2 Minute Medicine Rewind August 21, 2017

Sustained prescription opioid use among previously opioid-naïve patients insured through TRICARE (2006-2014)

The annual cost of treating prescription opioid use and abuse now exceeds $50 billion USD per year. However, the initial events, including injury or surgical procedures, leading to exposure to prescription opioids have not been well studied. In this retrospective cohort study, researchers identified and followed up all patients age 18-64 years insured through TRICARE (2006-2014) who had received a prescription for class II or III opioid analgesics that were also opioid naïve at the time of prescription, to evaluate the medical diagnoses associated with sustained opioid use. TRICARE is the insurance plan for the US Department of Defense, providing healthcare coverage for over 9 million beneficiaries. Researchers identified 117,118 that met criteria for sustained prescription opioid use, making continuous refills without a lapse between prescription of 7 days or longer for up to or exceeding 6 months. Only 800 individuals (0.7%) received their initial opioid prescription after an inpatient encounter, and only 458 (0.4%) having undergone an inpatient procedure. The most common diagnosis associated with initial opioid prescription for the entire cohort was ‘other ill-defined conditions’, and the most frequent diagnosis among patients treated in military facilities was lumbago. This study indicates that hospital-based events and associated procedures do not appear to be major drivers or contributors to the opioid epidemic, but rather most diagnoses leading to an opioid prescription were relatively non-specific.

Prevalence of 12-month alcohol use, high-risk drinking, and DSM-IV Alcohol Use Disorder in the United States, 2001-2002 to 2012-2013

Alcohol abuse and high-risk drinking are associated with high morbidity, in addition to impairing productivity and interpersonal functioning. Currently, there is a lack of current and comprehensive trend data on alcohol use, high-risk drinking and alcohol use disorder (AUD). In this retrospective cohort study, data from the National Institute on Alcohol Abuse and Alcoholism’s 2001-2002 and 2012-2013 national epidemiologic surveys were used to estimate the prevalence of 12-month alcohol use, high-risk drinking, and 12-month DSM-IV AUD overall and among important sociodemographic subgroups of the US population. The study sample included 43,093 participants and 36,309 participants from the 2001-2002 and 2012-2013 surveys, respectively. Researchers found that between 2001-2002 and 2012-2013, 12-month alcohol use, high-risk drinking, and AUD increased by 11.2%, 29.9%, and 49.4%, respectively. Twelve-month AUD amongst 12-month high-risk drinkers also increased by 17.2% from 46.5% in 2001-2002 to 54.5% in 2012-2013. With few exceptions, increases in alcohol use, high-risk drinking, and AUD were also statistically significant across sociodemographic subgroups. Increases in these outcomes were highest among females, older adults, racial and/or ethnic minorities, and individuals of a lower socioeconomic status. This study therefore demonstrates increases in alcohol use, high-risk drinking and AUD in the US population, with certain subgroups being particularly vulnerable.

Long-term clinical and immunological effects of probiotic and peanut oral immunotherapy after treatment cessation: 4-year follow-up of a randomised, double-blind, placebo-controlled trial

The prevalence of food allergy has increased considerably in the last several years. While management has traditionally consisted of allergen avoidance and education surrounding the handling of emergent allergic reactions, the constant vigilance required of individuals with food allergies is a source of disease burden, negatively impacting quality of life. Recently, there has been increased interest in the use of oral immunotherapy as a treatment for food allergy, by way of inducing desensitization or sustained unresponsiveness. While there have been promising findings in studies examining the effects of oral immunotherapy in patients with egg or milk allergies, there is limited data on long-term outcomes of peanut oral immunotherapy. The authors previously found that combined probiotic and peanut oral immunotherapy (PPOIT) was effective at inducing desensitization and 2-week sustained unresponsiveness in children with peanut allergy. In this 4-year follow-up study, 48 children with peanut allergy that had previously participated in PPOIT trial were followed up to assess whether the previously reported clinical and immunological benefits of PPOIT were maintained 4 years after treatment. Of these 48 children, 24 were from the PPOIT group and 24 were from the placebo group. Researchers found that 16 participants (67%) from the PPOIT group were still eating peanut 4 years after stopping study treatment, compared to just 1 individual (4%) from the placebo group (p=0.006). In addition, more participants in the PPOIT group were consuming more than 2 g of peanut protein per ingestion episode as compared to the placebo group (RR 11.7, 95% CI 1.5 to 90.6, p=0.019). Four PPOIT-treated participants and 6 placebo participants reported allergic reactions to peanut after intentional or accidental intake since stopping treatment, however, none experienced anaphylaxis. The results of peanut skin prick testing also demonstrated smaller wheals in individuals from the PPOIT group (p=0.035), in addition to significantly higher peanut sIgG4:sIgE ratios than placebo participants (p=0.031). Based on the results of a substudy where 27 participants (12 from PPOT, 15 from placebo) agreed to a food challenge to assess 8-week sustained unresponsiveness, 7 (58%) of 12 participants from the PPOIT group attained 8-week sustained unresponsiveness, compared with 1 (7%) of 15 participants from the placebo group (p=0.012).  This study therefore shows that PPOIT provides long-term clinical benefit, specifically, persistent suppression of the allergic immune response to peanut.

Effectiveness of a brief behavioural intervention on psychological distress among women with a history of gender-based violence in urban Kenya: a randomised clinical trial

Gender-based violence (GBV) is a major source of psychological morbidity, particularly in low- and middle-income countries. Many of these countries lack the healthcare resources to address resulting mental health issues. In response, the World Health Organization (WHO) developed a brief psychological intervention called Problem Management Plus (PM+) to be delivered by trained lay workers as a means of reducing psychological distress in those affected. This intervention consists of evidence-based strategies including behavioural activation, problem-solving, accessing social support, and stress reduction. In this randomized controlled trial, 421 women from Nairobi, Kenya, who had experienced GBV were randomized to receive PM+ provided by lay community health workers, or facility-based enhanced usual care (EUC) provided by community nurses. The primary outcome, psychological distress, was measured using the General Health Questionnaire (GHQ-12) and assessed at 3 months post-treatment. Researchers found that at 3 months of follow-up, women in the PM+ group had significantly greater changes from baseline as compared to women that received usual care (mean difference 3.33, 95% CI 1.86 to 4.79, p=0.001). Patients in the intervention group also demonstrated significant improvements according to the WHO Disability Adjustment Schedule (p=0.03), reduced symptoms of posttraumatic stress (p=0.05) and personally identified problems (p=0.001). This study therefore shows that a brief, lay-administered behavioural intervention results in moderate reductions in psychological distress in women that have been subject to GBV.

Association of preoperative anti-tumour necrosis factor therapy with adverse post-operative outcomes in patients undergoing abdominal surgery for ulcerative colitis

Even with optimal medical management, roughly one third of patients with ulcerative colitis (UC) requiring hospitalization for their disease will ultimately undergo surgery. Many of these patients fail to achieve disease control through medical therapy alone, or experience intolerable adverse effects of medications. Biologic agents, including anti-tumour necrosis factor (TNF) agents, have demonstrated improved mucosal healing, reductions in corticosteroid requirements, and induction or maintenance of remission, by way of interfering with the inflammatory cascade. However, as these inflammatory mechanisms play an important role in wound healing and the body’s own defense against infection, interference in this regard may have important implications for the surgical patient. In this retrospective cohort study, insurance claims data for 2476 patients that had undergone subtotal colectomy (STC) or total abdominal colectomy (TAC), combined total proctocolectomy with end ileostomy (TPC/EI) and/or ileal pouch-anal anastomosis (IPAA), were analyzed to assess the association of preoperative use of anti-TNF agents with postoperative outcomes. Outcomes included 90-day complications, emergency department (ED) visits and readmissions. Stratified by the type of surgery patients underwent, 38.4% underwent an STC/TAC, of which 26.7% had claims for an anti-TNF agent, primarily infliximab, within 90 days of surgery. Based on multivariate analyses, the receipt of anti-TNF therapy was not significantly associated with any of the primary outcomes. TPC/EI procedures were performed in 14.3% of the cohort. Similarly, 26.3% of this subcohort received an anti-TNF agent within 90 days of surgery. Compared to those without anti-TNF agent use, patients receiving anti-TNF therapy did not have more complications or ED visits, however, did have higher readmission rates (OR 1.83, 95% CI 1.08 to 3.10, p=0.02). Finally, 47.3% of the cohort underwent IPAA as their index UC-related procedure. Again, no significant associations were identified between anti-TNF therapy and ED visits or readmission; however, anti-TNF patients were more likely to experience complications (OR 1.38, 95% CI 1.05 to 1.82, p=0.02). This study therefore shows while anti-TNF receipt does not increase the odds of postoperative morbidity in patients that have undergone STC/TAC, the use of this biologic agent may increase the likelihood of experiencing postoperative complications in patients undergoing IPAA.

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