Background
In response to the opioid crisis in the United States, population-level prescribing of opioids has been decreasing; there are concerns, however, that dose reductions are related to ...potential adverse events.
Objective
Examine associations between opioid dose reductions and risk of 1-month potential adverse events (emergency department (ED) visits, opioid overdose, benzodiazepine prescription fill, all-cause mortality).
Design
This observational cohort study used electronic health record and claims data from eight United States health systems in a prescription opioid registry (Clinical Trials Network-0084). All opioid fills (excluding buprenorphine) between 1/1/2012 and 12/31/2018 were used to identify baseline periods with mean morphine milligram equivalents daily dose of ≥ 50 during six consecutive months.
Patients
We identified 60,040 non-cancer patients with ≥ one 2-month dose reduction period (600,234 unique dose reduction periods).
Main Measures
Analyses examined associations between dose reduction levels (1– < 15%, 15– < 30%, 30– < 100%, 100% over 2 months) and potential adverse events in the month following a dose reduction using logistic regression analysis, adjusting for patient characteristics.
Key Results
Overall, dose reduction periods involved mean reductions of 18.7%. Compared to reductions of 1– < 15%, dose reductions of 30– < 100% were associated with higher odds of ED visits (OR 1.14, 95% CI 1.10, 1.17), opioid overdose (OR 1.41, 95% CI 1.09–1.81), and all-cause mortality (OR 1.39, 95% CI 1.16–1.67), but lower odds of a benzodiazepine fill (OR 0.83, 95% CI 0.81–0.85). Dose reductions of 15– < 30%, compared to 1– < 15%, were associated with higher odds of ED visits (OR 1.08, 95% CI 1.05–1.11) and lower odds of a benzodiazepine fill (OR 0.93, 95% CI 0.92–0.95), but were not associated with opioid overdose and all-cause mortality.
Conclusions
Larger reductions for patients on opioid therapy may raise risk of potential adverse events in the month after reduction and should be carefully monitored.
The Centers for Disease Control and Prevention's 2022 Clinical Practice Guideline for Prescribing Opioids for Pain cautioned that inflexible opioid prescription duration limits may harm patients. ...Information about the relationship between initial opioid prescription duration and a subsequent refill could inform prescribing policies and practices to optimize patient outcomes. We assessed the association between initial opioid duration and an opioid refill prescription.
We conducted a retrospective cohort study of adults ≥19 years of age in 10 US health systems between 2013 and 2018 from outpatient care with a diagnosis for back pain without radiculopathy, back pain with radiculopathy, neck pain, joint pain, tendonitis/bursitis, mild musculoskeletal pain, severe musculoskeletal pain, urinary calculus, or headache. Generalized additive models were used to estimate the association between opioid days' supply and a refill prescription.
Overall, 220,797 patients were prescribed opioid analgesics upon an outpatient visit for pain. Nearly a quarter (23.5%) of the cohort received an opioid refill prescription during follow-up. The likelihood of a refill generally increased with initial duration for most pain diagnoses. About 1 to 3 fewer patients would receive a refill within 3 months for every 100 patients initially prescribed 3 vs. 7 days of opioids for most pain diagnoses. The lowest likelihood of refill was for a 1-day supply for all pain diagnoses, except for severe musculoskeletal pain (9 days' supply) and headache (3-4 days' supply).
Long-term prescription opioid use increased modestly with initial opioid prescription duration for most but not all pain diagnoses examined.
Background and Aims
Unintended pregnancy rates are high among women with substance use disorders (SUDs), which could be explained partly by lower use of and adherence to contraception. We aimed to ...test: (1) the association of SUD with prescription contraceptive use, contraceptive method selection and adherence; (2) whether practices participating in the Patient‐Centered Medical Home Initiative (PCMHI) had better contraceptive use and adherence for patients with SUD; and (3) for differences in the association of SUD with adherence by type of contraceptive used.
Design
Retrospective cohort analysis of claims and encounter data.
Setting
Massachusetts, USA.
Participants
A total of 47 902 women aged 16–45 years enrolled in Medicaid or Commonwealth Care in Massachusetts between 2010 and 2014.
Measurements
We examined three dependent variables: (1) use of a reversible prescription contraceptive during 2012; (2) the contraceptive methods used; and (3) the proportion of days covered by a prescription contraceptive in the year following the first prescription contraceptive claim. The primary predictor was diagnosed SUD, defined as at least one claim for an alcohol or drug use disorder.
Findings
SUD was associated with lower rates of prescription contraceptive use during 2012 19.2 versus 23.9%; adjusted odds ratio (aOR) = 0.79, P < 0.001. SUD was associated with decreased selection of long‐acting reversible contraception (LARC) compared with short‐acting contraception (SARC) (42.8 versus 44.5%; aOR = 0.83, P = 0.011). There was no significant association between SUD and adherence (aOR = 0.84, P = 0.068). PCMHI enrollment did not alter the relationship between SUD and contraceptive use or adherence. Contraceptive method did not impact the relationship between SUD and adherence.
Conclusion
Women with substance use disorders are less likely to use prescription contraceptives, especially long‐acting methods, but are not significantly less likely to adhere to them once prescribed than women without substance use disorders.
Many state Medicaid programs restrict access to buprenorphine, a prescription medication that relieves withdrawal symptoms for people addicted to heroin or other opiates. The reason is that officials ...fear that the drug is costlier or less safe than other therapies such as methadone. To find out if this is true, we compared spending, the use of services related to drug-use relapses, and mortality for 33,923 Massachusetts Medicaid beneficiaries receiving either buprenorphine, methadone, drug-free treatment, or no treatment during the period 2003-07. Buprenorphine appears to have significantly expanded access to treatment because the drug can be prescribed by a physician and taken at home compared with methadone, which by law must be administered at an approved clinic. Buprenorphine was associated with more relapse-related services but $1,330 lower mean annual spending than methadone when used for maintenance treatment. Mortality rates were similar for buprenorphine and methadone. By contrast, mortality rates were 75 percent higher among those receiving drug-free treatment, and more than twice as high among those receiving no treatment, compared to those receiving buprenorphine. The evidence does not support rationing buprenorphine to save money or ensure safety.
One hundred and fourteen (N=114) Master of Social Work students completed an online survey to explore whether demographic characteristics, prior international travel, and learning abroad program ...experience were associated with levels of CSWE competencies, racial attitudes, and attitudes toward mental health. Results indicate that multilingual students and students with prior international travel experience self-reported lower levels of policy skill development and lower overall competency development. Age and race were associated with students' attitudes toward those experiencing mental health concerns, with younger or non-Hispanic White students reporting lower stigma toward those with mental health concerns. No association was found between demographic characteristics, learning abroad participation, prior international travel, and racial attitudes. Implications for social work education, practice, and research are offered.
Persons aged <65 years account for a considerable proportion of US nursing home residents with schizophrenia. Because they are often excluded from psychiatric and long-term care studies, a ...contemporary understanding of the characteristics and management of working-age adults (22-64 years old) with schizophrenia living in nursing homes is lacking. This study describes characteristics of working-age adults with schizophrenia admitted to US nursing homes in 2015 and examines variations in these characteristics by age and admission location. Factors associated with length of stay and discharge destination were also explored.
This is a cross-sectional study using the Minimum Data Set 3.0 merged to Nursing Home Compare.
This study examines working-age (22-64 years) adults with schizophrenia at admission to a nursing home.
Descriptive statistics of resident characteristics (sociodemographic, clinical comorbidities, functional status, and treatments) and facility characteristics (ownership, geography, size, and star ratings) were examined overall, stratified by age and by admission location. Generalized estimating equation models were used to explore the associations of age, discharge to the community, and length of stay with relevant resident and facility characteristics. Coefficient estimates, adjusted odds ratios, and 95% CIs are presented.
Overall, many of the 28,330 working-age adults with schizophrenia had hypertension, diabetes, and obesity. Those in older age subcategories tended to have physical functional dependencies, cognitive impairments, and clinical comorbidities. Those in younger age subcategories tended to exhibit higher risk of psychiatric symptoms.
Nursing home admission is likely inappropriate for many nursing home residents with schizophrenia aged <65 years, especially those in younger age categories. Future psychiatric and long-term care research should include these residents to better understand the role of nursing homes in their care and should explore facility-level characteristics that may impact quality of care.
Only modest advances in AML therapy have occurred in the past decade and relapse due to residual disease remains the major challenge. The potential of the immune system to address this is evident in ...the success of allogeneic transplantation, however this leads to considerable morbidity. Dendritic cell (DC) vaccination can generate leukemia-specific autologous immunity with little toxicity. Promising results have been achieved with vaccines developed in vitro from purified monocytes (Mo-DC). We now demonstrate that blood DC (BDC) have superior function to Mo-DC. Whilst BDC are reduced at diagnosis in AML, they recover following chemotherapy and allogeneic transplantation, can be purified using CMRF-56 antibody technology, and can stimulate functional T cell responses. While most AML patients in remission had a relatively normal T cell landscape, those who had received fludarabine as salvage therapy have persistent T cell abnormalities including reduced number, altered subset distribution, failure to expand, and increased activation-induced cell death. Furthermore, PD-1 and TIM-3 are increased on CD4T cells in AML patients in remission and their blockade enhances the expansion of leukemia-specific T cells. This confirms the feasibility of a BDC vaccine to consolidate remission in AML and suggests it should be tested in conjunction with checkpoint blockade.
Objective
To assess the impact of a 2008 dose‐based prior authorization policy for Massachusetts Medicaid beneficiaries using buprenorphine + naloxone for opioid addiction treatment. Doses higher ...than 16 mg required progressively more frequent authorizations.
Data Sources
Mediciaid claims for 2007 and 2008 linked with Department of Public Health (DPH) service records.
Study Design
We conducted time series for all buprenorphine users and a longitudinal cohort analysis of 2,049 individuals who began buprenorphine treatment in 2007. Outcome measures included use of relapse‐related services, health care expenditures per person, and buprenorphine expenditures.
Data Collection/Extraction Methods
We used ICD‐9 codes and National Drug Codes to identify individuals with opioid dependence who filled prescriptions for buprenorphine. Medicaid and DPH data were linked with individual identifiers.
Principal Findings
Individuals using doses >24 mg decreased from 16.5 to 4.1 percent. Relapses increased temporarily for some users but returned to previous levels within 3 months. Buprenorphine expenditures decreased but total expenditures did not change significantly.
Conclusion
Prior authorization policies strategically targeted by dose level appear to successfully reduce use of higher than recommended buprenorphine doses. Savings from these policies are modest and may be accompanied by brief increases in relapse rates. Lower doses may decrease diversion of buprenorphine.
Antibody therapy for acute myeloid leukaemia Gasiorowski, Robin E.; Clark, Georgina J.; Bradstock, Kenneth ...
British journal of haematology,
February 2014, Letnik:
164, Številka:
4
Journal Article
Recenzirano
Summary
Novel therapies with increased efficacy and decreased toxicity are desperately needed for the treatment of acute myeloid leukaemia (AML). The anti CD33 immunoconjugate, gemtuzumab ozogamicin ...(GO), was withdrawn with concerns over induction mortality and lack of efficacy. However a number of recent trials suggest that, particularly in AML with favourable cytogenetics, GO may improve overall survival. This data and the development of alternative novel monoclonal antibodies (mAb) have renewed interest in the area. Leukaemic stem cells (LSC) are identified as the subset of AML blasts that reproduces the leukaemic phenotype upon transplantation into immunosuppressed mice. AML relapse may be caused by chemoresistant LSC and this has refocused interest on identifying and targeting antigens specific for LSC. Several mAb have been developed that target LSC effectively in xenogeneic models but only a few have begun clinical evaluation. Antibody engineering may improve the activity of potential new therapeutics for AML. The encouraging results seen with bispecific T cell‐engaging mAb‐based molecules against CD19 in the treatment of B‐cell acute lymphobalstic leukaemia, highlight the potential efficacy of engineered antibodies in the treatment of acute leukaemia. Potent engineered mAb, possibly targeting novel LSC antigens, offer hope for improving the current poor prognosis for AML.
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