A new study adds further evidence to suggest that opioid prescribing in the U.S. is skewed and concentrated among a few providers. Researchers looked at prescribing patterns in data from an unspecified national private insurer between 2003-2017.
Around 670,000 providers prescribed more than 8 million standard doses of opioid prescriptions — but more than a quarter of these prescriptions were written by only 1% of physicians. And in 2017, these physicians prescribed nearly half of all the dispensed opioids. This small group of doctors also prescribed higher doses than recommended, and for longer durations than guidelines allow.
What’s encouraging, the authors suggest, is that the vast majority of physicians do seem to follow guidelines. Some caveats: The study was based on one company’s data, and didn’t look at medical reasons behind prescriptions.
TRENDS AND PATTERNS OF GEOGRAPHIC VARIATIONS IN OPIOID PRESCRIBINGwith Wind
The document analyzes trends in opioid prescribing practices across US states from 2006 to 2017. It finds that while the total amount of opioids prescribed decreased over this period, the duration of prescriptions increased. Specifically:
- The total amount of opioids prescribed per person decreased 12.8% on average nationally, though there was significant variation between states.
- The mean duration of opioid prescriptions increased 37.6% nationally, with increases in every state.
- Prescriptions for durations of 30 days or longer, which are more likely to treat chronic pain, increased 37.7% nationally, with increases in 39 states.
- However, prescribing rates decreased for high dosages, short durations,
This study examined opioid prescribing patterns among Medicaid patients and providers in Oregon in 2013. It found that prescribing and use were highly concentrated, with the top 10% of providers accounting for over 80% of opioid prescriptions by morphine equivalent dose, and the top 10% of patients accounting for over 83% of doses. Patients in the highest decile of opioid use had higher rates of potential misuse indicators like prescription overlaps. While increasing opioid use overall was linked to higher misuse, receiving opioids from the highest-volume prescribers was associated with only modestly higher risks of certain misuse measures among highest-use patients. The study suggests targeting policies to high prescribers and users may be more effective than broad policies.
How Do Opioid Prices and the Evolving Opioid Crisis Relate to the North Ameri...with Wind
The Role of Opioid Prices in the Evolving Opioid Crisis is a publication by order of the Commander in Chief; Our 45th President, Mr. Donald J Trump.
This is an objective purview of the role pharmaceutical marketing and advertising and the one true law that is Supply and Demand have had on the current crisis North America finds itself in.
I aim to be objective - no subjective - or opinionated argument - merely share the presentation as it was originally published by < whitehouse.gov. >
I will state this - however - the opioid crisis - is real - it is not some propaganda cooked up by CDC - DEA - or the Free Masons (wholly misunderstood by today's youth - Illuminati).
It has - in some, shape, form or fashion - affected every single North American at some point over the entirety of this - ridiculous attempt at going to war - against substances.
For my opinions, feel free to connect on
< https://www.linkedin.com/in/oudcollective >
FOLLOW @oudcollective
< https://www.twitter.com/oudcollective >
or help out in pinning beginnings at
< https://www.pinterest.com/THEWINDLLC >
Best,
< linktr.ee/C.Brennan.Poole >
< https://allmylinks.com/chasing-the-wind >
Chasing the Wind, LLC DBA THE WIND LLC is licensed under a creative commons attribution share-alike (CC BY-SA) International 4.0 license. Link to license at < www.creativecommons.org/licenses/by-sa/4.0 >
This study analyzed health insurance claims data from 2001-2013 to examine trends in concurrent prescribing of opioids and benzodiazepines. It found that concurrent use increased sharply over this period, rising from 9% of opioid users in 2001 to 17% in 2013. Concurrent use was associated with significantly higher risks of emergency room visits or hospital admissions for opioid overdose. The study estimates that eliminating concurrent opioid-benzodiazepine use could reduce such overdose events by around 15%.
The document discusses the increasing abuse of heroin in the United States and its link to prescription drug abuse. It provides data from reports showing that people who abuse prescription painkillers are 19 times more likely to abuse heroin. With increased demand, drug trafficking organizations have increased heroin availability and purity. Law enforcement data demonstrates rising heroin seizures and overdose deaths linked to increased prescription opioid abuse. The document examines how some prescription opioid abusers may be turning to cheaper heroin as painkiller restrictions take effect.
This study examined the association between initial opioid prescribing patterns and the likelihood of long-term opioid use among patients who were opioid-naïve. The study used prescription drug monitoring program data from Oregon to identify over 500,000 patients who filled their first opioid prescription between 2012-2013. It found that receiving multiple prescriptions or higher total morphine milligram equivalents in the first 30 days was associated with greater odds of long-term opioid use (defined as 6 or more fills) in the following year. Patients who started on long-acting opioids also had higher risk than those starting on short-acting drugs. The associations remained after excluding patients likely using opioids for cancer or end-of-life care.
April 3, 2017
The current opiate epidemic has spurred long-overdue scrutiny on the pharmaceutical production and distribution of opiate medication, but it also raises questions of public policy and law regarding the regulation of medical access to and use of opiate medications with high potential for addiction. Expert panelists will address the challenges that arise from efforts to balance restrictions on access to opiates to limit addiction while also preserving sufficient access for legitimate medical management of pain.
Learn more on our website: http://petrieflom.law.harvard.edu/events/details/opiate-regulation-policies
TRENDS AND PATTERNS OF GEOGRAPHIC VARIATIONS IN OPIOID PRESCRIBINGwith Wind
The document analyzes trends in opioid prescribing practices across US states from 2006 to 2017. It finds that while the total amount of opioids prescribed decreased over this period, the duration of prescriptions increased. Specifically:
- The total amount of opioids prescribed per person decreased 12.8% on average nationally, though there was significant variation between states.
- The mean duration of opioid prescriptions increased 37.6% nationally, with increases in every state.
- Prescriptions for durations of 30 days or longer, which are more likely to treat chronic pain, increased 37.7% nationally, with increases in 39 states.
- However, prescribing rates decreased for high dosages, short durations,
This study examined opioid prescribing patterns among Medicaid patients and providers in Oregon in 2013. It found that prescribing and use were highly concentrated, with the top 10% of providers accounting for over 80% of opioid prescriptions by morphine equivalent dose, and the top 10% of patients accounting for over 83% of doses. Patients in the highest decile of opioid use had higher rates of potential misuse indicators like prescription overlaps. While increasing opioid use overall was linked to higher misuse, receiving opioids from the highest-volume prescribers was associated with only modestly higher risks of certain misuse measures among highest-use patients. The study suggests targeting policies to high prescribers and users may be more effective than broad policies.
How Do Opioid Prices and the Evolving Opioid Crisis Relate to the North Ameri...with Wind
The Role of Opioid Prices in the Evolving Opioid Crisis is a publication by order of the Commander in Chief; Our 45th President, Mr. Donald J Trump.
This is an objective purview of the role pharmaceutical marketing and advertising and the one true law that is Supply and Demand have had on the current crisis North America finds itself in.
I aim to be objective - no subjective - or opinionated argument - merely share the presentation as it was originally published by < whitehouse.gov. >
I will state this - however - the opioid crisis - is real - it is not some propaganda cooked up by CDC - DEA - or the Free Masons (wholly misunderstood by today's youth - Illuminati).
It has - in some, shape, form or fashion - affected every single North American at some point over the entirety of this - ridiculous attempt at going to war - against substances.
For my opinions, feel free to connect on
< https://www.linkedin.com/in/oudcollective >
FOLLOW @oudcollective
< https://www.twitter.com/oudcollective >
or help out in pinning beginnings at
< https://www.pinterest.com/THEWINDLLC >
Best,
< linktr.ee/C.Brennan.Poole >
< https://allmylinks.com/chasing-the-wind >
Chasing the Wind, LLC DBA THE WIND LLC is licensed under a creative commons attribution share-alike (CC BY-SA) International 4.0 license. Link to license at < www.creativecommons.org/licenses/by-sa/4.0 >
This study analyzed health insurance claims data from 2001-2013 to examine trends in concurrent prescribing of opioids and benzodiazepines. It found that concurrent use increased sharply over this period, rising from 9% of opioid users in 2001 to 17% in 2013. Concurrent use was associated with significantly higher risks of emergency room visits or hospital admissions for opioid overdose. The study estimates that eliminating concurrent opioid-benzodiazepine use could reduce such overdose events by around 15%.
The document discusses the increasing abuse of heroin in the United States and its link to prescription drug abuse. It provides data from reports showing that people who abuse prescription painkillers are 19 times more likely to abuse heroin. With increased demand, drug trafficking organizations have increased heroin availability and purity. Law enforcement data demonstrates rising heroin seizures and overdose deaths linked to increased prescription opioid abuse. The document examines how some prescription opioid abusers may be turning to cheaper heroin as painkiller restrictions take effect.
This study examined the association between initial opioid prescribing patterns and the likelihood of long-term opioid use among patients who were opioid-naïve. The study used prescription drug monitoring program data from Oregon to identify over 500,000 patients who filled their first opioid prescription between 2012-2013. It found that receiving multiple prescriptions or higher total morphine milligram equivalents in the first 30 days was associated with greater odds of long-term opioid use (defined as 6 or more fills) in the following year. Patients who started on long-acting opioids also had higher risk than those starting on short-acting drugs. The associations remained after excluding patients likely using opioids for cancer or end-of-life care.
April 3, 2017
The current opiate epidemic has spurred long-overdue scrutiny on the pharmaceutical production and distribution of opiate medication, but it also raises questions of public policy and law regarding the regulation of medical access to and use of opiate medications with high potential for addiction. Expert panelists will address the challenges that arise from efforts to balance restrictions on access to opiates to limit addiction while also preserving sufficient access for legitimate medical management of pain.
Learn more on our website: http://petrieflom.law.harvard.edu/events/details/opiate-regulation-policies
The document discusses addressing the opioid epidemic through a public health lens. It provides data on the rise in opioid-related deaths in Massachusetts from 2000-2016. It also discusses prevention, intervention, treatment and recovery efforts through Governor Baker's Opioid Working Group. This includes adopting core medical competencies focused on substance use, expanding treatment beds and recovery programs, and the Chapter 55 data initiative to better understand the epidemic through linking multiple health datasets.
This document summarizes opioid prescribing trends, policies, and their impacts in Canada and at the US-Canada border. It finds that while Canada and the US have high opioid consumption, Canadian policies like introducing tamper-deterrent OxyContin and a prescription monitoring program reduced potentially inappropriate prescribing by 1%. However, over 1 million such prescriptions remain, and inconsistencies in provincial policies and lack of prescriber access to prescription data limit the policies. The approval of generic long-acting oxycodone in Canada did not increase trafficking into the US, though losses cannot be tracked. Ongoing evaluation is needed to improve policies around opioid availability and curb misuse across the border.
This document summarizes New Jersey's response to the rise in prescription drug and heroin abuse. It discusses several key aspects of New Jersey's approach, including the prescription drug monitoring program (NJPMP), drug take-back programs like Project Medicine Drop, educational campaigns, a Good Samaritan law providing legal protection for those reporting overdoses, expansion of drug treatment programs, and a Medicaid lock-in program. The strategies aim to curb prescription drug diversion and abuse, expand access to treatment, prevent overdoses, and reduce related harms like the spread of HIV/AIDS and hepatitis C.
Consumer-Oriented Drug Information Service Needs Assessmentiosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
Global Medical Cures™ | Responding to America's Prescription Drug Abuse CrisisGlobal Medical Cures™
This document summarizes the growing problem of prescription drug abuse in America. Key points include:
- Prescription drug abuse is now the nation's fastest growing drug problem, with opioids like oxycodone being abused at increasing rates.
- Education of healthcare providers, patients, and the public is needed to increase awareness of the dangers of prescription drug misuse and how to properly use and dispose of medications.
- Tracking programs like prescription drug monitoring programs (PDMPs) in states can help identify "doctor shoppers" and reduce diversion, though more research is still needed on their effectiveness.
- A multifaceted approach including education, monitoring, safe disposal, and enforcement is needed to address the crisis of prescription drug
This document summarizes a presentation on insights from state policies and interventions to curb prescription drug overdoses. It describes several interventions:
1) PRIMUM, a system in North Carolina that alerts prescribers to patients' risk of misusing or abusing opioids at the point of care.
2) A project in Rhode Island that developed protocols to improve opioid prescription safety for trauma patients, including alerts if prescriptions exceed dosage thresholds and requiring naloxone co-prescriptions.
3) A study in Pennsylvania that used Medicaid claims data to identify risk factors for opioid overdoses, such as high dosage and multiple prescribers/pharmacies, to target high-risk patients.
This document summarizes trends in methamphetamine-related admissions to youth residential substance abuse treatment facilities in Canada between 2005-2006 and 2009-2010. It finds that the proportion of admissions primarily due to methamphetamine abuse dropped significantly from 21% in 2005-2006 to 6% in 2009-2010 based on a survey of executive directors of treatment facilities. This reduction was largely driven by declines in the provinces previously most impacted by methamphetamine abuse. The findings suggest that controls on methamphetamine precursor chemicals in Mexico during this period may have contributed to decreased admissions in Canada as well.
This document summarizes national trends in prescription drug expenditures in the United States for 2015 and provides projections for 2016. Key findings include:
- Total US prescription drug sales in 2015 were $419.4 billion, an 11.7% increase over 2014. Spending in clinics and non-federal hospitals increased 15.9% and 10.7%, respectively.
- Growth in overall spending was driven primarily by price increases for existing drugs (8.4%), with new drugs (2.7%) and changes in drug usage (0.5%) also contributing. Hospital spending growth was mainly from price increases, while clinic growth was mostly from increased drug usage.
- Projections estimate an 11-13%
This document discusses regulatory inefficiencies surrounding companion diagnostics and laboratory developed tests (LDTs) in the United States. It uses the case study of Genentech's drug MPDL3280A and its companion diagnostic to show that the FDA thoroughly regulates companion diagnostics but provides no oversight of clinical validity for LDTs. This allows multiple competing diagnostic tests to be used without proof of efficacy. The document also compares healthcare systems and technology assessment processes in the US, UK, and France to illustrate decentralized decision making in the US compared to centralized bodies in other countries.
This document provides an overview of a presentation on preventing opioid overdose deaths. The presentation features four speakers and focuses on explaining the opioid overdose crisis epidemiology, describing treatment options to reduce overdose deaths, and advocating for advancing research and clinical practice. The learning objectives are listed as explaining the overdose epidemic, describing treatment options for clinicians, and advocating for research and practice directions. Brief biographies and disclosures are provided for each speaker.
This document provides an overview of state prescription drug monitoring programs (PMPs) and summarizes their status and operations. It finds that 44 states currently operate PMPs that collect prescription data, with most programs housed in health departments or related agencies. States fund PMPs through various means like grants, state appropriations, and licensing/registration fees. Fourteen states receive funding from licensing and registration fees specifically. The overview examines PMP laws and operations to assist policymakers in addressing prescription drug abuse, addiction, and diversion.
April 3, 2017
The current opiate epidemic has spurred long-overdue scrutiny on the pharmaceutical production and distribution of opiate medication, but it also raises questions of public policy and law regarding the regulation of medical access to and use of opiate medications with high potential for addiction. Expert panelists will address the challenges that arise from efforts to balance restrictions on access to opiates to limit addiction while also preserving sufficient access for legitimate medical management of pain.
Learn more on our website: http://petrieflom.law.harvard.edu/events/details/opiate-regulation-policies
Prescription Medicines Costs in Context January 2020PhRMA
This document discusses the costs and context of prescription medicines. It notes that while prescription drug spending represents 14% of total healthcare spending and a small portion of Medicaid spending, it has enabled breakthrough treatments for chronic diseases. While brand drug prices grew by 0.3% in 2018 after rebates, spending on other healthcare services is projected to grow 5 times faster than prescription drug spending through the next decade. The document also outlines how generics have reduced costs significantly, providing $1.99 trillion in savings over 10 years, and how biosimilars are expected to reduce brand drug sales by $95 billion from 2019-2023 through increased competition.
This report examines CMS's oversight of Medicare Part D beneficiaries who receive opioid prescriptions and providers who prescribe opioids to these beneficiaries. It finds that while CMS provides guidance to Part D plan sponsors on monitoring beneficiaries at high risk of opioid overuse, it lacks complete data on the full population of beneficiaries at risk. It also finds that CMS oversees prescribing through its contractor NBI MEDIC but does not specifically analyze opioid prescription data or require reporting on actions taken regarding inappropriate opioid prescribing. The report concludes that CMS needs more comprehensive oversight to reduce the risks of opioid misuse, overdose, and inappropriate prescribing among Medicare beneficiaries.
Listeners participated in a live panel session addressing OHIP+, the recently announced expansion of the Ontario drug program to cover young people who are younger than 25 years-old.
Problems and challenges faced in consumer reporting of adverse drug reactions...Mohammed Alshakka
This document discusses consumer reporting of adverse drug reactions (ADRs) in developing countries like Yemen, Nepal, and Malaysia. It finds that Malaysia has a good system for consumer involvement, while Yemen lacks drug policies and regulation. Nepal's system is still developing and lacks consumer reporting. Consumer reporting can provide additional information to national pharmacovigilance programs and help reduce ADR-related illness, but is still not widely implemented in developing countries.
CAPCA wants to make sure that patients have access to innovative and effective cancer treatments, and Heather Logan, ED of CAPCA, will explain how CAPCA is going to do this and answer your questions about the process. This webinar will introduce you to CAPCA and its mandate and to the new pan-Canadian Cancer Drug Funding Sustainability Initiative (DFSI). The goal of DFSI is to ensure that patients continue to have access to innovative and effective cancer treatments, and that the cancer system is achieving maximum value for money invested.
This document discusses the opioid epidemic in America and proposes actions to address it. It summarizes that:
1) Nearly 200,000 Americans have died from prescription opioid overdoses since 1999, and up to 40% of long-term opioid therapy patients may be addicted.
2) Keeping chronic opioid therapy doses low can help reduce overdose risk. Many overdose deaths occur at doses of 50 mg or more per day, while most patients receive lower doses.
3) Immediate actions are needed to curb new inappropriate long-term opioid prescriptions, including more selective initial prescribing, checking prescription monitoring programs, and limiting initial supplies. Policies and regulations also need to be updated to reflect risks of addiction
Medical care responding_to_us_opioid_epidemic_von_korff_franklin_4-22-2016 (3)Paul Coelho, MD
This document discusses the opioid epidemic in America and proposes actions to address it. The key points are:
1) America is experiencing an unprecedented epidemic of prescription opioid addiction and overdose, with almost 200,000 deaths since 1999 mostly affecting patients prescribed opioids.
2) Proposed actions to address the epidemic include avoiding unnecessary opioid prescriptions, changing policies to reflect risks of addiction/overdose, and enhancing surveillance of opioid prescribing and patient safety.
3) Additional actions proposed are increasing clinical monitoring of patients on long-term opioid therapy, consistently offering to taper doses or discontinue opioids as an option, and ensuring treatment for addicted patients.
The document discusses addressing the opioid epidemic through a public health lens. It provides data on the rise in opioid-related deaths in Massachusetts from 2000-2016. It also discusses prevention, intervention, treatment and recovery efforts through Governor Baker's Opioid Working Group. This includes adopting core medical competencies focused on substance use, expanding treatment beds and recovery programs, and the Chapter 55 data initiative to better understand the epidemic through linking multiple health datasets.
This document summarizes opioid prescribing trends, policies, and their impacts in Canada and at the US-Canada border. It finds that while Canada and the US have high opioid consumption, Canadian policies like introducing tamper-deterrent OxyContin and a prescription monitoring program reduced potentially inappropriate prescribing by 1%. However, over 1 million such prescriptions remain, and inconsistencies in provincial policies and lack of prescriber access to prescription data limit the policies. The approval of generic long-acting oxycodone in Canada did not increase trafficking into the US, though losses cannot be tracked. Ongoing evaluation is needed to improve policies around opioid availability and curb misuse across the border.
This document summarizes New Jersey's response to the rise in prescription drug and heroin abuse. It discusses several key aspects of New Jersey's approach, including the prescription drug monitoring program (NJPMP), drug take-back programs like Project Medicine Drop, educational campaigns, a Good Samaritan law providing legal protection for those reporting overdoses, expansion of drug treatment programs, and a Medicaid lock-in program. The strategies aim to curb prescription drug diversion and abuse, expand access to treatment, prevent overdoses, and reduce related harms like the spread of HIV/AIDS and hepatitis C.
Consumer-Oriented Drug Information Service Needs Assessmentiosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
Global Medical Cures™ | Responding to America's Prescription Drug Abuse CrisisGlobal Medical Cures™
This document summarizes the growing problem of prescription drug abuse in America. Key points include:
- Prescription drug abuse is now the nation's fastest growing drug problem, with opioids like oxycodone being abused at increasing rates.
- Education of healthcare providers, patients, and the public is needed to increase awareness of the dangers of prescription drug misuse and how to properly use and dispose of medications.
- Tracking programs like prescription drug monitoring programs (PDMPs) in states can help identify "doctor shoppers" and reduce diversion, though more research is still needed on their effectiveness.
- A multifaceted approach including education, monitoring, safe disposal, and enforcement is needed to address the crisis of prescription drug
This document summarizes a presentation on insights from state policies and interventions to curb prescription drug overdoses. It describes several interventions:
1) PRIMUM, a system in North Carolina that alerts prescribers to patients' risk of misusing or abusing opioids at the point of care.
2) A project in Rhode Island that developed protocols to improve opioid prescription safety for trauma patients, including alerts if prescriptions exceed dosage thresholds and requiring naloxone co-prescriptions.
3) A study in Pennsylvania that used Medicaid claims data to identify risk factors for opioid overdoses, such as high dosage and multiple prescribers/pharmacies, to target high-risk patients.
This document summarizes trends in methamphetamine-related admissions to youth residential substance abuse treatment facilities in Canada between 2005-2006 and 2009-2010. It finds that the proportion of admissions primarily due to methamphetamine abuse dropped significantly from 21% in 2005-2006 to 6% in 2009-2010 based on a survey of executive directors of treatment facilities. This reduction was largely driven by declines in the provinces previously most impacted by methamphetamine abuse. The findings suggest that controls on methamphetamine precursor chemicals in Mexico during this period may have contributed to decreased admissions in Canada as well.
This document summarizes national trends in prescription drug expenditures in the United States for 2015 and provides projections for 2016. Key findings include:
- Total US prescription drug sales in 2015 were $419.4 billion, an 11.7% increase over 2014. Spending in clinics and non-federal hospitals increased 15.9% and 10.7%, respectively.
- Growth in overall spending was driven primarily by price increases for existing drugs (8.4%), with new drugs (2.7%) and changes in drug usage (0.5%) also contributing. Hospital spending growth was mainly from price increases, while clinic growth was mostly from increased drug usage.
- Projections estimate an 11-13%
This document discusses regulatory inefficiencies surrounding companion diagnostics and laboratory developed tests (LDTs) in the United States. It uses the case study of Genentech's drug MPDL3280A and its companion diagnostic to show that the FDA thoroughly regulates companion diagnostics but provides no oversight of clinical validity for LDTs. This allows multiple competing diagnostic tests to be used without proof of efficacy. The document also compares healthcare systems and technology assessment processes in the US, UK, and France to illustrate decentralized decision making in the US compared to centralized bodies in other countries.
This document provides an overview of a presentation on preventing opioid overdose deaths. The presentation features four speakers and focuses on explaining the opioid overdose crisis epidemiology, describing treatment options to reduce overdose deaths, and advocating for advancing research and clinical practice. The learning objectives are listed as explaining the overdose epidemic, describing treatment options for clinicians, and advocating for research and practice directions. Brief biographies and disclosures are provided for each speaker.
This document provides an overview of state prescription drug monitoring programs (PMPs) and summarizes their status and operations. It finds that 44 states currently operate PMPs that collect prescription data, with most programs housed in health departments or related agencies. States fund PMPs through various means like grants, state appropriations, and licensing/registration fees. Fourteen states receive funding from licensing and registration fees specifically. The overview examines PMP laws and operations to assist policymakers in addressing prescription drug abuse, addiction, and diversion.
April 3, 2017
The current opiate epidemic has spurred long-overdue scrutiny on the pharmaceutical production and distribution of opiate medication, but it also raises questions of public policy and law regarding the regulation of medical access to and use of opiate medications with high potential for addiction. Expert panelists will address the challenges that arise from efforts to balance restrictions on access to opiates to limit addiction while also preserving sufficient access for legitimate medical management of pain.
Learn more on our website: http://petrieflom.law.harvard.edu/events/details/opiate-regulation-policies
Prescription Medicines Costs in Context January 2020PhRMA
This document discusses the costs and context of prescription medicines. It notes that while prescription drug spending represents 14% of total healthcare spending and a small portion of Medicaid spending, it has enabled breakthrough treatments for chronic diseases. While brand drug prices grew by 0.3% in 2018 after rebates, spending on other healthcare services is projected to grow 5 times faster than prescription drug spending through the next decade. The document also outlines how generics have reduced costs significantly, providing $1.99 trillion in savings over 10 years, and how biosimilars are expected to reduce brand drug sales by $95 billion from 2019-2023 through increased competition.
This report examines CMS's oversight of Medicare Part D beneficiaries who receive opioid prescriptions and providers who prescribe opioids to these beneficiaries. It finds that while CMS provides guidance to Part D plan sponsors on monitoring beneficiaries at high risk of opioid overuse, it lacks complete data on the full population of beneficiaries at risk. It also finds that CMS oversees prescribing through its contractor NBI MEDIC but does not specifically analyze opioid prescription data or require reporting on actions taken regarding inappropriate opioid prescribing. The report concludes that CMS needs more comprehensive oversight to reduce the risks of opioid misuse, overdose, and inappropriate prescribing among Medicare beneficiaries.
Listeners participated in a live panel session addressing OHIP+, the recently announced expansion of the Ontario drug program to cover young people who are younger than 25 years-old.
Problems and challenges faced in consumer reporting of adverse drug reactions...Mohammed Alshakka
This document discusses consumer reporting of adverse drug reactions (ADRs) in developing countries like Yemen, Nepal, and Malaysia. It finds that Malaysia has a good system for consumer involvement, while Yemen lacks drug policies and regulation. Nepal's system is still developing and lacks consumer reporting. Consumer reporting can provide additional information to national pharmacovigilance programs and help reduce ADR-related illness, but is still not widely implemented in developing countries.
CAPCA wants to make sure that patients have access to innovative and effective cancer treatments, and Heather Logan, ED of CAPCA, will explain how CAPCA is going to do this and answer your questions about the process. This webinar will introduce you to CAPCA and its mandate and to the new pan-Canadian Cancer Drug Funding Sustainability Initiative (DFSI). The goal of DFSI is to ensure that patients continue to have access to innovative and effective cancer treatments, and that the cancer system is achieving maximum value for money invested.
This document discusses the opioid epidemic in America and proposes actions to address it. It summarizes that:
1) Nearly 200,000 Americans have died from prescription opioid overdoses since 1999, and up to 40% of long-term opioid therapy patients may be addicted.
2) Keeping chronic opioid therapy doses low can help reduce overdose risk. Many overdose deaths occur at doses of 50 mg or more per day, while most patients receive lower doses.
3) Immediate actions are needed to curb new inappropriate long-term opioid prescriptions, including more selective initial prescribing, checking prescription monitoring programs, and limiting initial supplies. Policies and regulations also need to be updated to reflect risks of addiction
Medical care responding_to_us_opioid_epidemic_von_korff_franklin_4-22-2016 (3)Paul Coelho, MD
This document discusses the opioid epidemic in America and proposes actions to address it. The key points are:
1) America is experiencing an unprecedented epidemic of prescription opioid addiction and overdose, with almost 200,000 deaths since 1999 mostly affecting patients prescribed opioids.
2) Proposed actions to address the epidemic include avoiding unnecessary opioid prescriptions, changing policies to reflect risks of addiction/overdose, and enhancing surveillance of opioid prescribing and patient safety.
3) Additional actions proposed are increasing clinical monitoring of patients on long-term opioid therapy, consistently offering to taper doses or discontinue opioids as an option, and ensuring treatment for addicted patients.
White Paper: Best Practices for Medical Benefit Management (MBM)Tai Freligh
Biologic, biotechnology-based, rare disease, or high-cost pharmaceuticals — collectively known as specialty drugs — can be covered under the pharmacy benefit, the medical benefit, or both depending on the benefit design plan sponsors require of the third-party administrator (including the pharmacy benefit manager – PBM; administrative service organization – ASO; or any administrator of a medical or pharmacy benefit).
On average, up to 50% of specialty drugs today are covered under the medical benefit.
With the exception of a few key therapy areas, traditional tools used to manage specialty drugs under the medical benefit, such as prior authorizations and medical benefit carve-outs (i.e., “white-bagging”), have yielded limited value to plan sponsors.
This thought leadership analysis, with insights from recognized industry experts, will provide an overview of the challenges.
Download the complete white paper to get the rest of the report, including a summary of the key issues plan sponsors must address and insights into best practices through an innovative new approach, Medical Benefit Drug Management (MBM).
Link: http://www.PharMedQuest.com/White-Paper
Pharmaceutical marketing aims to educate consumers and healthcare professionals about new treatments. While some question the value of marketing, it plays an important role in disseminating medical information. Recent changes include voluntary principles for direct-to-consumer ads and a strengthened industry code of ethics. Studies show marketing helps address underdiagnosis and undertreatment by raising disease awareness and prompting patients to see doctors. However, most physicians say clinical knowledge and patient needs strongly influence prescribing over marketing.
Pharmaceutical marketing to healthcare providers provides information on new treatment options, but it is only one of many factors that influence prescribing decisions. Surveys find clinical knowledge, patient factors, and insurance policies have greater impacts. Approximately 67% of US prescriptions are for generic drugs, much higher than other countries. While representatives provide information, prescribing is shaped more by clinical guidelines, peers, formularies, and insurers' prior authorization requirements than representative interactions.
This study analyzed Medicare patient data to compare outcomes for those treated by emergency physicians classified as either high-intensity or low-intensity opioid prescribers within individual hospitals. High-intensity prescribers were in the top quartile of opioid prescribing rates, while low-intensity prescribers were in the bottom quartile. The study found that rates of long-term opioid use, defined as 180 days or more of opioid supply within 12 months, were significantly higher for patients treated by high-intensity prescribers compared to low-intensity prescribers, even after accounting for patient characteristics. This suggests that physician prescribing behavior can influence long-term opioid use outcomes for patients.
The Centers for Medicare & Medicaid Services outlines their opioid misuse strategy to address the national opioid epidemic. Their strategy includes 4 priority areas: 1) implementing more effective strategies to reduce risks of opioid use disorder, overdoses, and inappropriate prescribing; 2) expanding access to naloxone to reverse overdoses; 3) expanding screening, diagnosis, and treatment of opioid use disorder including medication-assisted treatment; and 4) increasing use of evidence-based practices for pain management. Opioid misuse has led to alarming increases in overdoses and deaths, and CMS aims to combat this through promoting safe opioid use, improving access to treatment, and alternative pain management options.
This document discusses policies and structures that can help promote rational use of medicines globally. It recommends several core interventions, including:
1) Establishing a mandated national body to coordinate medicine use policies involving various stakeholders.
2) Developing evidence-based clinical guidelines to provide treatment benchmarks and promote rational prescribing.
3) Creating essential medicines lists based on treatments of choice to focus procurement, prescribing, and public sector activities.
4) Forming drugs and therapeutics committees in districts and hospitals to promote safe and effective medicine use locally.
Together, such coordinated policies and oversight structures can help address the widespread problem of irrational global medicine use and its health and economic impacts.
This article summarizes a large healthcare system's comprehensive approach to reducing inappropriate opioid prescribing. The healthcare system implemented policies restricting opioid prescriptions, monitoring processes for patients on long-term opioids, and integrated these changes into their electronic health records. An evaluation found reductions in high dose opioid prescriptions, large opioid prescriptions, combination opioid prescriptions, and brand name opioid prescriptions after implementing these interventions between 2010-2015. The article concludes the interventions were effective in positively affecting opioid prescribing practices in this healthcare system.
ER visits for opioid overdoses is rising in the U.S. Accurate ER reports from medical transcription services and proactive action can help minimize risks.
This document summarizes the evolution and current state of emergency medicine clinical pharmacists internationally. It describes how their role has expanded from medication distribution to active clinical roles on multidisciplinary teams. Studies show emergency medicine pharmacists can reduce medication errors, mortality, readmissions, and improve time to appropriate treatments. While initially confined to North America, their benefits are now reported internationally. More evidence is still needed on reducing adverse drug events, but existing data shows emergency medicine pharmacists improve patient outcomes and reduce costs.
BRP Pharmaceuticals is a leader in physician dispensing services that provides instant medication to patients located in Burbank, CA. Visit: http://www.brppharma.com/
Wide variation and excessive dosage of opioid prescriptions for common genera...Paul Coelho, MD
This study examined opioid prescribing patterns for common outpatient general surgery procedures. They found wide variation in the number of opioids prescribed, from 0 to over 100 pills for the same procedures. On average, only 28% of prescribed opioids were actually taken by patients. Less than 2% of patients requested refills. The study identified an "ideal" number of pills to prescribe for each procedure that would satisfy 80% of patients' needs and significantly reduce excess prescribing - for example, prescribing 5 pills for partial mastectomies instead of the typical 20 pills. Prescribing the ideal amounts could decrease total opioids prescribed by 43%.
Research MethodsLaShanda McMahonUniversity o.docxverad6
Research Methods
LaShanda McMahon
University of Phoenix
Formulating the Problem Statement and the Purpose Statement
Over the past decade, there have been several changes in drug addiction treatment that has shown results that show reduced associated health and social costs by more than the cost of the treatments. It has been found that treatments cost much less that the alternatives, such as incarcerating people with addictions. There are many savings related to healthcare, which includes, total savings that can exceed costs with a ratio of 12 to 1. Major savings to the individual and to society also stems from fewer interpersonal conflicts; greater workplace productivity; and fewer drug-related accidents, including overdoses and deaths (Woody, M.D., 2018).
Problem Statement
A common misperception is detoxification cures the addiction, yet addiction is a chronic disorder requiring long term multimodal treatment (Korsmeyer et al., 2009. Long-term treatment for substance abuse and co-occurring disorders might reduce recidivism rates and lessen costs for rehabilitation. Goldstein, A. (1997). examined the benefits of long-term substance abuse and posited the benefits. Goldstein further suggested not treating addiction appropriately or at all contributes to the high costs associated with substance use in the United States.
Insurance companies are reluctant to support long term substance abuse treatment; however, Weisner, Ray, Mertens, Satre and Moore (2003) noted patients receiving a minimum of six months substance treatment abstained from drug and alcohol use at least five years after treatment yet abusers of alcohol were less likely to remain sober for lengthy periods of time after treatment (Weisner et al., 2003).
According to the National Drug Institute (2012), every dollar invested in substance abuse treatment yields a return of $5.50 in reduced drug-related crime, costs associated with criminal justice, and theft. Healthcare savings can exceed costs by a 12 to 1 ratio. Therefore, drug addiction treatment reduces costs associated with primary care and is less costly than incarceration. Addressing addiction also contributes to the more positive aspects of life, such as increase in work productivity, and fewer incidents related to drug use, fewer overdoses and deaths.
Purpose Statement
The purpose of this correlational study is to see if a relationship exists among periods of sobriety and four levels of substance abuse treatment. The research will examine substance abuse treatment throughout various levels of care: higher levels (detox, Inpatient (IP), and Residential (RTC) and lower levels (partial hospitalization (PHP), Intensive Outpatient (IOP), and routine Outpatient (OP). Current trends in substance abuse treatment provides evidence that length of treatment is inadequate contributing to more frequent relapses among substance abusers. Longer treatment options for addiction may reduce the number of relapses, reduce costs asso.
The economic burden of prescription opioid overdose... 2013.Paul Coelho, MD
The document summarizes a study that estimates the total economic burden of prescription opioid overdose, abuse, and dependence in the United States in 2013 was $78.5 billion. Over one third of this cost ($28.9 billion) was due to increased healthcare and substance abuse treatment costs. Approximately one quarter of the total cost was borne by the public sector through healthcare, substance abuse treatment, and criminal justice costs. The study utilized national data on opioid overdose deaths and abuse/dependence prevalence to estimate costs across multiple sectors including healthcare, substance abuse treatment, criminal justice, and lost productivity.
Duplication prescribing and misuse of medicine can harm patients and lead to death. Duplication prescribing occurs when multiple medications are prescribed for the same condition without coordination. Misuse involves using medication other than as intended, such as through addiction. Strategies to reduce these risks include implementing electronic health records and clinical decision support to avoid therapeutic duplication, educating patients, and enhancing prescription drug monitoring programs and enforcement of drug disposal laws.
1. Co-prescribing opioids and benzodiazepines poses serious health risks like respiratory depression and increased risk of overdose death. Delaware has high rates of prescriptions for these drugs.
2. Delaware's PDMP collects prescription data that can help identify patients and providers with troubling patterns of co-prescribing to reduce risks. Regular screening and urine tests can also help address misuse.
3. PDMP data analysis found that in 2013 over 12% of individuals in Delaware filled prescriptions for both drug classes, putting them at risk. The PDMP is a valuable tool to improve prescribing practices and detect misuse.
A study on prescription pattern and rational use of statins in tertiary care ...SriramNagarajan16
Objectives
Our objectives are to evaluate prescription pattern and rational use of statins in a tertiary care corporate hospital.
Methodology
It was a prospective observational study conducted for a period of 6 months and included various departments of 300
bedded multi specialty tertiary care corporate hospital. A total of 200 patients were included and the study criteria
was inpatients and induvial more than 18 years of either gender who are prescribed with HMG-CoA reductase
inhibitors.
Results
In the present study 200 patients belonged to the age group of above 18 years, out of which about 65% were male
and 35% were female. Atorvastatin (67%) was prescribed mostly and Rosuvastatin (29.5%) was also used.
Conclusion
It is finally concluded that Rational and prophylactic use of statins can reduce further complications of Diabetes
Mellitus (DM) and cardiac events.
Statins treatment is favourable in long term treatment of diseases, it is most effectively used in treatment of serious
disease conditions which has shown its immense therapeutic role in treatment
Similar to New study supports notion of skewed opioid prescribing (20)
The world stands to lose close to 10% of total economic value by mid-century if climate change stays on the currently-anticipated trajectory, and the Paris Agreement and 2050 net-zero emissions targets are not met.
Many emerging markets have most to gain if the world is able to rein in temperature gains. For example, action today to get back to the Paris temperature rise scenario would mean economies in southeast Asia could prevent around a quarter of the gross domestic product (GDP) loss by mid-century that they may otherwise suffer. Our analysis in this report is unique in explicitly simulating for the many uncertainties around the impacts of climate change. It shows that those economies most vulnerable to the potential physical risks of climate change stand to benefit most from keeping temperature rises in check. This includes some of the world's most dynamic emerging economies, the engines of global growth in the years to come. The message from the analysis is clear: no action on climate change is not an option.
Promise and peril: How artificial intelligence is transforming health careΔρ. Γιώργος K. Κασάπης
AI has enormous potential to improve the quality of health care, enable early diagnosis of diseases, and reduce costs. But if implemented incautiously, AI can exacerbate health disparities, endanger patient privacy, and perpetuate bias. STAT, with support from the Commonwealth Fund, explored these possibilities and pitfalls during the past year and a half, illuminating best practices while identifying concerns and regulatory gaps. This report includes many of the articles we published and summarizes our findings, as well as recommendations we heard from caregivers, health care executives, academic experts, patient advocates, and others.
In 2020, Amnesty International recorded the lowest number of executions in over a decade at 483. This was a 26% decrease from 2019. Four countries - Iran, Egypt, Iraq and Saudi Arabia - accounted for 88% of all recorded executions. The global number of known death sentences also decreased by 36% compared to 2019, partly due to disruptions from the Covid-19 pandemic. However, some countries like Egypt more than tripled their executions and the US resumed federal executions after a 17-year hiatus, putting 10 men to death over 5 months. Overall, the report found that the trend towards global abolition of the death penalty continued in 2020, but the pandemic exacerbated the cruelty of capital punishment in some retaining
Aviva’s first How We Live report was published in September 2020 when the world was firmly in the grip of a global pandemic. In the UK the vaccination programme is well underway and the mood of the nation is hopeful. This latest How We Live report looks at the long-term effects of the Coronavirus outbreak and considers its impact on our future behaviours.
We interviewed 4,000 adults across the UK to gather their views on a wide range of lifestyle decisions including property priorities, home-working, green living, career paths, vehicle choices and holiday plans. We also asked whether people had experienced any positive outcomes from the Covid pandemic. This report considers the practical and emotional skills which have been fostered as a result. Since the beginning of 2020, the UK has seen immense change. As we look forward to a sense of “normality” it remains to be seen which aspects of life will return to their previous states, and where we can expect changes to become permanent fixtures.
The life insurance industry provides protection against the financial consequences of the premature death of a family breadwinner, disability, or outliving one’s retirement assets. But how are life insurance products actually designed and priced?
Product committees comprising agents, underwriters, actuaries, and senior management sit and discuss what new products should be offered. The agents have vast experience visiting with policyholders to determine their needs. Underwriters set the guidelines on which policyholders will be accepted and/or rated. Smart actuaries (while most would find this redundant, some would call it an oxymoron) assess the potential risks in these products and set a potential price. Senior management listens to agents, underwriters, and actuaries and helps finalize the product design, the guidelines for accepting risks, and the price. The programmers will also have to be contacted to determine the cost of administering the products. Many iterations of these discussions may take place before a product is ready for sale. The entire process could take up to a year.
Some of these products are quite complex, taking into account long-term interest rates and probabilities of death/survival, disability, and lapse. With this lengthy and rigorous process, one would imagine that few mistakes are made. However, this is not the case. What follows are a few examples of major product mistakes which cost the life insurance industry a lot of time, money, and bad publicity.
The COVID-19 pandemic and subsequent lockdowns forced many insurers to accelerate the transition to digital business models. In many countries, this transition has been remarkably successful, however, the crisis also highlighted the critical role played by national regulatory frameworks in both hindering and facilitating the shift to digitalisation in the insurance industry. COVID-19 lockdowns highlighted the critical role of national regulatory frameworks in both hindering and facilitating the shift to digitalisation in the insurance industry. Digitalisation is not a goal in itself, but provides insurers and their customers with benefits that are particularly useful in situations where in-person interactions cannot take place, played out in its fullest form during the COVID-19-induced lockdowns. Digitalisation drives an increase in speed and efficiency, irrespective of where the customer is located, and promises improved customer service and satisfaction.
The document discusses the Internet of Things (IoT) and its implications for insurance. It notes that as more "things" become connected to the internet and collect data, this creates opportunities for new types of insurance products based on device interactions and data-driven risk assessments. However, it also raises issues around data integrity, privacy, security and regulation that must be addressed. The insurance industry could gain over $1 trillion in new premiums if it properly manages risks related to data, cybersecurity, cloud computing and more.
The rapid rise of online political campaigning has made most political financing regulations obsolete, putting transparency and accountability at risk. Seven in 10 countries worldwide do not have any specific limits on online spending on election campaigns, with six out of 10 not having any restrictions on online political advertising at all.
Highlights
• On average, concerns over Innovation was ranked highest, followed by Implications of Covid-19 • Respondents indicated innovation is important, but are mostly in process
• Respondents were mostly confident in implementing their innovation plans.
• Nearly half of respondents indicated their focus was on the customer experience • Most respondents expect some negative impact from Covid-19, with decreased profit indicated most, followed by decreased sales effectiveness, which are likely related
• The most common change in response to the Covid-19 impact were workplace and staffing changes, followed by technology investments
• Of the respondents, 92% indicated cyber security was important or very important.
• Continuous effort was ranked highest, and Mitigating internal threats, Identifying external threats, and Prioritizing identifying cyber risks were ranked next.
• While 95% of respondents indicated emerging threats were important or very important, 28% Indicated they were very good at responding to them
• For resiliency and sustainability, corporate ESG and R&S for internal operations were ranked as the highest priorities
iis the institutes innovation covid-19
What North America’s top finance executives are thinking - and doingΔρ. Γιώργος K. Κασάπης
Each quarter (since 2Q10), CFO Signals has tracked the thinking and actions of CFOs representing many of North America’s largest and most influential companies. All respondents are CFOs from the US, Canada, and Mexico, and the vast majority are from companies with more than $1 billion in annual revenue. The 1Q 2021 survey was open from February 8-19, 2021. A total of 128 CFOs participated, 69% from public companies and 31% from privately held companies.
Democratic watchdog organization Freedom House has released its annual ranking of the world's most free and most suppressed nations.
The report is a key barometer for global democracy and this year's edition found that global freedom has declined for the 15th straight year. 2020 was a turbulent year with the pandemic, violent conflict and economic and physical insecurity leading to democracy's defenders sustaining heavy losses against authoritarian foes which has resulted in a shift in the internatioal baance in favor of tyranny.
A total of 195 countries and 15 territories were analyzed on their levels of access to political rights and civil liberties with the number experiencing a deterioration in their freedom scores exceeding the number that saw improvement by the widest margin since 2006. In 2020, nearly 75 percent of the world's population lived under a government that saw its democracy score decline in the past year.
Women, Business and the Law 2021 is the seventh in a series of annual studies measuring the laws and regulations that affect women’s economic opportunity in 190 economies. Amidst a global pandemic that threatens progress toward gender equality, the report identifies barriers to women’s economic participation and encourages reform of discriminatory laws. This year, the study also includes important findings on government responses to the COVID-19 crisis and pilot research related to childcare and women’s access to justice.
Strong competition undoubtedly contributes to a country’s productivity and economic growth. The primary objective of a competition policy is to enhance consumer welfare by promoting competition and controlling practices that could restrict it. More competitive markets stimulate innovation and generally lead to lower prices for consumers, increased product variety and quality, more entry and enhanced investment. Overall, greater competition is expected to deliver higher levels of welfare and economic growth.
Long-erm Care and Health Care Insurance in OECD and Other CountriesΔρ. Γιώργος K. Κασάπης
This report carries out a stocktaking of what systems have in OECD and non-OECD countries for longterm care and health care, as well as the types of insurance products that are made available in these countries. It is part of a broader project that examines the complementarity of the social security network with the private insurance market, which examines how insurance could support the public sector longterm care and health care systems, as well as considering the financing of long-term care and health care.
This tenth edition of Global Insurance Market Trends provides an overview of market trends to better understand the overall performance and health of the insurance market. This monitoring report is compiled using data from the OECD Global Insurance Statistics (GIS) exercise. The OECD has collected and analysed data on insurance in OECD countries, such as the number of insurance companies and employees, insurance premiums and investments by insurance companies, dating back to the 1980s. Over time, the framework of this exercise has expanded and now includes key items of the balance sheet and income statement of direct insurers and reinsurers.
Does AI threaten and undermine human value in the workplace more than any other technology? There have been significant advances in AI, but will their impact really be different this time?
This literature review takes stock of what is known about the impact of artificial intelligence on the labour market, including the impact on employment and wages, how AI will transform jobs and skill needs, and the impact on the work environment. The purpose is to identify gaps in the evidence base and inform future research on AI and the labour market.
The OECD has estimated that 14% of jobs are at high risk of automation.
•Despite this, employment grew in nearly all OECD countries over the period 2012-2019.
•At the country level, a higher risk of automation was associated with higher employment growth over the period. This might be because automation promotes employment growth by increasing productivity, although other factors are also at play.
•At the occupational level, however, employment growth was much lower in occupations at high risk of automation (6%) than in occupations at low risk (18%).
•Low-educated workers were more concentrated in high-risk occupations in 2012 and have become even more concentrated in these occupations since then.
•The low growth in jobs in high risk occupations has not led to a drop in the employment rate of low-educated workers. This is largely because the number of workers with a low education has fallen in line with the demand for these workers.
•Going forward, however, the risk of automation is increasingly falling on low-educated workers and the COVID-19 crisis is likely to accelerate automation, as companies reduce reliance on human labour and contact between workers, or re-shore some production.
Prescription drug prices in U.S. more than 2.5 times higher than in other cou...Δρ. Γιώργος K. Κασάπης
Prescription drugs cost an average of 2.56 times more in the United States than they do in 32 other countries, according to a new report from RAND Corporation.
That disparity is even greater for brand name drugs, with U.S. prices averaging 3.44 times those in comparison nations. The study also found that prices for unbranded generic drugs — which account for 84% of drugs sold in the United States by volume but only 12% of U.S. spending — are slightly lower in the United States than in most other countries.
‘A circular nightmare’: Short-staffed nursing homes spark Covid-19 outbreaks,...Δρ. Γιώργος K. Κασάπης
Nursing homes have suffered grievously in the coronavirus pandemic. Chronically understaffed, that’s getting worse, a new US Pirg Education Fund analysis says. The shortage of direct-care workers rose from 20% of U.S. nursing homes in May to 23% in December. Too few workers raises stress among staff, the authors argue, making them and the residents they care for more vulnerable to Covid-19 infections, reducing staff further in “a circular nightmare.”
This document analyzes the impacts of utility disconnection and eviction moratoria policies on COVID-19 infections and deaths across US counties. It finds that policies limiting evictions reduced COVID-19 infections by 3.8% and deaths by 11%, while moratoria on utility disconnections reduced infections by 4.4% and deaths by 7.4%. Had these policies been adopted nationwide, infections could have been reduced up to 14.2% and deaths up to 40.7% with eviction moratoria, and infections reduced up to 8.7% and deaths up to 14.8% with utility disconnection moratoria. The document provides background on housing precarity and heterogeneity in government COVID-
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
New study supports notion of skewed opioid prescribing
1. the bmj | BMJ 2020;368:l6968 | doi: 10.1136/bmj.l6968 1
RESEARCH
Opioid prescribing patterns among medical providers in the
United States, 2003-17: retrospective, observational study
Mathew V Kiang,1,2
Keith Humphreys,2,3
Mark R Cullen,1
Sanjay Basu4,5,6
Abstract
OBJECTIVE
To examine the distribution and patterns of opioid
prescribing in the United States.
DESIGN
Retrospective, observational study.
SETTING
National private insurer covering all 50 US states and
Washington DC.
PARTICIPANTS
An annual average of 669 495 providers prescribing
8.9 million opioid prescriptions to 3.9 million patients
from 2003 through 2017.
MAIN OUTCOME MEASURES
Standardized doses of opioids in morphine
milligram equivalents (MMEs) and number of opioid
prescriptions.
RESULTS
In 2017, the top 1% of providers accounted for 49% of
all opioid doses and 27% of all opioid prescriptions.
In absolute terms, the top 1% of providers prescribed
an average of 748 000 MMEs—nearly 1000 times more
than the middle 1%. At least half of all providers in the
top 1% in one year were also in the top 1% in adjacent
years. More than two fifths of all prescriptions written
by the top 1% of providers were for more than 50
MMEs a day and over four fifths were for longer
than seven days. In contrast, prescriptions written
by the bottom 99% of providers were below these
thresholds, with 86% of prescriptions for less than
50 MMEs a day and 71% for fewer than seven days.
Providers prescribing high amounts of opioids and
patients receiving high amounts of opioids persisted
over time, with over half of both appearing in adjacent
years.
CONCLUSIONS
Most prescriptions written by the majority of providers
are under the recommended thresholds, suggesting
that most US providers are careful in their prescribing.
Interventions focusing on this group of providers are
unlikely to effect beneficial change and could induce
unnecessary burden. A large proportion of providers
have established relationships with their patients over
multiple years. Interventions to reduce inappropriate
opioid prescribing should be focused on improving
patient care, management of patients with complex
pain, and reducing comorbidities rather than seeking
to enforce a threshold for prescribing.
Introduction
From 1999 to 2010, opioid prescribing in the US
quadrupled,1
reaching a per capita level well beyond
that of any other nation.2
The effectiveness of long
term opioid treatment for management of chronic pain
is unclear,3 4
but opioids remain an essential tool for
medical providers. Inappropriate opioid prescribing
can lead to diversion of, addiction to, and overdose
from prescription opioids,5-9
contributing to an epi
demic of opioid related deaths in recent years.10
Promoting cautious, scientifically justified, opioid
prescribing has become a leading goal of policy makers
in both government and healthcare.11-14
Strategies to reduce inappropriate opioid prescribing
range from broad policies or guidelines targeted at all
medical providers to narrow interventions focused
on providers prescribing high amounts of opioids.
Broad strategies include improving medical school
education curriculums and compulsory education
of providers,15
mandating the use of state level
prescription drug monitoring programs, creating
national clinical guidelines,16
and lowering the
default opioid dose in electronic health records.17-20
Targeted interventions typically focus on providers
who prescribe opioids above a specified threshold. A
common targeted intervention is the creation of “pill
mill” laws, which typically require documentation of
medical examinations and follow-up visits before and
after the prescribing of opioids, mandatory registration
of clinics with the state, or physician ownership of pain
clinics.21-25
Targeted interventions do not require new laws. For
example, one national pharmacy chain identified 42
providers, out of nearly one million, who prescribed
excessive levels of opioids (eg, 98th centile for volume,
95th centile for proportion, and had a high number of
patients who paid cash) and requested documentation
justifying their level of prescribing. Of the 42 providers
contacted, only six responded with medically justified
reasons. The remaining 36 who did not respond or did
1
Center for Population Health
Sciences, Stanford University
School of Medicine, 1701 Page
Mill Road, Palo Alto, CA 94304,
USA
2
Department of Psychiatry and
Behavioral Sciences, Stanford
University School of Medicine,
Palo Alto, CA, USA
3
Palo Alto VA Health Care
System, Palo Alto, CA, USA
4
Center for Primary Care,
Harvard Medical School,
Boston, MA, USA
5
Research and Analytics,
Collective Health, San Francisco,
CA, USA
6
School of Public Health,
Imperial College, London, UK
Correspondence to: M V Kiang
mkiang@stanford.edu
(or @mathewkiang on Twitter:
ORCID 0000-0001-9198-150X)
Additional material is published
online only. To view please visit
the journal online.
Cite this as: BMJ2020;368:l6968
http://dx.doi.org/10.1136/bmj.l6968
Accepted: 3 December 2019
WHAT IS ALREADY KNOWN ON THIS TOPIC
Opioid prescribing remains far higher in the US than in other countries, despite
efforts to reduce inappropriate opioid prescribing
Previous studies have noted that opioid prescribing in the US is skewed;
however, the extent of this skewness in a geographically diverse and
demographically representative population has not been well established
WHAT THIS STUDY ADDS
This study found that about 1% of providers account for nearly half of all opioid
doses and one quarter of all opioid prescriptions
The results suggest that rather than impose rigid thresholds on most providers,
who generally prescribe opioids safely, interventions should focus on the top 1%
of providers and their patients
The results also suggest that interventions should focus on improving patient
care, managing patients with complex pain, and reducing comorbidities
on4February2020byguest.Protectedbycopyright.http://www.bmj.com/BMJ:firstpublishedas10.1136/bmj.l6968on29January2020.Downloadedfrom
2. RESEARCH
2 doi: 10.1136/bmj.l6968 | BMJ 2020;368:l6968 | the bmj
not provide justification were no longer allowed to have
their prescriptions filled at this national pharmacy
chain.26
Alternatively, “light touch” interventions have
been proposed, such as sending letters to providers
whose prescribing patterns are higher than those
of their peers27
or notifying those providers whose
patients have had a fatal overdose.28
Both broad strategies and targeted interventions
are important for reducing inappropriate prescribing.
However, effective opioid prescribing is nuanced,
pain management is often complex, and there can be
legitimate clinical reasons for a provider prescribing
opioids in excess of recommended thresholds.
Strategies to reduce prescribing can result in un
intended consequences, such as misapplication,
which could result in poor care or sudden involuntary
discontinuation of opioids.29
Further, institutions and
agencies responsible for enforcing or implementing
these strategies may have limited resources and require
additional information to prioritize strategies.
For these reasons, data driven policy demands a
careful examination of opioid prescribing patterns over
a broader range of time, geography, and population.
Previous studies directly examining the distribution
of opioid prescriptions among providers have
been limited to geographically or demographically
narrow samples of providers or patients, over shorter
periods.30 31
This study seeks to fill these gaps, provide
clarity to policy makers, and assist institutions
with efforts to prioritize reduction. We examined a
repository of prescription claims from a large, national
insurance provider covering more than 60 million
unique individuals from 2003 to 2017. The insured
population includes all 50 US states and Washington
DC and is of similar age and sex to the US general
population. Using these data, we identified whether
opioids are roughly equally prescribed across US
medical providers or disproportionately prescribed by
a small subset of providers, how prescribing patterns
have changed over time, the extent to which top
prescribers and top receiving patients persisted over
time, and the relationship between high prescribing
and top receiving patients.
Methods
Data
From a total of 2.5 billion outpatient prescription
claims, we identified 134 million opioid prescriptions
in the Optum Clinformatics Data Mart Database
(Optum; 2003-17), a large deidentified database from a
national private insurance provider. Prescriptions that
were filled but not dispensed (that is, not received by
the patient) were excluded from the analysis to prevent
double counting, which might happen, for example, if
a prescription was transferred to, and dispensed by, a
different pharmacy. Prescription level data included
hashed patient identifiers, hashed provider identifiers
(thatis,DrugEnforcementAgencyandNationalProvider
Identifier), National Drug Code, quantity, number of
days of supply, and date of transaction. In addition, we
used the member, provider, and outpatient diagnostic
files from 2003 to 2017. An Optum affiliate company
assigns providers into one of 7106 categories, which
are grouped into 308 specialties. We merged provider
specialtiesinto16larger,mutuallyexclusivecategories:
addiction medicine, anesthesiology, surgery, critical
care, dentistry, emergency medicine, family medicine,
general medicine, hospice care, internal medicine,
obstetrics/gynecology, pediatrics, physical or pain
medicine and rehabilitation, pharmacy, unknown, and
all others. For female enrollees the median age was 34
years (50.5%, interquartile range 19-52 years) and for
male enrollees 33 years (49.5%, 18-49 years). The age
and sex distribution of enrollees in the Optum database
closely resembles that of the general US population
(supplementary table S1).
Defining drugs of interest
We followed US Centers for Disease Control and
Prevention (CDC) recommendations when selecting
the most appropriate opioids for our analysis.32
Specifically, we excluded buprenorphine products
prescribed as treatment for opioid use disorder, drugs
typically not used in outpatient settings (eg, fentanyl in
solution), cough and cold formulations, and injectable
or intravenous opioids.
As with any system, some unequal distribution
is expected,33
due, for example, to differences in
provider preferences,34
provider location,35
provider
specialties,36 37
or provider perceptions.38
Thus to
facilitate comparison, we tabulated eight benzo
diazepines used to treat anxiety, panic disorder,
seizures, alcohol withdrawal symptoms, and muscle
spasms: alprazolam, chlordiazepoxide, clonazepam,
diazepam, lorazepam, oxazepam, temazepam, and
triazolam. Similar to opioids, benzodiazepines have
highly variable prescribing patterns and a wide range
of doses and therapeutic uses, including episodic use.
A full list of National Drug Codes for each drug can be
found in the online code repository (see supplementary
materials section 1).
Quantities of interest
We estimated two primary quantities of interest for
each drug and year, for each provider: dose and
number of prescriptions. In addition, we estimated
three secondary quantities of interest: daily dose,
dose for each patient, and dose for each prescription.
Opioid doses were standardized to morphine milligram
equivalents (MMEs) using National Drug Code specific
conversion factors.32
Benzodiazepine doses were
standardized to lorazepam milligram equivalents.39-43
Dose was calculated as the quantity×drug stre
ngth×conversion factor. For each provider, we took the
total number of opioid or benzodiazepine prescriptions
across all patients. The daily dose was calculated as
the dose divided by the number of days supply for each
prescription. The dose for each patient was calculated
as the total dose divided by the number of unique
patients who received an opioid or benzodiazepine
prescription from each provider separately (that is, a
patient receiving multiple opioid prescriptions from
on4February2020byguest.Protectedbycopyright.http://www.bmj.com/BMJ:firstpublishedas10.1136/bmj.l6968on29January2020.Downloadedfrom
3. RESEARCH
the bmj | BMJ 2020;368:l6968 | doi: 10.1136/bmj.l6968 3
multiple providers counts as one unique patient
for each provider). The dose for each prescription
was calculated as the total dose divided by the total
number of opioid or benzodiazepine prescriptions for
each provider.
Estimating disproportionate levels of quantities of
interest
To describe the distribution of the above quantities
of interest, we partitioned providers, patients, and
provider-patient pairs with at least one opioid pre
scription into 100 equally sized groups. The groups
were separated according to centiles of the volume
of opioids prescribed, received, and transacted,
respectively. We then compared the prescribing
patterns of the top centile group of providers (that
is, top 1% of providers) with the median (50th)
centile group. Additionally, we quantified the entire
distribution of prescribing using the Gini coefficient—a
formal summary measure of global inequality.44 45
Supplementary materials section 2 presents the Gini
coefficient results.
Defining recent primary diagnoses and previous
diagnosis of malignant cancer
For the top centile of patients, we tabulated the recent
primary diagnoses of their visits to the provider. In the
Optum dataset, patient prescriptions and diagnoses
are not directly linked. Therefore, we conservatively
defined a recent primary diagnosis as any primary
diagnosis that occurred in the same year or in the year
before a patient appeared in the top centile of patients
receiving opioids. We collapsed these recent primary
diagnosis ICD-9 and ICD-10 codes (international
classification of diseases, ninth and 10th revisions,
respectively) into general medical categories using
the Clinical Classifications Software to ICD crosswalk
provided by the Agency for Healthcare Research
and Quality.46
We defined a previous diagnosis of
malignant cancer as the presence of an ICD code
for any malignant cancer in the current year or any
previous year in which the patient appeared in the top
centile of patients receiving opioids (supplementary
materials section 3). This definition conservatively
includes cancers in remission.
Sensitivity analyses
We conducted several sensitivity analyses. To test
the robustness of our results to miscoding or extreme
prescribing outliers, we repeated our analyses with
different levels of upper truncation. Specifically,
we removed the upper 0.01%, 0.05%, 1.0%, 2.5%,
5.0%, and 10% of prescribers for each year and drug
type. To test the robustness of our results to a high
prevalence of low activity prescribers, we repeated our
analyses with different levels of prescribing activity.
Specifically, we removed all providers who prescribed
fewer than 3, 6, 12, 24, 50, 100, and 200 prescriptions
a year. To test the robustness of our results to the
subset of opioids used, we repeated our analyses
using only opioids designated as schedule 2 under
the Controlled Substances Act. Schedule 2 controlled
substances are drugs with an accepted medical use
but with a high potential for misuse and that could
lead to psychological or physical dependence. To test
the sensitivity of the Gini coefficient, we estimated
several alternative measures of inequality: Ricci-
Schutz, Atkinson, Theil, and generalized entropy
(supplementary materials section 4).47
Finally, in
addition to standardized benzodiazepine and opioid
doses, we analyzed the prescribing patterns for 18
individual drugs, with a range of therapeutic uses
(supplementary materials section 5). In all instances,
our substantive conclusions remained the same.
Results for additional analyses are available using an
interactive results viewer (supplementary materials
section 6).
Patient and public involvement
No patients were involved in setting the research
question or the outcome measures, nor were they
involved in developing plans for design or imple
mentation of the study. No patients were asked to
advise about interpretation or writing up of results.
Results
Disproportionate prescribing patterns
Between 2003 and 2017, an average of 8.2 billion
MMEs were prescribed by 669 495 providers to 3.9
million patients a year (supplementary table S2 and
figs S1 and S2). These prescribing patterns correspond
to an average of more than 700 MMEs daily for each
provider, more than 120 MMEs daily for each patient,
more than 50 MMEs daily for each prescription, and
8.9 million opioid prescriptions a year. These averages,
however, mask highly skewed distributions.
In 2017, the top centile of providers prescribed
49% of all opioid doses and 27% of benzodiazepine
doses (fig 1). The distribution of prescriptions was
comparably disproportionate, with the top centile of
providers accounting for 27% of opioid prescriptions
and 19% of benzodiazepine prescriptions (fig 1). These
disproportionate prescribing patterns persisted after
accounting for prescription length, number of patients
for each provider, and number of prescriptions for each
provider (supplementary materials section 6).
The disproportionately high prescribing of the top
centile of providers has been stable since 2008 (fig
2) and is consistent across states (supplementary figs
S3 and S4). Between 2003 and 2017, the top centile
of providers prescribed between 42% (2005) and 49%
(2008) of opioid doses and accounted for between
18% (2004) and 27% (2017) of all opioid prescriptions
(fig 2). A lower level of disproportionate prescribing
was observed for benzodiazepines. Specifically, the
top centile of providers prescribed between 23%
(2006) and 29% (2008) of benzodiazepine doses
and accounted for between 17% (2006) and 21%
(2008) of all benzodiazepine prescriptions (fig 2).
The type of opioid or benzodiazepine prescribed
by the top centile of providers was similar to that
prescribed by all providers, with the exception of
on4February2020byguest.Protectedbycopyright.http://www.bmj.com/BMJ:firstpublishedas10.1136/bmj.l6968on29January2020.Downloadedfrom
4. RESEARCH
4 doi: 10.1136/bmj.l6968 | BMJ 2020;368:l6968 | the bmj
acetaminophen (paracetamol)/hydrocodone bitar
trate in 2007, which was slightly more commonly
prescribed than oxycodone hydrochloride by the top
centile (supplementary fig S5). For the top centile of
providers, the most commonly prescribed opioid in
each year was oxycodone hydrochloride, and the most
commonly prescribed benzodiazepine was alprazolam
(supplementary fig S5).
In 2017, the top centile of providers prescribed an
average of 748 000 MMEs—nearly 1000 times more
than the median centile group (supplementary figs
S6 and S7). The average amount prescribed by the top
centile of providers in 2017 was double the average
amount prescribed in 2003 (358 000 MMEs; 460 times
higher than the median centile). This pattern was not
seen for benzodiazepines. Specifically, in 2017 the
top centile of providers prescribed 290 times more
benzodiazepines than the median centile compared
with 176 times more in 2003 (supplementary figs
S6 and S7). The high levels of disparity between the
top and median centile groups of opioid prescribers
remained after accounting for differences in pre
scription length, the number of patients for each
provider, and the number of prescriptions for each
provider (supplementary materials section 6).
The 2016 CDC prescribing guidelines for treating
chronic pain recommend that new opioid prescriptions
for treating acute pain should comprise a dose of less
than 50 MMEs a day and a duration of fewer than seven
days (supplementary materials section 7).16
The top
centile of providers remained consistently above these
guidelines, with 42% to 49% of their prescriptions
being a higher dose than recommended. Similarly,
81% to 98% of prescriptions written by the top centile
of providers were for more than seven days. Despite the
disproportionate prescribing of the top centile, most
providersareprescribingwithintheseguidelines.Ineach
year from 2003 to 2017, at least 86% of prescriptions by
the bottom 99% of providers were less than 50 MMEs
a day. Similarly, at least 71% of prescriptions by the
bottom 99% of providers were for fewer than seven days
(supplementary table S3 and fig S8).
Characteristics of the top centile group of providers
and patients
More than half of the top centile of opioid prescribers
areinfamilymedicine(24%),physicalorpainmedicine
and rehabilitation (14%), anesthesiology (14%), or
internal medicine (13%); about one third are classified
as other (17%) or unknown (14%). Physical or pain
medicine and rehabilitation and anesthesiology are
the most over-represented specialties in the top centile,
with each accounting for just 1% of providers across
all centiles. Family medicine and internal medicine
are slightly over-represented in the top centile, and
account for just 13% and 8% of providers, respectively,
across all centiles. Hospice and critical care specialists
accounted for less than 1% of both the top centile
group and across all providers (supplementary fig S9).
Among the top centile of patients receiving opioids,
the most common recent primary diagnostic indication
was a “back problem,” followed by “other connective
tissue disease,” “other aftercare,” “other nervous
system disorders,” and “unclassified” (supplementary
table S4). Less than 20% of patients in the top centile
receiving opioids had any diagnosis of malignant
cancer during the study period (including patients
with cancers currently in remission) (supplementary
table S5).
In 2017, the top centile of patients receiving opioids
was prescribed 2.87 billion MMEs (28% of all opioids
transacted), 70% of which originated from the top
centileofproviders(fig3).Thislevelofdisproportionate
transactions between provider and patient was not
observed for benzodiazepines. Specifically, the top
centile of patients receiving benzodiazepine were
prescribed only 12% of all benzodiazepine doses,
about half of which originated from the top centile of
providers (fig 3). As a result of the disproportionate
prescribing of the top centile, the bottom 90 centiles of
providers accounted for only 12% of opioids transacted
compared with 26% for benzodiazepine. Similarly, as a
result of the highly linked nature of the top centile of
providers and patients, the majority of opioids (72%)
originating from the bottom 90 centiles of providers
were received by the bottom 90 centiles of patients.
The top centile providers, patients, and provider-
patient pairs persisted over time (fig 4). Specifically,
between 54% and 73% of the top of providers in any
year were also in the top centile in the previous year,
with modest reduction in more distant years. The
pattern of high overlap in adjacent years was also
Doses
Proportion
Opioids
Benzodiazepines
0
0.4
0.6
1.0
0.8
0.2
Prescriptions
Top centile of prescribers (cumulative)
Proportion
0 25 50 75 100
0
0.4
0.6
1.0
0.8
0.95
0.67
0.2
0.53
0.99
0.27
0.88
0.78
0.49
Fig 1 | Distribution of standardized doses and prescriptions for opioids and
benzodiazepines across all providers in 2017. Dotted lines show top 1%, 5%, 10%, and
50% of providers for each type of drug along with proportion of opioids distributed by
each of these groups
on4February2020byguest.Protectedbycopyright.http://www.bmj.com/BMJ:firstpublishedas10.1136/bmj.l6968on29January2020.Downloadedfrom
5. RESEARCH
the bmj | BMJ 2020;368:l6968 | doi: 10.1136/bmj.l6968 5
seen, though attenuated, among top centile patients
and provider-patient pairs (fig 4), suggesting that high
opioid prescribing and receiving is stable over time and
the top centile provider-patient pairs have established
associations over multiple years (supplementary figs
S10 and S11).
Discussion
Promotion of cautious, scientifically justified opioid
prescribing is an important public health goal. The
US has started to make progress towards this goal
in recent years.48
Policy makers use broad, tailored
strategies to reduce inappropriate opioid prescribing.
To understand the implications of these strategies,
including unintended consequences, and to prioritize
their implementation, requires a nuanced description
of opioid prescribing patterns. Skewed opioid pre
scribing has been found in previous studies, although
to different extents. One study carried out a smaller
examination of a single state and another, was a
geographically dispersed examination of the older
Medicare Part D population.30 31
Our study extends
these reports by examining a large, national sample
with an age and sex distribution closely resembling
that of the US general population. Additionally, this
study adds detail by examining trends over time
by provider specialty, underlying opioid type, and
provider-patient linkages.
Our results clarify an important medical reality.
Specifically, our results suggest that interventions
targeted at high prescribing opioid providers should
be prioritized for three reasons. First, most of the
prescriptions written by the majority of providers are
below recommended thresholds, suggesting that most
US providers prescribe opioids carefully. Additional,
potentially burdensome, constraints on this set of
providers are unlikely to be beneficial. Because the
majority of opioid prescriptions by this group are
probably appropriate, any increase in restrictions
is more likely to reduce appropriate use rather than
prevent those of concern. Second, the top centile of
providers is stable over time, which suggests that
interventions targeted at this group will produce
sustained results. Third, the top centile of providers
accounts for a disproportionate number of patients
receiving high amounts of opioids , and interventions
targeted here will reach these high risk patients
efficiently.
In addition, our results suggest that interventions
must be nuanced and tailored. More than one
quarter of providers in the top centile specialize in
anesthesiology or physical or pain medicine and
rehabilitation, two specialties in which additional
training in clinically appropriate opioid prescribing
is received. Further, a substantial fraction of the top
centile of provider-patient pairs overlap in adjacent
years, suggesting established relationships over many
years. Extended relationships with patients could
enable providers to have a better understanding of
patients’ needs and a readiness to taper doses. Lastly,
the top centile of patients remains the same over time,
which suggests that interventions based on improving
patient care, management of patients with complex
problems, and reducing comorbidities, rather than
enforced interventions focused on rigid thresholds, are
necessary to reduce demand for opioids.
Limitations of this study
Our analysis has important limitations. First, our data
wereobtainedfromasinglenationalinsurercomprising
mostly employer based, privately insured patients and
may not be fully generalisable to the whole of the US.
Second, the prescription data included only dispensed
prescriptions and not prescriptions that were written
by providers but never received by patients; therefore,
these data represent a potentially biased subset of
provider prescribing patterns. Nevertheless, these data
covered a patient population closely representative of
theageandsexdistributionofthegeneralUSpopulation
(supplementary table S1). Additionally, when our
data were compared with a careful examination of
opioid prescriptions in California, similar results were
found (supplementary fig S12). Third,prescriptions
attributed to one provider could have originated from
care provided by a different provider (for example,
primary care providers carrying out the treatment
plan of a pain clinic). Fourth, opioids are a diverse
set of drugs and standardizing doses into MMEs is
necessary for comparisons; however, MMEs may not
fully reflect the dependence, overdose, or mortality
potential of different opioids. Sensitivity analyses
using only schedule 2 opioids—those considered to
have the highest potential for misuse—nevertheless
Doses
Proportion
Opioids
Benzodiazepines
0
0.4
0.6
1.0
0.8
0.2
Prescriptions
Year
Proportion
2003 2005 2007 2009 2011 2013 2015 2017
0
0.4
0.6
1.0
0.8
0.2
Fig 2 | Proportion of standardized doses and prescriptions prescribed by top 1% of
providers for opioids and benzodiazepines, 2003-17
on4February2020byguest.Protectedbycopyright.http://www.bmj.com/BMJ:firstpublishedas10.1136/bmj.l6968on29January2020.Downloadedfrom
6. RESEARCH
6 doi: 10.1136/bmj.l6968 | BMJ 2020;368:l6968 | the bmj
reached the same substantive conclusions. Similarly,
benzodiazepines are diverse, and conversion factors
for equipotency between different benzodiazepines
have not been well studied. Importantly, our data did
not allow us to assess the clinical appropriateness of
any opioid or benzodiazepine prescription. Lastly,
reducing inappropriate opioid prescribing is a
worthwhile goal in and of itself; however, the opioid
overdose crisis has shifted from prescription opioids
to illicit opioids,10 49
such as heroin and synthetic
opioids, which have mortality rates that are higher than
those of prescription opioids and are increasing more
rapidly. Therefore, the effect of strategies to reduce
inappropriate prescribing on the opioid overdose
crisis at large is probably limited. The recent increase
in deaths from illicit opioids is, in part, an unintended
consequence of reducing the availability of medically
prescribed opioids, which has led some opioid
dependent patients to turn to the illicit marketplace.50
Conclusions and policy implications
Our study shows that in the claims database of a
national private insurer, a small portion of providers
account for a highly disproportionate proportion of
opioids. Further, these providers persist over time and
are often linked with patients receiving high amounts
of opioids. A corollary of this finding is that most of
the prescriptions written by the majority of providers
are below recommended thresholds. Specialties with
additional training in clinically appropriate opioid
prescribing—for example, anesthesiology and physical
or pain management and rehabilitation—are over-
represented in the top centile of opioid prescribing
providers. Lastly, we found that a substantial
proportion of provider-patient pairs are linked over
time. These findings suggest that interventions
promoting careful prescribing should be tailored for,
and targeted at, the top centile of opioid prescribing
providers and focus on providing supportive care of
Opioids
Benzodiazepines
Bottom 90
2nd-10th
1st
Bottom 90
2nd-10th
1st
Bottom 90
2nd-10th
1st
Bottom 90
2nd-10th
1st
0.0
2.5
5.0
7.5
10.0
0.0
0.1
0.2
0.3
0.4
Provider
centile group
Patient
centile group
Standardizeddosestransacted(billions)Standardizeddosestransacted(billions)
Fig 3 | Volume of opioid and benzodiazepine doses transacted between provider and
patient centile groups, 2017
Providers Patients Provider-patient pairs
2009
2008 2010 2012 2014 2016 2008 2010 2012 2014 2016 2008 2010 2012 2014 2016
2011
2013
2015
2017
Year jYear jYear j
Yeari
0.00 0.25 0.50 0.75
Proportion from year i in year j
Fig 4 | Persistence of top centile of providers, patients, and provider-patient pairs over time.
on4February2020byguest.Protectedbycopyright.http://www.bmj.com/BMJ:firstpublishedas10.1136/bmj.l6968on29January2020.Downloadedfrom
7. RESEARCH
the bmj | BMJ 2020;368:l6968 | doi: 10.1136/bmj.l6968 7
patients with complex problems rather than seeking to
enforce a threshold for prescribing.
We thank Lesley Park, Emma Hallgren, Valerie Meausoone, and
Isabella Chu at the Stanford Center for Population Health Sciences
Data Core for technical assistance.
Contributors: MVK and SB conceptualized the paper. MVK analyzed
the data with input from SB. All authors interpreted results. SB and
MRC provided financial support for the data and computational
resources. MVK, SB, and KH wrote the initial draft with all authors
providing critical feedback and edits to subsequent revisions. All
authors approved the final draft of the manuscript. MVK and SB
are the guarantors. The corresponding author attests that all listed
authors meet authorship criteria and that no others meeting the
criteria have been omitted.
Funding: This study did not receive specific funding. MVK is supported
in part by the National Institute on Drug Abuse of the National
Institutes of Health (NIH) (T32 DA035165). MVK and SB were
supported in part by the National Institute on Minority Health and
Health Disparities of the NIH (DP2 MD010478). KH was supported
by a senior research career scientist award from the Veterans Affairs
Health Services Research and Development Service and a grant
from Stanford Neurosciences Institute. Data access was provided by
the Stanford Center for Population Health Sciences Data Core. The
Population Health Sciences Data Core is supported by an NIH national
center for advancing translational science clinical and translational
science award (UL1 TR001085) and internal Stanford funding. The
funders had no role in the study design, data collection and analysis,
decision to publish, or preparation of the manuscript. The content
is solely the responsibility of the authors and does not necessarily
represent the official views of the funders, federal government, or
any current or former employers of the authors. Data and analyses
were conducted at Stanford University under a data use agreement
between Stanford and Optum.
Competing interests: All authors have completed the ICMJE uniform
disclosure form at www.icmje.org/coi_disclosure.pdf and declare:
no support from any organization for the submitted work; SB reports
grants from the US National Institutes of Health, US Department of
Agriculture, and Robert Wood Johnson Foundation, and personal fees
from Collective Health, KPMG, Research Triangle International, PLOS
Medicine, and the New England Journal of Medicine, outside the
submitted work; no financial relationships with any organizations that
might have an interested in the submitted work in the previous three
years; no other relationships or activities that could appear to have
influenced the submitted work.
Ethical approval: This study was approved by the Stanford University
institutional review board (PHS-40974).
Data sharing: Original, prescription level and diagnosis level data
tied to individuals, providers, locations, and time are considered
personally identifiable health information. These data cannot be
shared owing to risks of breaching patient confidentiality. The
authors have posted full reproducible code on the public GitHub
repository associated with this project, such that researchers who
engage in a data use agreement with Optum can use this code to
reproduce or extend the analysis. Aggregated data are available
to the extent allowed by a data use agreement. The repository is
available at https://github.com/mkiang/disproportionate_prescribing
(supplementary materials section 1).
The lead author (MVK) affirms that the manuscript is an honest,
accurate, and transparent account of the study being reported; that
no important aspects of the study have been omitted; and that any
discrepancies from the study as planned have been explained.
Dissemination to participants and related patient and public
communities: There are no plans to disseminate the results of the
research to study participants or the relevant patient community.
This is an Open Access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this work
non-commercially, and license their derivative works on different
terms, provided the original work is properly cited and the use is non-
commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
1 Centers for Disease Control and Prevention. Vital Signs: Overdoses
of Prescription Opioid Pain Relievers United States, 1999--2008.
MMWR Morb Mortal Wkly Rep 2011;60:1487-92.
2 Humphreys K. Avoiding globalisation of the prescription opioid
epidemic. Lancet 2017;390:437-9. doi:10.1016/S0140-
6736(17)31918-9
3 Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy
reconsidered. Ann Intern Med 2011;155:325-8. doi:10.7326/0003-
4819-155-5-201109060-00011
4 Chou R, Deyo R, Devine B, et al. The effectiveness and risks of long-
term opioid treatment of chronic pain. Evid Rep Technol Assess (Full
Rep) 2014;218:1-219. doi:10.23970/ahrqepcerta218
5 Kolodny A, Courtwright DT, Hwang CS, et al. The prescription opioid
and heroin crisis: a public health approach to an epidemic of
addiction. Annu Rev Public Health 2015;36:559-74. doi:10.1146/
annurev-publhealth-031914-122957
6 Compton WM, Volkow ND. Abuse of prescription drugs and the
risk of addiction. Drug Alcohol Depend 2006;83(Suppl 1):S4-7.
doi:10.1016/j.drugalcdep.2005.10.020
7 Darnall BD, Stacey BR, Chou R. Medical and psychological risks
and consequences of long-term opioid therapy in women. Pain
Med 2012;13:1181-211. doi:10.1111/j.1526-4637.2012.01467.x
8 Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan
MD. The role of opioid prescription in incident opioid abuse and
dependence among individuals with chronic noncancer pain: the role
of opioid prescription. Clin J Pain 2014;30:557-64. doi:10.1097/
AJP.0000000000000021
9 Edlund MJ, Sullivan M, Steffick D, Harris KM, Wells KB. Do users of
regularly prescribed opioids have higher rates of substance use
problems than nonusers?Pain Med 2007;8:647-56. doi:10.1111/
j.1526-4637.2006.00200.x
10 Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS.
Changing dynamics of the drug overdose epidemic in the United
States from 1979 through 2016. Science 2018;361:eaau1184.
doi:10.1126/science.aau1184
11 Bohnert ASB, Guy GPJr, Losby JL. Opioid prescribing in the United
States before and after the Centers for Disease Control and
Prevention’s 2016 opioid guideline. Ann Intern Med 2018;169:367-
75. doi:10.7326/M18-1243
12 Lin LA, Bohnert ASB, Kerns RD, Clay MA, Ganoczy D, Ilgen
MA. Impact of the Opioid Safety Initiative on opioid-related
prescribing in veterans. Pain 2017;158:833-9. doi:10.1097/j.
pain.0000000000000837
13 Soelberg CD, Brown REJr, Du Vivier D, Meyer JE, Ramachandran BK.
The US opioid crisis: current federal and state legal issues. Anesth
Analg 2017;125:1675-81. doi:10.1213/ANE.0000000000002403
14 CDC Injury Center. Opioid overdose: CDC guideline for prescribing
opioids for chronic pain. https://www.cdc.gov/drugoverdose/
prescribing/guideline.html. 2019.
15 National Academies of Sciences, Engineering, and Medicine.
Pain management and the opioid epidemic: balancing societal
and individual benefits and risks of prescription opioid use.
Washington, DC: National Academies Press, 2017. https://doi.
org/10.17226/24781.
16 Dowell D, Haegerich TM, Chou R. CDC Guideline for
prescribing opioids for chronic pain--United States, 2016.
JAMA 2016;315:1624-45. doi:10.1001/jama.2016.1464
17 Chiu AS, Jean RA, Hoag JR, Freedman-Weiss M, Healy JM, Pei KY.
Association of lowering default pill counts in electronic medical
record systems with postoperative opioid prescribing. JAMA
Surg 2018;153:1012-9. doi:10.1001/jamasurg.2018.2083
18 Zivin K, White JO, Chao S, et al. Implementing electronic health record
default settings to reduce opioid overprescribing: a pilot study. Pain
Med 2019;20:103-12. doi:10.1093/pm/pnx304
19 Delgado MK, Shofer FS, Patel MS, et al. Association between
electronic medical record implementation of default opioid
prescription quantities and prescribing behavior in two emergency
departments. J Gen Intern Med 2018;33:409-11. doi:10.1007/
s11606-017-4286-5
20 Blutinger EJ, Shofer FS, Meisel Z, Perrone J, Engel-Rebitzer E,
Delgado MK. Variability in emergency department electronic medical
record default opioid quantities: a national survey. Am J Emerg
Med 2019;66:3. doi:10.1016/j.ajem.2019.03.023
21 Chang HY, Murimi I, Faul M, Rutkow L, Alexander GC. Impact of
Florida’s prescription drug monitoring program and pill mill law on
high-risk patients: a comparative interrupted time series analysis.
Pharmacoepidemiol Drug Saf 2018;27:422-9. doi:10.1002/
pds.4404
22 Lyapustina T, Rutkow L, Chang H-Y, et al. Effect of a “pill mill” law on
opioid prescribing and utilization: the case of Texas. Drug Alcohol
Depend 2016;159:190-7. doi:10.1016/j.drugalcdep.2015.12.025
23 Kennedy-Hendricks A, Richey M, McGinty EE, Stuart EA, Barry CL,
Webster DW. Opioid overdose deaths and Florida’s crackdown
on pill mills. Am J Public Health 2016;106:291-7. doi:10.2105/
AJPH.2015.302953
24 Rutkow L, Chang H-Y, Daubresse M, Webster DW, Stuart EA,
Alexander GC. Effect of Florida’s prescription drug monitoring
program and pill mill laws on opioid prescribing and use. JAMA Intern
Med 2015;175:1642-9. doi:10.1001/jamainternmed.2015.3931
25 Chang H-Y, Lyapustina T, Rutkow L, et al. Impact of prescription
drug monitoring programs and pill mill laws on high-risk
on4February2020byguest.Protectedbycopyright.http://www.bmj.com/BMJ:firstpublishedas10.1136/bmj.l6968on29January2020.Downloadedfrom
8. RESEARCH
No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
opioid prescribers: a comparative interrupted time series
analysis. Drug Alcohol Depend 2016;165:1-8. doi:10.1016/j.
drugalcdep.2016.04.033
26 Betses M, Brennan T. Abusive prescribing of controlled substances-
-a pharmacy view. N Engl J Med 2013;369:989-91. doi:10.1056/
NEJMp1308222
27 Sacarny A, Yokum D, Finkelstein A, Agrawal S. Medicare letters to curb
overprescribing of controlled substances had no detectable effect
on providers. Health Aff (Millwood) 2016;35:471-9. doi:10.1377/
hlthaff.2015.1025
28 Doctor JN, Nguyen A, Lev R, et al. Opioid prescribing decreases after
learning of a patient’s fatal overdose. Science 2018;361:588-90.
doi:10.1126/science.aat4595
29 Dowell D, Haegerich T, Chou R. No shortcuts to safer opioid prescribing.
N Engl J Med 2019;380:2285-7. doi:10.1056/NEJMp1904190
30 Chen JH, Humphreys K, Shah NH, Lembke A. Distribution of
opioids by different types of medicare prescribers. JAMA Intern
Med 2016;176:259-61. doi:10.1001/jamainternmed.2015.6662
31 Swedlow A, Ireland J, Johnson G. Prescribing patterns of schedule
II opioids in California workers’ compensation. California Workers’
Compensation Institute; 2011. https://www.cwci.org/document.
php?file=1438.pdf.
32 National Center for Injury Prevention and Control. CDC compilation of
benzodiazepines, muscle relaxants, stimulants, zolpidem, and opioid
analgesics with oral morphine milligram equivalent conversion
factors, 2017 version. Centers for Disease Control and Prevention;
2017. https://www.cdc.gov/drugoverdose/resources/data.html.
33 Reed WJ. The Pareto, Zipf and other power laws. Econ
Lett 2001;74:15-9. doi:10.1016/S0165-1765(01)00524-9
34 Barnett ML, Olenski AR, Jena AB. Opioid-prescribing patterns
of emergency physicians and risk of long-term use. N Engl J
Med 2017;376:663-73. doi:10.1056/NEJMsa1610524
35 Schieber LZ, Guy GPJr, Seth P, et al. Trends and patterns of geographic
variation in opioid prescribing practices by state, United States,
2006-2017. JAMA Netw Open 2019;2:e190665. doi:10.1001/
jamanetworkopen.2019.0665
36 Guy GPJr, Zhang K. Opioid prescribing by specialty and volume
in the U.S. Am J Prev Med 2018;55:e153-5. doi:10.1016/j.
amepre.2018.06.008
37 Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-
prescribing rates by specialty, U.S., 2007-2012. Am J Prev
Med 2015;49:409-13. doi:10.1016/j.amepre.2015.02.020
38 Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain
assessment and treatment recommendations, and false beliefs about
biological differences between blacks and whites. Proc Natl Acad Sci
U S A 2016;113:4296-301. doi:10.1073/pnas.1516047113
39 MDCalc. Benzodiazepine conversion calculator. https://www.mdcalc.
com/benzodiazepine-conversion-calculator
40 DeCarolis DD, Rice KL, Ho L, Willenbring ML, Cassaro S. Symptom-
driven lorazepam protocol for treatment of severe alcohol withdrawal
delirium in the intensive care unit. Pharmacotherapy 2007;27:510-8.
doi:10.1592/phco.27.4.510
41 Latt N, Conigrave K, Saunders JB, Marshall JE, Nutt D, eds.
Addiction medicine . Oxford University Press, 2009. doi:10.1093/
med/9780199539338.003.0003
42 Tyrer P, Silk KR, eds. Cambridge textbook of effective treatments in
psychiatry . Cambridge University Press, 2008:3-15. doi:10.1017/
cbo9780511544392.002
43 Gelenberg AJ, Keith S, eds. The practitioner’s guide to psychoactive
drugs . Springer US, 1998:153-212. doi:10.1007/978-1-4615-
5877-4_4.
44 Gini C. Measurement of inequality of incomes. The Economic Journal.
1921. https://www.jstor.org/stable/2223319.
45 Mills JA, Zandvakili S. Statistical inference via bootstrapping for
measures of inequality. J Appl Econ 1997. doi:10.1002/(SICI)1099-
1255(199703)12:2133::AID-JAE4333.0.CO;2-H.
46 AHRQ. Agency for Healthcare Research and Quality. HCUP-US Tools
Software. https://www.hcup-us.ahrq.gov/tools_software.jsp
47 Cowell FA. Measuring inequality. London School of Economics
perspectives in economic analysis. Oxford Scholarship Online,
2011:1-16. doi:10.1093/acprof:osobl/9780199594030.003.0001
48 United Nation’s International Narcotics Control Board. Progress in
ensuring adequate access to internationally controlled substances
for medical and scientific purposes: supplement to the report of the
board for 2018. https://doi.org/10.18356/9b973caa-en.
49 Kiang MV, Basu S, Chen J, Alexander MJ. Assessment of
changes in the geographical distribution of opioid-related
mortality across the United States by opioid type, 1999-
2016. JAMA Netw Open 2019;2:e190040. doi:10.1001/
jamanetworkopen.2019.0040
50 Martin J, Cunliffe J, Décary-Hétu D, Aldridge J. Effect of restricting
the legal supply of prescription opioids on buying through
online illicit marketplaces: interrupted time series analysis.
BMJ 2018;361:k2270. doi:10.1136/bmj.k2270
Web appendix: Supplementary materials
on4February2020byguest.Protectedbycopyright.http://www.bmj.com/BMJ:firstpublishedas10.1136/bmj.l6968on29January2020.Downloadedfrom