Geographic Variation in the Prescription of Schedule II Opioid Analgesics among Outpatients in the United States

Autor: Jennifer Stoddard, Kevin A. Schulman, Alan Wright, Jasmina I. Radeva, Lesley H. Curtis, Raymond L. Woosley, Steve Hutchison, Peter E. Dans
Rok vydání: 2006
Předmět:
Zdroj: Health Services Research. 41:837-855
ISSN: 1475-6773
0017-9124
DOI: 10.1111/j.1475-6773.2006.00511.x
Popis: Effective management of pain often requires the use of opioid analgesics (American Pain Society 1999, 2002; World Health Organization 2000; American Pain Society 2004). Because of their potential for abuse, opioid analgesics are regulated under federal narcotics and controlled substances laws (Joranson et al. 2000). The Controlled Substances Act of 1970 authorizes the Drug Enforcement Administration to supervise the manufacturing and distribution of legal narcotics and places all substances regulated under existing federal law into one of five schedules. Schedule II is reserved for drugs or substances with (a) high potential for abuse, (b) currently accepted medical use in treatment in the United States, and (c) potential for severe psychological or physical dependence if abused. Currently, 11 oral opioid analgesics have a Schedule II assignment (Drug Facts 2002). In addition to federal regulations, many states have enacted programs to monitor the use of opioid analgesics. Although details vary by state, prescription monitoring programs typically collect prescribing and dispensing data from pharmacies, review and analyze the data, and disseminate information to appropriate law enforcement and regulatory authorities (Joranson et al. 2000). Recent analyses suggest that the use of opioid analgesics has grown considerably over the last decade. From 1990 to 1996, there were steady increases in the use of morphine, fentanyl, oxycodone, and hydromorphone (Joranson et al. 2000). The same pattern persisted from 1997 to 2002, with marked increases in the use of fentanyl and oxycodone (Gilson et al. 2004). Considerable attention has been given to the use and abuse of controlled-release oxycodone hydrochloride (Clancy 2000; Gold 2000; Graettinger 2000; Ordway 2000; Tough 2001). Notably, abuse and diversion of controlled-release oxycodone has been concentrated in certain geographic areas, with abuse in rural Maine, Kentucky, Virginia, and West Virginia bringing national attention to the problem (Clines and Meier 2001; Rogers 2001; Rosenberg 2001; Drug Enforcement Administration 2002). Geographic variations in the use of other prescription medications have been previously examined. In particular, significant geographic variation has been documented in the use of stimulant medication in children (Zito et al. 1997; Wennberg and Wennberg 2000; Cox et al. 2003), antihypertensive medications in the Veterans Affairs health system (Lopez et al. 2004), and lipid lowering drugs, proton pump inhibitors, antianxiety drugs, and antihistamines among adults in Michigan (Wennberg and Wennberg 2000). By contrast, an analysis of medication use for five conditions (depression, asthma, congestive heart failure, rheumatoid/osteoarthritis, and upper respiratory infection) in 11 California regions found relatively little geographic variation (DuBois, Batchlor, and Wade 2002). To date, no study has explored geographic variation in the use of opioid analgesics. Examining geographic variation in the use of opioid analgesics is particularly important given the presence of state policies that may limit the prescription of these drugs. That is, geographic variation may yield important insights about the effects of these state policies. Evidence from the 1989 National Ambulatory Medical Care Survey (NAMCS) suggests that physicians in states with multiple-copy prescription programs are significantly less likely to prescribe opioid analgesics during an office visit (Wastila and Bishop 1996). Although a nationally representative sample, the observed NAMCS sample visits that occurred in states with multiple-copy prescription programs were likely heavily weighted toward states with especially large populations. Consequently, the generalizability of the findings to other states is unclear. Prior work has also identified other factors related to the medical and nonmedical use of abusable prescription drugs. A study using the 1987 National Medical Expenditure Survey found that female gender, age less than 35 years, socioeconomic status, and diagnosis were independently and positively associated with the probability of narcotic analgesic use (Simoni-Wastila 2000). Using the 1991 National Household Survey on Drug Abuse (NHSDA), Simoni-Wastila, Ritter, and Strickler (2004) identified female gender, age less than 35 years, annual income greater than $40,000, poor health status, and use of illicit drugs in the previous year as independent predictors of nonmedical use of prescription drugs. Simoni-Wastila and Strickler (2004) found that female gender and single marital status were positively and independently associated with problem use of narcotic analgesics, whereas age less than 25 years and illicit drug use in the previous year were negatively associated. In the present study, we used a large, outpatient pharmaceutical claims database of commercially insured individuals to build upon prior work in two ways. First, we examined state-level prevalence of and geographic variations in the use of Schedule II oral opioid analgesics. Second, we investigated the influence of prescription monitoring programs and a variety of other factors on county-level claim rates for all opioid analgesics and for controlled-release oxycodone alone. Based on prior work, we hypothesized that the presence of a prescription monitoring program would be negatively and independently associated with claim rates for opioid analgesics, whereas female gender, age less than 35 years, and prior use of illicit drugs would be positively and independently associated.
Databáze: OpenAIRE
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