Pharmacology
30 Oct Earlier Isotretinoin Discussion May Decrease Long-Term Antibiotic Use For Acne
[caption id="attachment_18899" align="alignleft" width="185"]
Dr. Nagler[/caption]
MedicalResearch.com Interview with:
Arielle Nagler MD
Instructor, Department of Ronald O. Perelman Department of Dermatology
NYU Langone Medical Center
Medical Research: What is the background for this study of acne patient who eventually require isotretinoin?
Dr. Nagler: Isotretinoin is a highly effective medication for the treatment of severe acne. In fact, it is the only medication that has been shown to provide patients with a durable cure for acne. However, its use is limited by its known teratogenicity as well as controversies regarding its relationship with psychiatric disturbances and inflammatory bowel disease. For many patients, systemic antibiotics provide an effective treatment for inflammatory acne. However, antibiotics do not provide the long term clearance that isotretinoin provides. Moreover, antibiotics are getting increasing attention due to fears of emerging bacterial resistance. There has been a recent emphasis on limiting antibiotic use in acne. As a result, this study sought to understand antibiotic use patterns amongst patients who eventually received isotretinoin.
26 Oct Baby Boomers Have More Chronic Conditions and Out-of-Pocket Medical Expenses
MedicalResearch.com Interview with: Sue Dong, DrPH Data Center Director CPWR-The Center for Construction Research and Training Silver Spring, MD, 20910 Medical Research: What is the background for this study? What are the main findings? Response: The Center for Construction Research and Training (CPWR) is a nonprofit organization funded by NIOSH and several other federal government agencies. The aging workforce study is part of our NIOSH projects. According to our surveillance data (using the Current Population Survey), more than 30% of US workers were baby boomers in 2014, and about 63% of those baby boomers were aged 55 and up. Overall, the baby boomer generation is composed of 75 million Americans who have reached or will soon reach their retirement years. Despite the impending magnitude of societal disruption, information on health status among baby boomers and the potential burden faced by this cohort is still scarce. We hope this study can provide some needed information on the aging population in the US. To address this concern, we used data from the Health and Retirement Study (HRS). HRS is a national longitudinal survey of Americans aged 50 and over, which started in 1992. The baby boomer cohort (including Early Baby Boomers and Mid Baby Boomers who were born between 1948 and 1959) was added to the survey in recent years. HRS collects information on demographics, employment, health, health expenditures, etc. The rich information and relatively consistent survey instruments used over time allowed us to conduct this study. Medical Research: What are the main findings? Response: We estimated medical conditions and expenditures among the baby boomer cohort and compared them with the original HRS cohort (born between 1931 and 1941). We found that the baby boomers were more likely to report chronic conditions than the previous generation (HRS cohort) at similar ages. For example, at age 51-61, about 70% of the baby boomer cohort had at least one chronic condition, while 60% of the HRS cohort had at least one chronic condition. By detailed condition, 42.2% of baby boomers had high blood pressure, compared to 32.1% of the HRS cohort; 14.4% of the baby boomers had diabetes, nearly twice the proportion for the HRS cohort (7.8%). Overall, baby boomers had higher prevalence of chronic conditions for the nine conditions we measured compared to the HRS cohort at the same age. We also found that the baby boomers were more likely to be overweight compared to the previous generation. The prevalence of obesity was 37% among baby boomers, but it was 21.9% among the HRS cohort when they were at similar ages In terms of medical expenditures, the average out-of-pocket expenditure (OOPE) for the past two years for those aged 51-61 was $2,156 for the HRS cohort, but $3,118 for the baby boomers. Dollar value was adjusted to 2012 dollars for even comparison. The findings will be presented at the recent APHA annual conference in Chicago.24 Oct Does Lithium Really Cause Kidney Toxicity?
Posted at 12:29h
in Author Interviews, Bipolar Disorder, Kidney Disease, Lancet, Mental Health Research, Pharmacology
MedicalResearch.com Interview with:
Dr. Stefan Clos MSc Applied Health Statistics
Psychiatrist
Murray Royal Hospital
Scotland UK
Medical Research: What is the background for this study?
Dr. Clos: For more than 40 years there has been a debate about the long-term effect of lithium maintenance therapy on renal function. There is a lack of good quality data from randomized clinical trials and two previous meta-analyses from 2010 and 2012 suggest that little evidence exists for a clinically significant reduction in renal function in most patients who are on lithium therapy. However, the two publications point out the poor quality of available study data, emphasising the need for large scale epidemiological studies that control for confounders. Several population-based studies have since attempted to address this problem, but had insufficient ability to adjust for confounders or had limitations because of inappropriate cross-sectional study design or did not include an appropriate comparator group.
16 Oct Prescription Opioid Overdose Deaths Increase 35%
MedicalResearch.com Interview with: Beth Han, MD, PhD, MPH Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services Rockville, Maryland Medical Research: What is the background for this study? What are the main findings? Dr. Han: Since 1999, the United States has experienced increases in negative consequences and deaths associated with nonmedical use of prescription opioids. During this period, emergency department visits and drug overdose deaths involving these drugs have increased rapidly. To fully understand the current status of this public health crisis and who is currently most affected, we conducted this study based on nationally representative U.S. surveillance data. Our main study findings include:- Among adults age 18 through 64 years, the prevalence of nonmedical use of prescription opioids decreased from 5.4 percent in 2003 to 4.9 percent in 2013, but the prevalence of prescription opioid use disorders increased from 0.6 percent in 2003 to 0.9 percent in 2013. The 12-month prevalence of high-frequency use (200 days or more) also increased from 0.3 percent in 2003 to 0.4 percent in 2013.
- Mortality assessed by drug overdose death rates involving prescription opioids increased from 4.5 per 100,000 in 2003 to 7.8 per 100,000 in 2013. The average number of days of nonmedical use of prescription opioids increased from 2.1 in 2003 to 2.6 in 2013. The prevalence of having prescription opioid use disorders among nonmedical users increased to 15.7 percent in 2010, 16.1 percent in 2011, 17 percent in 2012, and 16.9 percent in 2013, from 12.7 percent in 2003.
07 Oct CDC Study Finds Anaphylaxis Rare After Vaccinations, With No Fatalities
MedicalResearch.com Interview with: Michael M. McNeil, MD, MPH Centers for Disease Control and Prevention Atlanta, GA Medical Research: What is the background for this study? What are the main findings? Dr. McNeil : Anaphylaxis is an uncommon potentially life-threatening allergic reaction which can occur immediately (usually within minutes) after exposures to food, drugs, venom and vaccines. More than 100 million people in the U.S. receive vaccinations each year. Most vaccines have the potential to trigger anaphylaxis, but the rates at which it occurs after vaccination are not well known. The CDC study examined data from the Vaccine Safety Datalink (VSD), a collaborative project between CDC and 9 integrated healthcare organizations, which contains vaccination records on more than 9 million patients. The study sought to determine the rates of anaphylaxis after all vaccines combined and some individual vaccines including seasonal influenza vaccines given to children and adults. Patients studied received vaccinations between January 1, 2009 – December 31, 2011. Electronic medical record data was screened for patients with specific diagnostic codes for anaphylaxis or who had received epinephrine prescriptions as a treatment for potential anaphylaxis. Researchers were able to look at data from 25,173,965 vaccinations during 17,606,500 visits to healthcare providers. The researchers identified 33 confirmed vaccine-triggered anaphylaxis cases that occurred after more than 25 million vaccine doses. The rate of anaphylaxis was calculated at 1.31 per million doses for all vaccines, and 1.35 per million for seasonal inactivated influenza vaccines. Patients ranged in age from 4 to 65 with a median age of 17. None of the patients with anaphylaxis were below the age of 4 years old. Only one of the 33 patients was hospitalized, and none died as a result of anaphylaxis. A majority (85%) of the case-patients had pre-existing atopic disease including previous anaphylaxis, asthma, and allergies.29 Sep Rural Teens More Likely To Abuse Prescription Opioids
MedicalResearch.com Interview with:
Shannon M. Monnat, PhD
Assistant Professor of Rural Sociology, Demography, and Sociology
Department of Agricultural Economics, Sociology, and Education
The Pennsylvania State University
University Park, PA 16802
Medical Research: What is the background for this study? What are the main findings?
Dr. Monnat: Given concurrent rapid increases in opioid prescribing and adolescent prescription opioid misuse since the 1990s and historical problems with opioid abuse in rural areas, we were interested in whether adolescents in rural areas were more likely to abuse prescription opioids than their peers in urban areas. Adolescence is a really crucial time to study substance abuse disorders because most abuse begins during adolescence, and individuals who begin use before age 18 are more likely to develop a long-term disorder as an adult compared to those who first try a substance later in life. The active ingredient in prescription opioids and heroin is the same. Prescription opioids are highly addictive and can be dangerous if utilized incorrectly. Prescription opioid abuse is currently responsible for over 16,000 deaths in the US annually and has an estimated annual cost of nearly $56 billion dollars. Therefore, it is correctly viewed as a major public health problem.
We found that teens living in rural areas are more likely to abuse prescription opioids compared to teens living in large urban areas. Several important factors increased rural teens’ risk of abusing prescription opioids, including that they are more likely to rely on emergency department treatment than their urban peers, they have less risky attitudes and perceptions about substance abuse than their urban peers, and they are less likely to be exposed to drug/alcohol prevention messages outside of the school environment than their urban peers. Rural teens are also buffered by several factors that help to reduce opioid abuse, including stronger religious beliefs, less depression, less peer substance abuse, and less access to illicit drugs. If not for these protective factors, the current epidemic we see in rural areas could be even worse.
We also found that both rural and urban adolescents were most likely to report obtaining the prescriptions they abused from friends or family. However, rural adolescents were less likely than urban adolescents to obtain the pills this way. Rural adolescents were more likely than urban adolescents to report getting the pills they abuse directly from physicians.
31 Aug Algorithm Attempts To Overcome Medical Intolerance In Hypertensive Patients
MedicalResearch.com Interview with:
Dr M Lobo PhD FRCP
Director Barts BP Centre of Excellence
Consultant Physician and Hon Senior Lecturer
NIHR Barts Cardiovascular Biomedical Research Unit
William Harvey Research Institute, London
Medical Research: What hypothesis did you set out to investigate and why?
Dr. Lobo: We investigated the clinical utility of a novel treatment algorithm for multi-drug intolerant patients with hypertension who are at very high risk of cardiovascular disease due to uncontrolled blood pressure and inability to take conventional (guideline-based) antihypertensive regiments. These patients are often poorly managed by primary care physicians (or specialists such as cardiologists) because there has been little interest/research in medication intolerance. There has however been a major focus on drug non-adherence as a cause of failure to control hypertension - we believe that a key cause of non-adherence is medication intolerance which patients do not always volunteer.
Medical Research: What is the report's ultimate take-away message?
Dr. Lobo: Our novel stepwise algorithm was successful in managing uncontrolled hypertension in the majority of patients without needing an increase in their medicines burden. The message therefore is that patients who do not tolerate their antihypertensives do not have to put up with side effects and resultant poor quality of life as we have demonstrated that there are ways to get around medication intolerances.
21 Aug Florida’s Drug and Pill Mills Law Reduced Opioids Prescriptions
MedicalResearch.com Interview with:
Lainie Rutkow, JD, PhD, MPH
Associate Professor
Department of Health Policy and Management
Johns Hopkins Bloomberg School of Public Health
Medical Research: What is the background for this study? What are the main findings?
Dr. Rutkow: Rates of prescription drug diversion and misuse, as well as overdose deaths, have increased throughout the United States. CDC estimates that each day, 44 people die from a prescription drug overdose. In the mid-2000s, Florida was viewed as the epicenter of this epidemic, with prescription drug overdose deaths increasing more than 80% from 2003 to 2009. In response, Florida enacted several laws to mitigate prescription drug abuse and diversion. Its pill mill law required pain management clinics to register with the state and prohibited physician dispensing of certain drugs. Florida’s Prescription Drug Monitoring Program (PDMP) collects data about dispensing of prescription drugs and can be accessed by physicians and pharmacists. Little is known about how these laws have affected prescribing of opioids.
We applied comparative interrupted time series analyses to pharmacy claims data to examine four outcomes related to opioid prescribing in Florida, with Georgia as a comparison state. We found that in the first year of implementation, Florida’s Prescription Drug Monitoring Program and pill mill law were associated with modest reductions in prescription opioid volume, prescriptions written, and the dose per prescription. These declines were statistically significant among the highest volume prescribers and patients at baseline.
19 Aug Routine Urinalysis Tests Can Lead To Overtreating Asymptomatic Patients
MedicalResearch.com Interview with:
Jerome A. Leis, MD MSc FRCPC
Division of Infectious Diseases
Sunnybrook Health Sciences Centre
Physician Lead, Antimicrobial Stewardship Team
Faculty Quality Improvement Advisor, Centre for QuIPS
Assistant Professor, Department of Medicine
University of Toronto
Sunnybrook Health Sciences Centre
Toronto, Ontario
Medical Research: What is the background for this study? What are the main findings?
Dr. Leis: We know that urinary tract infections are frequently diagnosed among general medicine patients who lack symptoms of this infection. We wondered whether urinalysis ordering practices in the Emergency Department influence diagnosis and treatment for urinary tract infection among these asymptomatic patients. We found that over half of patients admitted to the general medicine service underwent a urinalysis in the Emergency Department of which over 80% lacked a clinical indication for this test. Urinalysis results among these asymptomatic patients did influence diagnosis as patients with incidental positive results were more likely to undergo urine cultures and treatment with antibiotics for urinary tract infection. The study suggests that unnecessary urinalysis ordering contributes to over-diagnosis and treatment of urinary tract infection among patients admitted to general medicine service.
15 Jul Co-ingestion of Benzodiazepines and Opioids Contributes to Overdose and Death
MedicalResearch.com Interview with: Christopher M. Jones, Pharm D., M.P.H Senior advisor, Office of Public Health Strategy and Analysis Office of the Commissioner, Food and Drug Administration Medical Research: What is the background for this study? Dr. Jones: Opioid analgesics and benzodiazepines are the two most common drug classes involved in prescription drug overdose deaths. In 2010, 75% of prescription drug overdose deaths involved opioid analgesics and 29% involved benzodiazepines. Opioid analgesics and benzodiazepines are also the most common drugs associated with emergency department visits due to nonmedical use of prescription drugs. Combined opioid and benzodiazepine use has been suggested as a risk factor for overdose death. Opioids and benzodiazepines have complex drug interactions and in combination can result in synergistic respiratory depression, but the exact mechanisms by which benzodiazepines worsen opioid-related respiratory depression are not fully understood. Widespread co-use of benzodiazepines and opioids has been documented in both chronic pain and addiction treatment settings. Studies suggest that among patients who receive long-term opioids for chronic non-cancer pain, 40% or more also use benzodiazepines. Among patients who abuse opioids, benzodiazepine abuse also is prevalent, and co-users report using benzodiazepines to enhance opioid intoxication. This study builds on the prior literature by analyzing trends on how the combined use of opioids and benzodiazepines in the U.S. contributes to the serious adverse outcomes of nonmedical use–related ED visits and drug overdose deaths. A better understanding of the consequences of co-use of these medications will help identify at-risk populations, inform prevention efforts, and improve the risk–benefit balance of these medications. Medical Research: What are the main findings? Dr. Jones: From 2004 to 2011, the rate of nonmedical use–related Emergency Department visits involving both opioid analgesics and benzodiazepines increased from 11.0 to 34.2 per 100,000 population. During the same period, drug overdose deaths involving both drugs increased from 0.6 to 1.7 per 100,000. Statistically significant increases in Emergency Department visits occurred among males and females, non-Hispanic whites, non-Hispanic blacks, and Hispanics, and all age groups except 12–17-year-olds. For overdose deaths, statistically significant increases were seen in males and female, all three race/ethnicity groups, and all age groups except 12–17-year-olds. Benzodiazepine involvement in opioid analgesic overdose deaths increased each year, increasing from 18% of opioid analgesic overdose deaths in 2004 to 31% in 2011.14 Jul Women’s Out-of-Pocket Expenses For Contraceptives Drop After ACA
MedicalResearch.com Interview with:
Nora V. Becker MD/PhD candidate
Department of Health Care Management and Economics
Wharton School, University of Pennsylvania, in Philadelphia.
Medical Research: What is the background for this study? What are the main findings?
Response: The Affordable Care Act mandates that private health insurance plans cover prescription contraceptives with no consumer cost sharing. The positive financial impact of this new provision on consumers who purchase contraceptives could be substantial, but it has not yet been estimated. Using a large administrative claims data set from a national insurer, we estimated out-of-pocket spending before and after the mandate. We found that mean and median per prescription out-of-pocket expenses have decreased for almost all reversible contraceptive methods on the market. The average percentages of out-of-pocket spending for oral contraceptive pill prescriptions and intrauterine device (IUD) insertions by women using those methods both dropped by 20 percentage points after implementation of the ACA mandate. We estimated average out-of-pocket savings per contraceptive user to be $248 for the IUD and $255 annually for the oral contraceptive pill.
25 Jun Opioids and Barbituates Commonly Prescribed For Headaches
Posted at 20:33h
in Author Interviews, Neurological Disorders, NYU/NYMC, Opiods, Pain Research, Pharmacology
MedicalResearch.com Interview with:
Dr. Mia T. Minen, MD, MPH
Director, Headache Services
NYU Langone Medical Center
Assistant professor, Department of Neurology
Medical Research: What is the background for this study? What are the main findings?
Dr. Minen: We conducted a survey on opioid and barbiturate use among patients visiting a headache center to find out which medications they were receiving for treatment. There’s limited evidence that long-term use of these medications can help treat headaches or migraines, and even short-term use in small quantities can cause medication overuse headache. It is important to determine which providers start these medications so that educational interventions can be tailored to these physician specialties to try to prevent situations such as incorrect prescribing practices and medication overuse.
In this sample of patients from a specialty headache center, approximately 20 percent of patients -- or 1 in 5 -- were using opioids or barbiturates, and about half had been prescribed these medications at some point in the past for their headaches. These findings show that opioids and barbiturates are commonly prescribed to patients with headaches. While two-thirds of patients found opioids or barbiturates helpful, many did not like them, were limited by side effects or did not find them to be helpful. Emergency department physicians were reported to be the most frequent first prescribers of opioids and general neurologists were the most frequent prescribers of barbiturate-containing medications. Primary care physicians were also identified as frequent first prescribers of these medications.
24 Jun Larger Study Finds No Link Between Melanoma and Viagra
MedicalResearch.com Interview with:
Dr. Stacy Loeb, MD, MSc
Department of Urology, Population Health,
and Laura and Isaac Perlmutter Cancer Center
New York University, New York
Medical Research: What is the background for this study?
Dr. Loeb: A paper published last year suggested a relationship between use of (Viagra) and melanoma. That study had only 142 cases of melanoma, and of these men 14 had used sildenafil. This study got a lot of publicity leading numerous patients to express concern over whether erectile dysfunction drugs could cause melanoma.
Our goal was to look more closely at this issue in a larger population from Sweden (including 4065 melanoma cases of whom 435 used any type of erectile dysfunction drug- Viagra, as well as Levitra and Cialis). Sweden has a national health system so we were able to access prescription records for men across the entire country, which we linked to the national registries for melanoma and basal cell skin cancer.
08 Jun Women On Both Diabetes and Depression Medications Have Increased Risk of Myocardial Infarction
Posted at 13:13h
in Author Interviews, Depression, Diabetes, Heart Disease, Pharmacology, Women's Heart Health
MedicalResearch.com Interview with
Dr. Karin Rådholm MD Ph.D. student
Division of Community Medicine, Primary Care, Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University
Department of Local Care West, County Council of Östergötland,
Linköping, Sweden
MedicalResearch: What is the background for this study?
Dr. Rådholm: Psychosocial risk factors and depressive disorders often co-occur with general medical comorbidities, such as myocardial infarction. Depression is more common in patients with diabetes than in patients without diabetes. About 10-30% of patients with diabetes have a comorbid depressive disorder, which is double the estimated prevalence of depression in individuals without diabetes. There is an association between comorbid depressive symptoms and diabetes complications. This is believed to be mainly due to poor adherence to treatment recommendations and diabetes self-management activities, but could also possibly be due to biological and behavioural causes that could predispose for both metabolic and affective disorders. The general risk of myocardial infarction is strongly dependent on age and sex, where men have an earlier disease onset compared to women. In the general population women are at much lower risk for ischemic heart disease mortality than men are. However, women with diabetes are at especially high risk for coronary heart disease, relatively more so than men with type 2 diabetes, meaning that the impact of diabetes on the risk of coronary death is significantly greater for women than men. The age- and gender-specific risk for myocardial infarction due to diabetes with coexistent depression has not previously been described. Data on all dispensed drug prescriptions in Sweden are available in the Swedish Prescribed Drug Register and all myocardial infarctions are registered in the Myocardial Infarction Statistics. These registers are population-based and have a total national coverage and high validity, which has been previously shown. Prescribed and dispensed antidiabetics and antidepressants were used as markers of disease.
Our objective was to prospectively explore the gender- and age-specific risk of first myocardial infarction in people treated with antidiabetic and/or antidepressant drugs compared to participants with no pharmaceutical treatment for diabetes or depression in a nationwide register study.
27 May Some Birth Control Pills Have Slightly Higher Risk Of Venous Thromboembolism
MedicalResearch.com Interview with: Yana Vinogradova, Research Fellow Division of Primary Care School of Medicine University of Nottingham Medical Research: What is the background for this study? What are the main findings? Response: Combined oral contraceptives are an effective method of birth control but do have measurable side effects. One – common to all combined contraceptives and sometimes fatal – is an increased risk of venous thromboembolism (VTE). A number of earlier studies investigated VTE risks for different types of hormonal contraceptives, but all were performed some years ago or had insufficient data to analyse newer preparations, while some included only healthy users and others did not adequately control for lifestyle and health issues. The data used for this study were representative of the UK population and covered all currently prescribed drugs, with results adjusted for the widest possible range of available relevant factors. We found that the venous thromboembolism risks of combined oral contraceptives appear to fall into two distinct groups. Newer drugs containing gestodene, desogestrel, drospirenone or cyproterone were associated with risks of VTE between 1.5 and 1.8 times higher than both the older compositions containing norethisterone or levonorgestrel and the relatively newer norgestimate. While our findings are statistical associations between different compositions and venous thromboembolism risks, they do represent more comprehensive and reliable information for doctors making evidence-based prescribing decisions.13 May Frequent ER Visits Linked To Prescription Drug Overdose
MedicalResearch.com Interview with: Joanne Brady, PhD candidate Department of Anesthesiology, College of Physicians and Surgeons Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY Medical Research: What is the background for this study? What are the main findings? Response: Prescription drug overdose is a major public health problem in the United States. Prescription drug overdose mortality has increased dramatically over the past twenty five years. Frequent emergency department utilization may be a marker for risk of prescription drug overdose death. The current study assessed how frequency of emergency department visits in the past year related to risk of subsequent prescription drug overdose death. In a cohort of patients visiting the emergency department, patients with four or more visits to the emergency department in the past year were at substantially higher risk for prescription drug overdose death than patients who visited the emergency department one or fewer times. As the number of visits to the emergency department increased from 0 - 1 to 4 or more for any reason the risk of dying from prescription drug overdose also increased.08 May Orthopedic Patients and Their Families At Risk For Opioid Abuse
MedicalResearch.com Interview with:
Hassan R. Mir, MD, MBA
Associate professor of Orthopaedics and Rehabilitation
Vanderbilt Orthopaedic Institute and
and
Dr. Brent J. Morris, M.D.
Shoulder and Elbow Surgery Fellowship
Texas Orthopaedic Hospital University of Texas Houston Health Science Center,
Houston, Texas
Medical Research: What is the background for this study? What are the main findings?
Dr. Mir: The past few decades have seen an alarming rise in opioid use in the United States, and the negative consequences are dramatically increasing. The US represents less than 5% of the world's population, yet consumes 80% of the global opioid supply. Management of pain is an important part of patient care, however, the increased usage of opioids for the treatment of pain has led to several unanticipated aftereffects for individual patients and for society at large.
Orthopaedic surgeons are the third highest prescribers of opioid prescriptions among physicians in the United States. Orthopaedic patients can experience a tremendous amount of pain with acute injuries and chronic conditions, and the treatment plan may involve opioid prescriptions for relief of discomfort. A significant number of orthopaedic patients and their families are at risk for repercussions from opioid use. We must work together to decrease the use of opioids for musculoskeletal pain.
Clinicians should aim to control pain and improve patient satisfaction while avoiding overprescribing opioids. A comprehensive strategy of risk assessment is needed to identify patients who may be at risk for opioid abuse. Objective measures including patient history, recognition of aberrant behavior, urine drug testing, state prescription drug–monitoring programs, and opioid risk-assessment screening tools may be necessary in select cases.
01 Apr More Dialysis Patients Becoming Pregnant
MedicalResearch.com Interview with:
Dr. Mala Sachdeva MD
North Shore University Hospital, Long Island Jewish Medical Center
Assistant Professor, Nephrology, Internal Medicine
Hofstra North Shore-LIJ School of Medicine
Medical Research: What is the background for this study?
Dr. Sachdeva: The last study examining pregnancy and dialysis outcomes in the United States was performed more than 15 years ago. Our study was conducted to evaluate practice patterns and to trend maternal and fetal outcomes in the pregnant dialysis female over the past five years. We did a surveymonkey-based survey of American nephrologists on their knowledge of managing pregnancy patients on dialysis.
Medical Research: What are the main findings?
Dr. Sachdeva: Over the past five years, more than 59 pregnancies have been reported. During this time period, almost half of the American nephrologist respondents (43%) have cared for pregnant females on hemodialysis. Hence, we can see that more nephrologists are now faced with taking care of the pregnant dialysis patient. Although a good number of patients initiated dialysis during pregnancy (32%), the majority (58%) of pregnancies occurred within the first five years of being on maintenance dialysis.
Pregnancy outcomes can improve. Of the reported pregnancies 23% did not result in live births. 50% of the pregnancies were complicated by preeclampsia. There were no maternal deaths.
Most nephrologists prescribe 4 to 4.5 hours of hemodialysis. 64% of respondents provide dialysis for six days per week. Only 21% aimed for a target predialysis BUN of less than 20 mg/dL while 66% of nephrologists targeted a BUN less than 50mg/dL. 75% of respondents do not have access to fetal monitoring during dialysis for their pregnant patient.
There are approximately 32% of American nephrologists who are somewhat to very uncomfortable caring for a pregnant woman on hemodialysis. 51% of American nephrologists or a member of their staff counsel their female dialysis patients about contraception.
So in summary, while majority of the US based nephrologists are trying to dialyze pregnant ESRD patients with more intense prescriptions, there are still some gaps with comfort and knowledge.
13 Mar Abuse Deterrent Opioids Inadvertently Led To Increased Heroin Use
MedicalResearch.com Interview with:
Theodore J. Cicero, PhD
Professor, Vice Chairman for Research
Department of Psychiatry, Washington University
St Louis, Missouri
MedicalResearch: What is the background for this study? What are the main findings?
Dr. Cicero: Prescription opiate abuse (eg Vicodin, Percocet, OxyContin) has reached epidemic proportions in this country over the past decade. Although most people swallow the drugs whole, a relatively large number either chew the drugs to produce an immediate delivery of large quantities of drugs or they crush them and/or dissolve them in some solvent which makes them useful for intranasal (eg snorting) or intravenous administration. Non-oral routes, particularly injection, represent the most serious public health risk due to a high incidence of infection, including Hepatitis C and HIV, and the much greater severity of abuse. In an effort to reduce these practices, drug companies are introducing so-called abuse deterrent formulations (ADF) which are resistant to crushing or dissolving in an aqueous solution. In one such important effort, the company responsible for distributing one of the most widely abused prescription opiates, OxyContin, introduced an ADF in 2010. Although the abuse deterrent formulations was highly successful in reducing abuse of OxyContin by either chewing, crushing, or dissolving in water, there was none-the-less a clear limit to how effective it was. For example, some people simply switched to the oral route of administration or never did snort or inject the drug, whereas a small number found ways to defeat the abuse deterrent formulations and persisted in harmful patterns of abuse. Unfortunately, there was also an unintended result. ADF-OxyContin caused many individuals to abandon the use of OxyContin - a good thing - in favor of other opiates (a bad thing). Most serious, however, was that 70% of those who switched drugs moved from OxyContin to heroin abuse. Although by no means the only factor, the abuse deterrent formulations has contributed to the wide-spread reports of heroin abuse in suburban and rural Caucasian male and females, a group here-to-fore not the typical heroin users (i.e. poor minorities, living in large urban centers).
03 Mar Brain Opioids Malresponsive in Major Depressive Disorder
MedicalResearch.com Interview with: Dr. David T. Hsu Ph.D Department of Psychiatry, Stony Brook University, Stony Brook, NY Department of Psychiatry The Molecular & Behavioral Neuroscience Institute University of Michigan, Ann Arbor, MI Medical Research: What is the background for this study? What are the main findings? Dr. Hsu: The opioid system is known for its role in...
03 Mar More Physicians Per Capita Means More Prescriptions Per Capita
MedicalResearch.com Interview with:
Eili Y. Klein Ph.D. Assistant Professor
Department of Emergency Medicine
Johns Hopkins University
Baltimore, MD 21209
Medical Research: What is the background for this study? What are the main findings?
Dr. Klein: Antibiotic prescriptions rates vary widely across the country. We saw this at the state level, where rates in the highest prescribing states were as high as 1,200 prescriptions per 1,000 people to the lowest rates which were around 500 prescriptions per 1,000 people (see resistancemap.org). Europe has similar variation in prescribing rates across countries, and research there has documented a number of potential reasons for this such as education, access to health insurance, use of childcare centers, and cultural differences. However, the healthcare system in the US is structured differently than in Europe, so we set out to see if similar factors underlay differences in antibiotic prescribing in the US.
Understanding the drivers of differences in prescribing is important because it can help predict how future changes in demographics and socioeconomic characteristics will affect future antibiotic consumption. It also enables predictions in consumption as a result of interventions that target the healthcare delivery system, and also enables better targeting of information campaigns, such as the CDC's Get Smart Program, on appropriate antibiotic prescribing to specific sub-populations. Finally, it allows providers to better understand how their practice is driven by external factors.
The results of the study found that a primary factor driving differences in prescribing was the density of physicians. In other words, the more physicians there are per capita, the more prescriptions per capita. This result could just be due to more physicians making it easier to access a doctor and thus people go to visit a physician more. However, it could also suggest that physicians are competing to attract or retain patients in some manner and this is driving up prescriptions. To try to understand which of these effects was dominating the change, we examined the role of retail and urgent care clinics.
Stand-alone urgent care clinics and clinics incorporated into the retail arm of a store (e.g., CVS minute clinic) are truly an American-style invention, and bear little similarity to how most Europeans receive healthcare. Over the last decade these establishments have exploded in popularity and greatly expanded their reach. Surprisingly what we found was that in low-income areas, a clinic increased the prescribing rate, but didn't affect the rate that physicians were prescribing antibiotics. Thus, in these areas the story is all about access. Improving access to healthcare increases the likelihood that people will go to the doctor when they are sick and that increases the rate that people get prescribed antibiotics. This contrasted with wealthier areas, where we found that a clinic increased the rate of prescribing by physicians, which is likely due to competition. This competition can take multiple forms, from increasing the probability of getting an antibiotic as a physician is worried you won't come back otherwise, to changes in how physician offices work so that it is easier to walk-in to your doctor or get a same-day appointment. Though we were not able to quantify which of these effects was dominant in this research.
21 Feb Pharmacy Shopping and Overlapping Prescriptions Linked To Opioid Overdose
MedicalResearch.com Interview with:
Dr. Zhou Yang
Office of the Associate Director for Policy
Centers for Disease Control and Prevention, Atlanta, GA
Medical Research: What is the background for this study?
Response: Prescription drug misuse and abuse, largely those involving opioid painkillers, have been characterized as an epidemic. According to a CDC report, drug-related overdose has surpassed traffic crashes to become the leading cause of injury death in the U.S. in 2009. Medicaid programs in most states implement Patient Review and Restriction (PRR) programs, also called ‘lock-in’ program. The PRR programs use a set of behavioral indicators to identify patients at higher risk of opioid drug misuse and abuse, and ‘locks’ them in to a designated provider, pharmacy, or both. Pharmacy shopping is one of the key indicators employed by the PRR program. However, definition of pharmacy shopper varies widely across states. In addition, the PRR programs have not paid attention to the indicators of prescribing overlapped drugs, which we see as a missed opportunity to help the PRR program to better target users at high risk of overdose.
Medical Research: What are the main findings?
Response: Among a number of currently used definitions of pharmacy shopping, we found that the definition of ‘four or more pharmacies visited within any 90-day period’ is the most effective one. We also found that having overlapping opioid prescriptions is associated with an elevated risk of overdose. In fact, patients who exhibited both pharmacy shopping and having overlapping prescription had more than twice the risk of overdose than those who only exhibited pharmacy shopping.
29 Jan US Opioid Death Rate Flattens, Heroin Deaths Increase
MedicalResearch.com Interview with:
Richard C. Dart, M.D., Ph.D
Denver Health & Hospital Authority
Professor, University of Colorado School of Medicine
Medical Research: What is the background for this study? What are the main findings?
Dr. Dart: For the past two decades, prescription opioid medication abuse has increased significantly in the US. An estimated 25 million people initiated nonmedical use of pain relievers between 2002 and 2011. In 2010 the number of death attributed to prescription opioid medications reached 16,651. The RADARS® System (Researched Abuse, Diversion and Addiction Related Surveillance) has been monitoring prescription drug abuse and diversion for over 13 years. We use a “mosaic” approach, measuring abuse and diversion from multiple perspectives, to describe this hidden phenomenon as comprehensively as possible.
For the current publication we used 5 separate RADARS® System programs to collect data and the study period was from January 2002 through December 2013. We noticed a substantial increase of prescription drug abuse from 2002 through 2010, followed by a flattening or decrease in 2010 and, lastly, a decline in 2011 through 2013. We also noticed a similar pattern in opioid-related deaths. Nonmedical use did not change significantly among college students.
16 Jan Medicaid to Medicare Transition Challenging For Mental Health Patients
Posted at 19:02h
in Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, JAMA, Medicare, Mental Health Research, Pharmacology
MedicalResearch.com Interview with:
Dr. Jeanne Madden PhD
Instructor, Department of Population Medicine
Harvard Medical School
Medical Research: What is the background for this study? What are the main findings?
Dr. Madden: When Medicare Prescription Drug Coverage started in 2006, many experts voiced concerns about disabled patients with serious mental illness making the transition from state Medicaid coverage to Medicare. Our study is one of the first to examine the impact of the transition in mentally ill populations. People living with schizophrenia and bipolar disorder are at high risk of relapse and hospitalization and are especially vulnerable to disruptions in access to their treatments.
We found that the effects of transitioning from Medicaid to Medicare Part D depended on where patients lived. Transition to Part D in states that put limits on Medicaid drug coverage resulted in fewer patients going without treatment.
By contrast, in states with more generous drug coverage, we saw reductions in use, of antipsychotics in particular, after patients shifted to Medicare Part D. This may have been due to new cost controls used within many private Medicare drug plans. Given that most states in the US are in this latter category, with the relatively generous Medicaid drug coverage, we also found reductions in antipsychotic use nation-wide.
Although a very large group of people made that transition from Medicaid to Medicare in 2006, thousands more still transition every year because when disabled people qualify for Medicare, they must wait 2 years for their benefits kick in. Also, many other disabled patients are on Medicaid only and don’t qualify for Medicare. They are of course affected by restrictions on Medicaid coverage, which vary from state to state.
12 Jan Genetics and Common Bacteria Affect Atherosclerosis Progression
MedicalResearch.com Interview with:
Caroline Attardo Genco, PhD
Professor Department of Medicine, Section of Infectious Diseases Department of Microbiology
Boston University School of Medicine
Boston MA
MedicalResearch: What is the background for this study? What are the main findings?
Dr. Genco: Atherosclerosis is a common cardiovascular disease associated with heart attack and stroke. Although it has been shown that a diet high in fat as well as exposure to certain bacteria can cause atherosclerosis (the buildup of fats, cholesterol, and other substances on artery walls which can restrict blood flow), we have for the first time identified distinct gene pathways that are altered by these different stimuli. One of these bacteria, Porphyromonas gingivalis, is found in the mouth of humans with periodontal disease. Another is the bacteria Chlamydia pneumoniae, which causes pneumonia. We found that even though these three different stimuli all cause atherosclerosis, the gene pathways are distinct depending upon stimulus. This is the first study that has performed side-by-side comparison of genome-wide gene expression changes to address this issue.
In this study, we used four experimental groups to compare genome-wide expression changes in vascular tissue. The first group was subjected to Porphyromonas gingivalis, while the second group received Chlamydia pneumoniae. The third group was placed on a high-fat Western style diet, while the fourth group was the control group. In collaboration with the Clinical and Translational Science Institute (CTSI) at Boston University, we performed genome-wide microarray profiling and analysis of vascular tissue from all groups to reveal gene pathways altered in vascular tissue by each treatment group.
These findings may explain how specific infections or high-fat diet may cause atherosclerotic plaques to undergo changes that affect their size and stability and may ultimately lead to a heart attack.
07 Jan Proton Pump Inhibitors Not Helpful For Irritable Babies
MedicalResearch.com Interview with:
Prof. H. Szajewska
The Medical University of Warsaw
Department of Paediatrics
Warsaw, Poland
Medical Research: What is the background for this study?
Dr. Szajewska: Proton pump inhibitors (PPIs) are increasingly being used in the management of irritability and excessive crying in young infants. For example, a 7-fold increase in PPI prescriptions for infants was demonstrated in one US-based study. While differences among countries may occur, over-prescription of PPIs for infants remains a problem. The use of PPIs is mainly based on the assumption that these symptoms are attributable to gastroesophageal reflux or gastroesophageal reflux disease. Indeed, in infants, common symptoms of both conditions include regurgitation or vomiting associated with irritability or crying. However, there is still uncertainty with regard to the role of proton pump inhibitors for the management of excessive crying and irritability.
Dr. Szajewska: What are the main findings?
We aimed to examine whether proton pump inhibitors are effective in the management of excessive crying and irritability in infants. Only 5 randomized controlled trials fulfilled the inclusion criteria, so the evidence remains limited. There was variability in how crying/irritability outcomes were reported, but all trials used reliable methods. Some trials showed a decrease in crying/irritability from baseline to the end of the intervention; a similar effect was observed in the control group. However, no significant differences between the treatment groups were observed.
19 Dec Both Ibuprofen and Morphine Work For Childhood Fracture Pain
MedicalResearch.com Interview with: Naveen Poonai MSc MD FAAP FRCPC Paediatric Emergency Physician Children's Hospital, London Health Sciences Center Assistant Professor Paediatrics and Internal Medicine Schulich School of Medicine and Dentistry London, Ontario, Medical Research: What is the background for this study? What are the main findings? Dr. Poonai: We found that in children discharged home with a fracture, both ibuprofen and oral morphine were effective at relieving pain. However, there were no significant differences in efficacy between the two agents and oral morphine was associated with more side effects. MedicalResearch.com: What was most surprising about the results? Dr. Poonai: The most surprising findings for us were that over 70% of children experienced pain significant enough to require analgesia once they were discharged home. Furthermore, we were surprised to find that the anecdotally more potent agent morphine, was equivalent to ibuprofen for post-fracture pain relief in children.17 Dec Public Disclosure of Antibiotic Prescription Rates Decreased Usage
MedicalResearch.com Interview with:
Dong Wook Shin, MD, MBA, DrPH
Assistant Professor, Center for Health Promotion/Dept.of Family Medicine
Seoul National University Hospital
Medical Research: What is the background for this study? What are the main findings?
Response: In South Korea, the National Health Insurance provides universal coverage and the Health Insurance Review & Assessment Service (HIRA) oversees claims reviews. HIRA has reported the rates of antibiotic prescriptions for upper respiratory tract infections in each clinic via web site since 2006. We assessed the effect of public disclosure.
The main findings are that decreases of antibiotic uses were observed since the public disclosure of the prescription rates regardless of hospital level.
11 Dec Opioids: Total and Daily Dose Both Indicators of Overdose Risk
MedicalResearch.com Interview with:
Barbara J Turner MD, MSEd, MA, MACP
James D and Ona I Dye Professor of Medicine
Director, Center for Research to Advance Community Health (ReACH)
University of Texas Health Science Center San Antonio
Medical Research: What is the background for this study? What are the main findings?
Dr. Turner: Daily dose of opioid analgesics has been widely used to assess the risk of overdose death and this risk has been reported to be greatest for a morphine equivalent dose at least 100 to 120 mg per day. However, the total dose of filled opioid prescriptions over a period of time may offer a complementary measure of the risk to that provided by the daily dose. In fact, the total dose is not necessarily a simple linear transformation of the daily dose because not all patients use opioids every day, instead it reflects the total amount of opioids available to a patient.
Among 206,869 national HMO patients aged 18-64 with non-cancer pain filling at least 2 schedule II or III opioid analgesic prescriptions, the rate of overdose was 471 per 100,000 person-years. Over the study period of 3.5 years, risk of drug overdose was two to three times greater for patients with a daily dose >100 mg regardless of the total dose filled or a daily dose of 50-99 mg with a high total dose (>1830 mg) filled a six month interval (versus no opioids). The overdose risk was increased slightly for 50-99 mg per day with a lower total dose and not increased at all for daily doses under 20 mg regardless of the total dose.