Central Nervous System-Active Prescriptions in Older Veterans: Trends in Prevalence, Prescribers, and High-risk Populations

Burke, Robert E.; Pelcher, Lindsay; Tjader, Andrew; Linsky, Amy M.; Thorpe, Carolyn T.; Turner, Justin P.; Rose, Liam

doi:10.1007/s11606-023-08250-z

Cited by 3 publications

(2 citation statements)

References 27 publications

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“…First, gabapentinoid prescribing has increased dramatically in recent years in the United States-tripling between 2009 and 2020, with disproportionate increase among older adults and those with multimorbidity 14 -due to frequent off-label use for a variety of medical conditions and a perception by prescribers that it has a favorable safety profile. [15][16][17][18][19][20] Second, the gabapentinoid-LD prescribing cascade has been identified in prior studies involving data sources from the United States, Canada, and Denmark, making it an emblematic prescribing cascade through which to investigate those groups at highest risk of prescribing cascades. 8,11 Moreover, rich US Veterans Affairs (VA) clinical and prescribing data represent a unique opportunity to investigate which groups of older veterans are at highest risk of experiencing the gabapentinoid-LD prescribing cascade.…”

Section: Key Pointsmentioning

confidence: 99%

“…We chose to focus on the gabapentinoid–LD cascade for several reasons. First, gabapentinoid prescribing has increased dramatically in recent years in the United States—tripling between 2009 and 2020, with disproportionate increase among older adults and those with multimorbidity 14 —due to frequent off‐label use for a variety of medical conditions and a perception by prescribers that it has a favorable safety profile 15–20 . Second, the gabapentinoid–LD prescribing cascade has been identified in prior studies involving data sources from the United States, Canada, and Denmark, making it an emblematic prescribing cascade through which to investigate those groups at highest risk of prescribing cascades 8,11 .…”

Section: Introductionmentioning

confidence: 99%

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Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid–loop diuretic cascade

Growdon,

Jing,

Morris

et al. 2024

J American Geriatrics Society

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BackgroundPrescribing cascades are important contributors to polypharmacy. Little is known about which older adults are at highest risk of experiencing prescribing cascades. We explored which older veterans are at highest risk of the gabapentinoid (including gabapentin and pregabalin)–loop diuretic (LD) cascade, given the dramatic increase in gabapentinoid prescribing in recent years.MethodsUsing Veterans Affairs and Medicare claims data (2010–2019), we performed a prescription sequence symmetry analysis (PSSA) to assess loop diuretic initiation before and after gabapentinoid initiation among older veterans (≥66 years). To identify the cascade, we calculated the adjusted sequence ratio (aSR), which assesses the temporality of LD relative to gabapentinoid initiation. To explore high‐risk groups, we used multivariable logistic regression with prescribing order modeled as a binary dependent variable. We calculated adjusted odds ratios (aORs), measuring the extent to which factors are associated with one prescribing order versus another.ResultsOf 151,442 veterans who initiated a gabapentinoid, there were 1,981 patients who initiated a LD within 6 months after initiating a gabapentinoid compared to 1,599 patients who initiated a LD within 6 months before initiating a gabapentinoid. In the gabapentinoid–LD group, the mean age was 73 years, 98% were male, 13% were Black, 5% were Hispanic, and 80% were White. Patients in each group were similar across patient and health utilization factors (standardized mean difference <0.10 for all comparisons). The aSR was 1.23 (95% CI: 1.13, 1.34), strongly suggesting the cascade's presence. People age ≥85 years were less likely to have the cascade (compared to 66–74 years; aOR 0.74, 95% CI: 0.56–0.96), and people taking ≥10 medications were more likely to have the cascade (compared to 0–4 drugs; aOR 1.39, 95% CI: 1.07–1.82).ConclusionsAmong older adults, those who are younger and taking many medications may be at higher risk of the gabapentinoid–LD cascade, contributing to worsening polypharmacy and potential drug‐related harms. We did not identify strong predictors of this cascade, suggesting that prescribing cascade prevention efforts should be widespread rather than focused on specific subgroups.

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Section: Key Pointsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid–loop diuretic cascade

Growdon,

Jing,

Morris

et al. 2024

J American Geriatrics Society

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Secular Trends in Central Nervous System-Active Polypharmacy Among Serial Cross-Sections of US Adults, 2009–2020

Terman,

Niznik,

Growdon

et al. 2023

Drugs Aging

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Opioid use and risks in candidates and recipients of liver transplant

Rubin,

Aby,

Barman

et al. 2024

Liver Transplantation

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Opioid use is extremely prevalent among cirrhosis and liver transplant (LT) patients, despite concerns regarding opioid-related risks in this population. While there are many theoretical risks of opioids in patients with hepatic dysfunction, there is limited evidence on the effect of opioid use on clinical outcomes in cirrhosis and pre- and post-LT patients specifically. As a result there is significant center-level variability in opioid-related practice and policies. The existing data–largely based on retrospective observational studies–does suggest that opioids are associated with increased health resource utilization pre- and post-LT, and that they may precipitate hepatic encephalopathy (HE) in patients with cirrhosis and increase risk of graft loss and death post-LT. The strongest predictor of opioid use post-LT is opioid use prior to transplant; thus, a focus on safe opioid use in the pre- and peri-transplant periods is essential for minimizing opioid-related harms. We describe three strategies to guide LT providers, including: 1) Improved characterization of pain, mental health symptoms, and opioid and polysubstance use; 2) Minimization of opioid prescriptions for those at highest risk of adverse events; and 3) Safe prescribing strategies for those who do use opioids and for management of opioid use disorder (OUD). Ultimately, our goal is to improve quality of life and transplant outcomes among cirrhosis and LT patients, particularly those living with concurrent pain, mental health, and substance use disorders.

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Central Nervous System-Active Prescriptions in Older Veterans: Trends in Prevalence, Prescribers, and High-risk Populations

Cited by 3 publications

References 27 publications

Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid–loop diuretic cascade

Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid–loop diuretic cascade

Secular Trends in Central Nervous System-Active Polypharmacy Among Serial Cross-Sections of US Adults, 2009–2020

Opioid use and risks in candidates and recipients of liver transplant

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