prolonged opioid use, and 2,052 (9%) had extra-prolonged opioid use. Patients who received mastectomy plus reconstruction had the highest rate of prolonged opioid use (38%) followed by mastectomy alone (15%). A multivariable logistic regression confirmed that patients with mastectomy and reconstruction had the highest odds ratio of prolonged opioid use compared to lumpectomy and whole breast irradiation (adjusted odds ratio, 5.6; 95% confidence interval, 5.1-6.1). Mean daily opioid dose was consistently high without any obvious dosage reduction among patients with opioid use. Interpretation This large observational study showed a high rate of prolonged opioid use among patients who received surgery for early-stage breast cancer and found significant difference in prolonged opioid use by treatment type. Implications for practice This large observational study found a high rate of prolonged opioid use among working-age patients with early-stage breast cancer who received curative surgery, especially among patients who received mastectomy. Among patients with opioid use, the mean daily opioid dose was consistently high without any obvious dosage tapering. This study highlights the need to emphasize appropriate opioid therapy and potential dosage reduction or discontinuation among patients with early-stage breast cancer who received surgical interventions.

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.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.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%).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.

Background Prescription opioids have been increasingly prescribed for chronic pain while the opioid-related death rates grow. Naloxone, an opioid antagonist, is increasingly recommended in these patients, yet there is limited research that investigates the intention to get naloxone. This study aimed to investigate intention toward getting naloxone in patients prescribed opioids for chronic pain and to assess the predictive utility of the theory of reasoned action (TRA) constructs in explaining intention to get naloxone. Methods This was a cross-sectional study of a panel of U.S. adult patients prescribed opioids for chronic pain using a Qualtrics®XM survey. These patients participated in the study during February to March 2020. The online internet survey assessed the main outcome of intention to get naloxone and constructs of TRA (attitudes and subjective norms); additional measures assessed the characteristics of patients’ opioid overdose risk factors, knowledge of naloxone, and their demographics. The relationship between TRA constructs, namely, attitudes and subjective norms, and the intention variable was examined using logistic regression analyses with the intention outcome contrasted as follows: high intention (scores ≥ 5) and non-high intention (scores Results A total of 549 participants completed the survey. Most of them were female (53.01%), White or Caucasian (83.61%), non-Hispanic (87.57%) and had a mean age of 44.16 years (SD = 13.37). Of these, 167 (30.42%) had high intention to get naloxone. The TRA construct of subjective norm was significantly associated with increased likelihood of higher intentions to get naloxone (OR 3.04, 95% CI 2.50–3.70, P Conclusions Our study provides empirical support of the TRA in predicting intention to get naloxone among chronic pain patients currently taking opioids. Subjective norms significantly predicted intention to get naloxone in these patients. The interventions targeting important reference groups of these patients would have greater impact on increasing intention to get naloxone in this population. Future studies should test whether theory-based interventions focusing on strengthening subjective norms increase intention to get naloxone in this population.

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.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.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.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]).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.

To assess the association of the transition from incident opioid use to incident chronic opioid therapy (COT) with the trajectories of healthcare utilization and expenditures.We used a longitudinal, retrospective cohort design, including seven 120-day time periods covering preindex (tMultivariable analyses were performed on utilization (population-averaged [PA] logistic regression), expenditures (PA generalized estimating equations), and expenditure estimates (counterfactual prediction). The data used were from a commercial claims database (10% random sample from the IQVIA Real-World Data Adjudicated Claims - US database) from 2006-2015.Patients on COT were more likely to use inpatient services (adjusted odds ratio, 1.11; 95% CI, 1.01-1.21) compared with those who did not. Although expenditures peaked during the index period (tThe period after incident opioid prescription but before transition to COT is an important time for payers to intervene.

Aims: To compare county-level differences in the number of buprenorphine prescribers listed in the publicly available Substance Abuse and Mental Health Services Administration (SAMHSA) Buprenorphine Practitioner Locator and in the Drug Enforcement Administration’s (DEA) Controlled Substance Act (CSA) database and to determine if disparities in access exist in poorer areas with more non-white residents. Design: Cross-sectional study Setting: TexasMeasurements: 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%). This difference was magnified in Texas Public Health Region 11. This is the poorest region of the state (23.7% of residents below the federal poverty line) and contains the most non-white residents 87.4% vs 54.9% (SD: 13.6%). This region had the lowest number of buprenorphine prescribers with 3.8 providers per 100,000 on the DEA CSA database and 2.5 providers per 100,000 in the SAMHSA Buprenorphine Practitioner Locator.Conclusions: The lack of a complete, public registry of buprenorphine prescribers makes it difficult for patients to identify a convenient buprenorphine prescriber and for referring physicians to help their patients access care. This may be especially true in poorer and more diverse areas with fewer buprenorphine prescribers.

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.To evaluate the association of cash payment with intensity of opioid prescriptions.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.Cash payment was associated with 30% higher mean daily MME (59 vs. 45; P0.001) 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; P0.001) 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.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.

OBJECTIVES: To measure the change in the daily number of patients receiving buprenorphine and buprenorphine prescribers during the early phase of the COVID-19 (SARS-CoV-2) pandemic in Texas. METHODS: Counts of the number of patients filling and number of providers prescribing buprenorphine were calculated for each weekday between November 4, 2019 and May 12, 2020. The change in daily patients and prescribers between March 2, 2020 and May 12, 2020, was modeled as a change in slope compared to the baseline period using autoregressive, interrupted time series regression. RESULTS: The rate of change of daily buprenorphine prescriptions (s = -1.75, 95% CI = -5.8-2.34) and prescribers (s = -0.32, 95% CI = -1.47-0.82) declined insignificantly during the COVID-19 period compared to the baseline. CONCLUSIONS: Despite a 57% decline in ambulatory care utilization in the south-central US during March and April of 2020, health services utilization related to buprenorphine in Texas remained robust. Protecting access to buprenorphine as the COVID-19 pandemic continues to unfold will require intensive efforts from clinicians and policy makers alike. While the presented results are promising, researchers must continue monitoring and exploring the clinical and humanistic impact of COVID-19 on the treatment of substance use disorders.

Many variables influence a preceptor's experiential evaluation of a pharmacy learner. However, the impact of social desirability bias, or the measure of an individual's need for social approval, and its impact on the truthfulness of an evaluation is not well understood. Social desirability may present a barrier to students receiving accurate and truthful evaluations. Differences in the effect of social desirability may be seen between full-time faculty and non-faculty preceptors. Colleges of pharmacy should work to support preceptors by providing professional development, standardizing evaluation processes, and ensuring two-way communication. Additionally, a social desirability measure could be used for each preceptor and used by the experiential team to identify preceptors potentially in need of additional development. Future studies should evaluate the effect of social desirability on how preceptors complete evaluations, and propose methods to mitigate this form of bias in the evaluation process.

The United States is in an acceleration phase of the COVID-19 pandemic. Currently there is no known effective therapy or vaccine for treatment of SARS-CoV-2, highlighting urgency around identifying effective therapies.The purpose of this study was to evaluate the role of hydroxychloroquine therapy alone and in combination with azithromycin in hospitalized patients positive for COVID-19.Multi-center retrospective observational study.The Henry Ford Health System (HFHS) in Southeast Michigan: large six hospital integrated health system; the largest of hospitals is an 802-bed quaternary academic teaching hospital in urban Detroit, Michigan.Consecutive patients hospitalized with a COVID-related admission in the health system from March 10, 2020 to May 2, 2020 were included. Only the first admission was included for patients with multiple admissions. All patients evaluated were 18 years of age and older and were treated as inpatients for at least 48h unless expired within 24h.Receipt of hydroxychloroquine alone, hydroxychloroquine in combination with azithromycin, azithromycin alone, or neither.The primary outcome was in-hospital mortality.Of 2,541 patients, with a median total hospitalization time of 6 days (IQR: 4-10 days), median age was 64 years (IQR:53-76 years), 51% male, 56% African American, with median time to follow-up of 28.5 days (IQR:3-53). Overall in-hospital mortality was 18.1% (95% CI:16.6%-19.7%); by treatment: hydroxychloroquine+azithromycin, 157/783 (20.1% [95% CI: 17.3%-23.0%]), hydroxychloroquine alone, 162/1202 (13.5% [95% CI: 11.6%-15.5%]), azithromycin alone, 33/147 (22.4% [95% CI: 16.0%-30.1%]), and neither drug, 108/409 (26.4% [95% CI: 22.2%-31.0%]). Primary cause of mortality was respiratory failure (88%); no patient had documented torsades de pointes. From Cox regression modeling, predictors of mortality were age65 years (HR:2.6 [95% CI:1.9-3.3]), white race (HR:1.7 [95% CI:1.4-2.1]), CKD (HR:1.7 [95%CI:1.4-2.1]), reduced O2 saturation level on admission (HR:1.5 [95%CI:1.1-2.1]), and ventilator use during admission (HR: 2.2 [95%CI:1.4-3.3]). Hydroxychloroquine provided a 66% hazard ratio reduction, and hydroxychloroquine+azithromycin 71% compared to neither treatment (p0.001).In this multi-hospital assessment, when controlling for COVID-19 risk factors, treatment with hydroxychloroquine alone and in combination with azithromycin was associated with reduction in COVID-19 associated mortality. Prospective trials are needed to examine this impact.

OBJECTIVE: Inappropriate prescribing of opioids has contributed to misuse and a rise in accidental deaths. The purpose of this study was to determine the incidence of chronic opioid use in previously opioid-naïve patients who received opioids for analgesia while in the intensive care unit (ICU) and to identify potential risk factors in patients that transition to chronic opioid use. METHODS: A retrospective analysis included patients admitted to the medical, surgical, or cardiovascular ICU at the Michael E. DeBakey VA Medical Center in Houston, Texas, between August 2017 and December 2017. Patients were screened to confirm opioid-naïve status prior to admission, defined as ≤ 30 days of opioid prescription use in the prior 12 months. Patients were included if they received a continuous opioid infusion for ≥ 12 consecutive hours. Prescription fill data from the health record were examined at 3, 6, and 12 months postdischarge to determine whether patients were receiving chronic opioid treatment. RESULTS: Records of 330 patients were reviewed and 118 patients met the inclusion criteria. All patients received fentanyl infusion, for a median time of 35 hours (interquartile range 18.8–64.7 hours). Ninety (76.3%) patients were receiving opioids postdischarge at 3 months, 23 (19.5%) at 6 months, and 9 (7.6%) at 12 months. At 3 months, ICU type (odds ratio [OR], 3.9; 95% CI 1.73–8.75; P < .001) and being a surgical patient (OR, 7.8; 95% CI 3.26–18.56; P < .001) were risk factors for chronic opioid use. No specific risk factors were found to increase the risk of chronic opioid use at 6 and 12 months. CONCLUSIONS: The incidence of chronic opioid use decreased at 6 and 12 months compared with that of 3 months postdischarge. ICU type and hospital admission related to surgery were not associated with increased opioid use at 3 months.

Introduction Prescription opioid misuse is a risk factor for opioid use disorder (OUD). Patients who misuse prescribed opioids and those who misuse illicit opioids are demographically and medically distinct groups, and research has shown there is heterogeneity in treatment response between these groups. The objective of this study was to measure the adjusted odds of successful stabilization on buprenorphine in patients with baseline prescription opioid use compared to those not prescribed opioids. Methods A cohort of patients newly prescribed a buprenorphine product indicated for OUD between January 1 and November 30, 2018, were identified from the Texas Prescription Monitoring Program. We excluded those under the age of 15 and those who filled an opioid prescription after initiating buprenorphine to limit misclassification. We then stratified the cohort based on type of prescription opioid use in the pre-index period. We defined chronic opioid use as being prescribed opioids for a period of 90 out of 120 days, ending no sooner than 90 days prior to treatment initiation. We defined acute opioid use as filling any opioid prescription in the 90 days prior to initiating buprenorphine. The outcome of interest—stabilization on buprenorphine—was met by filling two prescriptions totaling 30-days' supply with no more than a six-day gap in therapy. We used multiple logistic regression to estimate the odds of stabilization in the prescription opioid use categories compared to those with no pre-index, opioid prescriptions. Results Among 6756 eligible patients, 44.1% used prescription opioids in the 90 days prior to buprenorphine initiation. Of these, 62.2% met the criteria for acute prescription opioid use and 37.8% for chronic prescription opioid use. Patients with prescription opioid use at baseline were more likely to be older and insured compared to those with no prescription opioid use. After adjustment for covariates, both prescription opioid use groups were significantly more likely to be successfully stabilized on therapy (Acute: aOR = 1.53, 95% CI = 1.37–1.72; Chronic: aOR = 2.43, 95% CI = 2.08–2.85). In a second model, those with chronic prescription opioid use were significantly more likely than those with acute prescription opioid use to be successfully stabilized (aOR = 1.60, 95% CI = 1.31–1.90). Conclusion Persistence to buprenorphine treatment for OUD is, in part, dependent on baseline prescription opioid use. This study suggests that patients with chronic prescription opioid use may be more likely than nonprescription opioid users to be successfully stabilized on treatment and may thus benefit more from pharmacotherapy with buprenorphine than those with no prescription opioid use. Failing to account for this variation in future studies of buprenorphine treatment persistence may lead to significant residual confounding and biased results. Extending access to buprenorphine among those with prescription OUD may have a significant impact on opioid related morbidity and mortality.

Introduction Opioid stewardship efforts can promote safe and effective use of opioids to optimize pain control and minimize unintended consequences. The purpose of this study is to assess the difference in post-operative opioid discharge prescribing in patients undergoing coronary artery bypass graft (CABG) surgery following implementation of a tripartite opioid stewardship intervention. Methods This was a single-center, quality improvement study at a large, quaternary academic medical center. Adult patients undergoing CABG from July 2019 to June 2020 (pre-intervention) and November 2020 to February 2021 (post-intervention) were included. The intervention included adopting hospital-wide post-surgical opioid discharge prescribing guidelines, discharge prescriber education, and electronic medical record changes. The primary outcome was the proportion of patients receiving an opioid prescription at discharge. Secondary outcomes included total morphine milligram equivalents (MME) prescribed and non-opioid analgesics prescribed at discharge. Results A total of 200 patients were included in the study; 100 pre- and 100 post-intervention. There was no difference in opioid discharge prescribing at discharge (74% pre-intervention vs. 72% post-intervention; P = .87). There was no difference in MMEs prescribed at discharge (145.6 ± 57 pre- vs. 162.2 ± 95 post-; P = .202). No difference was seen in non-opioid analgesic prescriptions prescribed at discharge (35% pre- vs. 40% post-; P = .56). Conclusion A multipronged opioid stewardship intervention did not lead to a reduction in opioid prescribing at discharge. Post-intervention, there was a non-statistically significant increase in the proportion of patients who received non-opioid analgesics discharge. Future studies should assess the effect of different stewardship interventions on prescribing and patient outcomes.

Objective: To qualitatively assess prescribers’ perceptions regarding the consequences associated with hydrocodone rescheduling among geriatric patients being discharged from inpatient settings . Design: This was a cross-sectional study . Setting: Two focus groups were conducted by a trained facilitator in a metropolitan academic medical center in January 2016 . Participants: Prescribers who manage noncancer pain for geriatric patients were recruited. Focus groups were recorded, transcribed, and then analyzed using ATLAS.ti Qualitative Data Analysis software. Codes were derived from six primary research questions and results were summarized into key themes regarding the impact of rescheduling . Main outcome measures: Prescribers’ perceptions regarding hydrocodone rescheduling . Results: Prescribers mentioned that they review the prescription monitoring program (PMP) more often before prescribing opioids after rescheduling. They expressed concern regarding the required special serialized prescription forms needed to issue schedule II prescriptions. This led to substituting hydrocodone with potentially less effective pain medications, the inability to issue refills on hydrocodone prescriptions, and an ethical concern over prescribing hydrocodone to patients not under their direct care. Additionally, rescheduling has affected the coordination of care upon discharge, as patients moving to long-term care or skilled nursing facilities may not have adequate pain management when transferred . Conclusions: The majority of physicians felt rescheduling negatively impacted both practical and ethical aspects of patient care related to pain management after discharge. Rescheduling has changed physicians’ hydrocodone prescribing patterns, leading to more caution when prescribing hydrocodone and greater use of the PMP. Future studies should assess geriatric patients’ satisfaction and quality of life regarding pain management since hydrocodone was rescheduled .

Background Research has confirmed a lack of knowledge regarding the risks of unused medications including diversion, misuse, or accidental overdose among health care professionals (Abdulmajeed, 2020). Nurses and pharmacists are often who patients interact with the most regarding medications; therefore, early education on proper storage and disposal is vital (Bowen, Rotz, Patterson, & Sen, 2017; Celio, Ninane, Bugnon, & Schneider, 2018). Objectives The study's objective is to explore safe drug storage and disposal knowledge, attitudes, and practices of professional pharmacy (Pharm.D.) and nursing students. Design This research is an exploratory cross-sectional study from May to September 2019. Methods An anonymous online survey was administered to a purposive sample of Pharm.D. and nursing students who were 18 years and older and enrolled in the site's accredited Pharm.D. and nursing programs (N = 210). Responses were analyzed using descriptive statistics. Results Common disposal methods reported by students of their personal medications such as pills and liquids included discarding medications with the household trash (range 30% to 55%) and medication disposal products/bag (range 19% to 28%). More than half of the participants (50.4%) had unused prescription medication at home, 35% kept the medication for later use, and almost 20% of the participants reported sharing personal medications with others. Conclusion Although the majority of student participants had adequate knowledge of the appropriate methods for safe drug disposal, few reported using them for their own personal medications. The findings suggest there is a disconnect between the participants' knowledge of the appropriate methods of safe drug storage and disposal in a professional setting and their own practices. Further research is needed to explore and address the reasons for this disconnect. Additionally, findings from this research will assist in the development of and/or the improvement of interdisciplinary educational materials among pharmacy and nursing students.

Objective: This study was conducted to assess pharmacists’ practices when counseling patients on their prescription medications, and their preferences for training. Methods: Five focus group discussions of community pharmacists (n=45, with seven to eleven participants in each group) were conducted in a major metropolitan city in the southern United States. Participants were recruited via email using a list of community pharmacists provided by the Texas State Board of Pharmacy. All focus group discussions were structured using a moderator guide consisting of both discrete and open-ended questions. Qualitative analysis software was used to analyze the data with a thematic analysis approach. Results: The participants in this study had a high self-efficacy regarding their ability to counsel on both new and opioid prescriptions. Many pharmacists experienced the same barriers to counseling and agreed on the components o counseling. However, the themes that emerged showed that the participants exhibited only a partial understanding of the components of counseling. The themes that emerged in the thematic analysis were perceived confidence and discordant counseling practices, inadequate infrastructure, lack of comprehensive counseling, inconsistent use of the Prescription Drug Monitoring Program (PDMP), and pharmacists’ desired training/assistance. Conclusions: Community pharmacists are in a unique position to help combat the opioid crisis; however, there has been very little research on the pharmacist-patient interaction in this context. With policy changes, such as the PDMP mandate, going into effect across the country, it is important to capitalize on the potential community pharmacists have in ameliorating the opioid crisis in the United States.

Objective Unused medications in the home are often improperly stored and may lead to unintentional harm, misuse, and diversion. Single-use disposal systems products allow consumers to safely inactivate unused medication and provide an environmentally friendly alternative to flushing medication down the toilet or discarding in the trash. The objective of this commentary was to review current medication disposal options and inform pharmacists of new products that may be used by patients to dispose of medications in the home setting. Data sources Current recommendations on medication disposal from U.S. regulatory agencies (e.g., the Environmental Protection Agency) were reviewed and summarized comparatively. Information on the mechanism of action, price, and method of use of 8 new single-use disposal systems suitable for outpatient use were taken from each product manufacturer’s website. Summary Eight single-use disposal systems were identified. Seven products used chemical deactivation to render medication safe for disposal, and 1 product allowed consumers to mail medication to a central processing facility for incineration. Products ranged in size from 2 oz to 1 gal, offering consumers the ability to dispose of anywhere from 60 to 3000 tablets per unit, respectively. Unit costs varied widely from $5 per single-use pouch to $190 for a 40-gal box intended for incineration. Conclusion Pharmacists and consumers must consider cost, effectiveness, and environmental impact when recommending and selecting products for medication disposal at home. More research is needed to understand the cost-effectiveness of each disposal system and to identify strategies to encourage uptake by health systems and use by consumers. Including content on home medication disposal in pharmacist–continuing education activities and raising workforce awareness of these products are critical to improving public safety.

Care of individuals with Alzheimer's Disease and Related Dementias (ADRD) poses special challenges. As the disease progresses, individuals with ADRD require increasing levels of medical care, caregiver support, and long-term care which can lead to substantial economic burden. Areas covered: In this expert review, we synthesized findings from studies of costs of ADRD in the United States that were published between January 2006 and February 2017, highlighted major sources of variation in costs, identified knowledge gaps and briefly outlined directions for future research and implications for policy and program planning. Expert commentary: A consistent finding of all studies comparing individuals with and without ADRD is that the average medical, non-medical, and indirect costs of individuals with ADRD are higher than those without ADRD, despite the differences in the methods of identifying ADRD, duration of the study, payer type and settings of study population. The economic burden of ADRD may be underestimated because many components such as direct non-medical costs for home safety modifications and adult day care services and indirect costs due to the adverse impact of ADRD on caregivers' health and productivity are not included in cost estimates.

Over 25 million Americans reported having daily pain and between 5 and 8 million Americans used opioids to treat chronic pain in 2012. This is the first systematic review with meta-analysis to determine the effects of long-term opioid use on the Physical Component Summary (PCS) score and Mental Component Summary (MCS) scores of a Health-Related Quality of Life instrument in adults without opioid use disorder. The a priori eligibility criteria for the PubMed (MEDLINE), Scopus, and PsyINFO searches were (1) randomized controlled trial, (2) at least one opioid intervention group, (3) minimum of 4-week duration of opioid use, (4) comparative control group, and (5) adults ≥18 years that do not have dominant disease. The unit of analysis was the standardized mean difference effect size (Hedges’s g). All results were pooled using random-effects models. Of the 340 non-duplicate citations screened, 19 articles comprising 26 treatment comparisons and 6168 individuals (treatment n = 3160; comparators n = 3008 with duplicates removed) met the inclusion criteria for the systematic review. Thirteen treatment comparisons were available for the meta-analysis. Across all PCS analyses, small, statistically significant improvements were observed (opioid versus opioid only: g = 0.27, 95% CI 0.05–0.50, opioid versus placebo only: g = 0.18, 95% CI 0.08–0.28, and all studies combined: g = 0.22, 95% CI 0.11–0.32). There were small but not statistically significant changes on the MCS scores. Overall, high heterogeneity was present. PCS scores improve with no change in MCS scores. However, long-term opioid trials are rare and only two trials included lasted longer than 1 year.

OBJECTIVE: To estimate the excess direct annual healthcare expenditures associated with Alzheimer's and related dementias(ADRD) among community-dwelling older adults in the United States. METHODS: This retrospective cross-sectional study compared the annual healthcare expenditures between elderly individuals aged 65 years and older with ADRD (n = 662) and without ADRD (n = 13,398) using data from the Medical Expenditure Panel Survey (MEPS) for the years 2007, 2009, 2011 and 2013. Adjusted total annual medical expenditures was estimated using generalized linear model with gamma distribution and log link in 2013 U.S. dollars. Adjusted inpatient, outpatient, emergency, home healthcare and prescription drug expenditures, were estimated using two-part logit-generalized linear regression models. RESULTS: The adjusted mean total healthcare expenditures were higher for the ADRD group as compared to the no ADRD group($14,508 vs. $10,096). Among those with ADRD, 34.3% of the expenditures were for home healthcare as compared to 4.4% among those without ADRD. Among users, the ADRD group had significantly higher home healthcare ($3,240 vs. $566) and prescription drug expenditures($3,471 vs. $2,471). There were no statistically significant differences in inpatient, emergency room and outpatient expenditures between the ADRD and no ADRD group. CONCLUSION: ADRD in U.S. community-dwelling elders is associated with significant financial burden, primarily driven by increased home healthcare use.