Two studies published in JAMA Internal Medicine in June, while not without limitations, offer insight into the making of America’s opioid epidemic.
The studies, an original investigation and a research letter, bring several disturbing, though not surprising, facts to light.
The investigation by Harvard public health researchers examined new opioid prescriptions to Medicare recipients who became hospitalized. They analyzed a random 20 percent sample of beneficiaries hospitalized in 2011.1
Among 623,957 hospitalizations, 14.9 percent received opioids within a week of discharge. Of those, 42.5 percent still were getting opioids 90 days later. The study authors said they had no way of examining whether doctors followed appropriate prescribing guidelines in each and every case. But the study found that hospitals that scored higher in pain-related questions on patient satisfaction surveys called HCAHPS tended to prescribe more opioids.
Therein lies a potentially dangerous duality. Hospitals are offered financial incentives for patient satisfaction scores based on that survey. Meanwhile, the nation is in the throes of an opiate addiction epidemic.
For many, these painkillers are the gateway to heroin. Heroin-related overdose deaths were up nearly 300 percent in the U.S. from 2002 to 2013, according to the U.S. Centers for Disease Control and Prevention.2
The more opiates that are prescribed, the more likely they can fall into the hands of those who use them illicitly. The cat has long been out of the bag, so to speak, that high school and even middle school children are raiding their parents medicine cabinets and the medicine cabinets of their friends and relatives and getting hooked on painkillers. The research letter published alongside the original investigation shows why this is happening so frequently.
One in Five Prescribed Opiates Share with Others
According to the letter, many people do not finish their opiate prescriptions. But instead of disposing of them, they share them with others or keep them in cabinets that are not locked.
The authors of the letter, doctors and social scientists from the Johns Hopkins Bloomberg School of Public Health, surveyed almost 3,300 people from a nationally representative sample, oversampling adults with at least one child in the household.3 They found that:
More than 57 percent of people had leftover medications. Of those, 49 percent said they keep it for future use.
Almost 21 percent said they shared their medications with others.
Fourteen percent said they likely would let a family member use their opioid medication in the future. Almost eight percent said they would share it with a friend.
Seventy-three percent said they would share to help another person treat their pain. More than 17 percent said they would share with someone who does not have insurance and cannot afford the opiate medication.
Almost 10 percent listed “other” as reasons for sharing, such as sharing for recreational use.
Only 21 percent said they keep the medication in a cabinet that locks or even just latches.
Questions Raised About Prescribing Appropriateness Need to Be Answered
In the original investigation, the researchers said their study had several limitations.
“Given only one year of data, we could not study whether hospitals with higher adjusted rates of post-discharge opioid use had greater adverse events related to opioids, though many studies demonstrate links between opioid use and adverse opioid-related outcomes,” the Harvard researchers wrote.
They also noted their study was limited to Medicare beneficiaries. “Medicare is an important population to consider, however, given that opioid use among the elderly and disabled is associated with higher mortality and other adverse outcomes.”
Of the patients in the study, 82.7 percent suffered from high blood pressure, 65 percent from high cholesterol, 55.7 percent from anemia, almost half from rheumatoid arthritis, half from heart disease, 40 percent had diabetes, more than 31 percent were diagnosed with depression and 3.4 percent suffered from congestive heart failure.
The authors stressed that the positive association between prescribing opioids and higher HCAHPS scores was “not only modest in size but may have been confounded by unobserved hospital or population characteristics.”
In the discussion portion of the study, they noted, “Inappropriate differences across hospitals in new post-discharge opioid use may stem from systematic differences in practice patterns, which may be related to prescribing culture, other hospital characteristics, or possibly pay-for-performance measures related to the quality of inpatient pain management. Our finding that patients in the top decile of hospitals were twice as likely to fill a prescription for an opioid within seven days of hospital discharge as patients in the bottom decile suggests that appropriate reasons for these observed differences, while important, may not fully explain the gap.”
The authors said further studies could answer some of the important questions that their investigation raises. “To the extent that prescribing of opioids at discharge is aberrantly high at some hospitals, further detailed inquiry may be warranted into the appropriateness of this prescribing and whether opioid prescribing rates could be safely reduced in those hospitals.”
1.Anupam, B. Jena, et al. (2016, June 13). Hospital Prescribing of Opioids to Medicare Beneficiaries. JAMA Internal Medicine. Retrieved July 3, 2016, from http://archinte.jamanetwork.com/article.aspx?articleid=2527391
2.U.S. Centers for Disease Control and Prevention. (2016, March 14) Heroin Overdose Data. Retrieved July 3, 2016, from http://www.cdc.gov/drugoverdose/data/heroin.html
3.Kennedy-Hendrick, A et al. (2016, June 13). Medication Sharing, Storage, and Disposal Practices for Opioid Medications Among US Adults. Retrieved July 3, 2016, from http://archinte.jamanetwork.com/article.aspx?articleid=2527388
Written by David Heitz
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