Date of Graduation

2017

Document Type

Dissertation

Degree Type

PhD

College

School of Pharmacy

Department

Pharmaceutical Sciences

Committee Chair

Nilanjana Dwibedi

Committee Co-Chair

Charles D Ponte

Committee Member

Usha Sambamoorthi

Committee Member

Virginia G Scott

Committee Member

Douglas M Ziedonis

Abstract

In the United States (US), chronic non-cancer pain (CNCP) is prevalent among adults with costs exceeding half a billion dollars annually and can be especially burdensome for working age adults due to lost productivity and negative impacts on quality of life.An estimated 43% of adults experience pain, and the majority of them are working age (22--64 years). Despite lack of robust evidence on the efficacy and effectiveness of opioids relieving CNCP, and currently-available effective non-opioid treatments, many patients still receive opioid therapy. Opioids are associated with significant negative health consequences up to and including addiction to opioids which further increases their risk for overdose and death.10 Effective clinical, policy, and community responses to solve the opioid epidemic focus on a continuum beginning with appropriate initiation of opioids and ending with harm reduction efforts. The first step is the appropriate initiation of opioids because as many as 46% of adults who were initiated on opioids transition into chronic opioid users. Chronic opioid therapy (COT) can exacerbate current conditions and lead to development of new chronic physical and mental health conditions, and other opioid-related adverse effects including overdose. These negative consequences related to opioids lead to high economic burden through increased emergency room, inpatient, and other healthcare utilization and healthcare expenditures. Analysis of COT and its economic burden is especially important among working-age adults who receive opioids more frequently when they experience pain.;This study was conducted to (1) assess factors which predict the transition to COT, (2) estimate the changes in healthcare utilization and expenditure associated with the transition to COT, and (3) to identify educational strategies that can be used to fill knowledge gaps about opioids, naloxone, and opioid use disorder treatment medications for a group of healthcare professionals who are well suited to help alleviate the opioid epidemic.;First, we identified leading predictors associated with incident COT among adults without cancer in the US using a 10% random sample of working-age adults (age 28--63 years) insured in commercial plans, who were initiated on opioids between January 2007 through May 2015. The four leading predictors of COT were opioid duration-of-action [AOR= 12.28; 95%CI= 8.06-18.72], parent opioid tramadol vs. codeine, [AOR= 7.26; 95%CI= 5.20-10.13], the presence of conditions highly likely to cause chronic pain [AOR= 5.47; 95%CI=3.89-7.68] and drug use disorders [AOR= 4.02; 95%CI= 2.53-6.40]. Next, using the same data source, we assessed the association between transitioning from incident opioid use to chronic opioid therapy (COT), on the trajectories of health utilization and expenditures. Patients who transitioned to COT were more likely to use inpatient services [AOR=1.11, 95%CI(1.01,1.21)] compared to those who did not transition. While expenditures peaked during the transition period (t4) for all users, differences in unadjusted average, 120-day expenditures between COT and no COT users were highest in t4 for total ({dollar}4,607) and inpatient expenditures ({dollar}2,453). COT users had significantly higher total (beta=0.183, p<0.01) and inpatient expenditures (beta=0.448, p<0.001). For these first two aims, we found that initial opioid regimen characteristics are powerful predictors of COT, and the period after incident opioid prescription, but before COT, is an important time for intervention for payers.;Patients who have already transitioned to COT, or even opioid misuse or abuse need increased levels of care. The third aim sought to identify educational strategies related to opioids, buprenorphine products, and naloxone, for pharmacists, and to determine geographic locations to reduce the risk of opioid overdose in West Virginia (WV). A mixed-methods design included a prospective cross-sectional survey administered in two phases to increase coverage of the whole state, then results were weighted based on a census of all pharmacists in WV. Most pharmacists perceived high risk of opioid misuse in their area and high perceived efficacy about naloxone as a treatment for opioid overdose, but many did not feel comfortable selling naloxone. Opioid attitudes significantly differed between pharmacists in different EPPM-assigned categories. Filling practices differed; 73% stocked buprenorphine/naloxone and only 58% stocked buprenorphine. Pharmacists with higher perceived efficacy of buprenorphine products were more likely to be willing to fill non-local prescriptions. County-level disparities between actual and perceived risk for opioid misuse were observed. In the qualitative evaluation, pharmacists listed many barriers to caring for patients prescribed opioids or buprenorphine products. By tailoring educational strategies and objectives to pharmacists in specific geographic locations, more effective CPE can be delivered to community pharmacists in WV to improve access to naloxone and buprenorphine products as well as improve their understanding of addiction and psychosocial treatments.

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