More than 2,100 core titles have been selected for Doody’s Core Titles 2012 by 87 academically affiliated healthcare professionals and 104 medical librarians. The list is available to licensees at the Doody’s Core Titles website and to Doody’s Review Service subscribers. It is also licensed and republished by numerous book distributors and eBook aggregators like Rittenhouse, Ovid, EBSCO, ebrary, and many others.

Coincidentally, the May issue of the Rittenhouse Update eNewsletter features an interview with Anne Hennessy, DCT Editor in Chief, and me. The interview included a number of provocative questions, and we’d welcome your views on two in particular:

1. What do you see as the three biggest changes in the medical publishing industry over the last 30 years?

2. What is the need for specialization within the medical library, and how is that evolving?

In pregnant women, premature rupture of the membranes (the chorion and the amniotic sac) is a problem that can lead to infections in both mother and baby by permitting hostile bacteria to colonize the birth canal. Often, but not always, this premature rupture quickly causes the woman to go into labor, greatly reducing risks to the baby.

But what if the woman does not go into labor? Standard practice in the U.S. and many other advanced nations is to induce labor. If the pregnancy already has run to full term, this is intuitively appealing. However, even in the U.S., cautious clinicians take a wait-and-see approach, particularly if the baby is premature. Is this prudent?

In this week’s paper, Dutch researchers looked at women whose pregnancies were not yet at term when their membranes ruptured. There was little difference in pregnancy outcome for mothers, or for babies, between inducing labor and a careful wait-and-see approach called “expectant management.”

Obviously, expectant management took more work — monitoring, lab tests, and simple patient management. And it goes against the tendency of both doctors and patients to “do something quick” when a medical problem arises. More tellingly, if the goal is to save money and/or fit neatly into an obstetrician’s schedule, expectant management probably won’t catch on.

Check out the abstract below or go right to the free full text.

PubMed Citation:

PLoS Med. 2012 Apr;9(4):e1001208. Epub 2012 Apr 24.

Induction of Labor versus Expectant Management in Women with Preterm Prelabor Rupture of Membranes between 34 and 37 Weeks: A Randomized Controlled Trial.

van der Ham DP, Vijgen SM, Nijhuis JG, van Beek JJ, Opmeer BC, Mulder AL, Moonen R, Groenewout M, van Pampus MG, Mantel GD, Bloemenkamp KW, van Wijngaarden WJ, Sikkema M, Haak MC, Pernet PJ, Porath M, Molkenboer JF, Kuppens S, Kwee A, Kars ME, Woiski M, Weinans MJ, Wildschut HI, Akerboom BM, Mol BW, Willekes C; on behalf of the PPROMEXIL trial group.

Source

Department of Obstetrics and Gynecology, Maastricht University Medical Center, GROW-School for Oncology and Developmental Biology, Maastricht, The Netherlands.

Abstract

BACKGROUND:

At present, there is insufficient evidence to guide appropriate management of women with preterm prelabor rupture of membranes (PPROM) near term.

METHODS AND FINDINGS:

We conducted an open-label randomized controlled trial in 60 hospitals in The Netherlands, which included non-laboring women with >24 h of PPROM between 34(+0) and 37(+0) wk of gestation. Participants were randomly allocated in a 1∶1 ratio to induction of labor (IoL) or expectant management (EM) using block randomization. The main outcome was neonatal sepsis. Secondary outcomes included mode of delivery, respiratory distress syndrome (RDS), and chorioamnionitis. Patients and caregivers were not blinded to randomization status. We updated a prior meta-analysis on the effect of both interventions on neonatal sepsis, RDS, and cesarean section rate. From 1 January 2007 to 9 September 2009, 776 patients in 60 hospitals were eligible for the study, of which 536 patients were randomized. Four patients were excluded after randomization. We allocated 266 women (268 neonates) to IoL and 266 women (270 neonates) to EM. Neonatal sepsis occurred in seven (2.6%) newborns of women in the IoL group and in 11 (4.1%) neonates in the EM group (relative risk [RR] 0.64; 95% confidence interval [CI] 0.25 to 1.6). RDS was seen in 21 (7.8%, IoL) versus 17 neonates (6.3%, EM) (RR 1.3; 95% CI 0.67 to 2.3), and a cesarean section was performed in 36 (13%, IoL) versus 37 (14%, EM) women (RR 0.98; 95% CI 0.64 to 1.50). The risk for chorioamnionitis was reduced in the IoL group. No serious adverse events were reported. Updating an existing meta-analysis with our trial results (the only eligible trial for the update) indicated RRs of 1.06 (95% CI 0.64 to 1.76) for neonatal sepsis (eight trials, 1,230 neonates) and 1.27 (95% CI 0.98 to 1.65) for cesarean section (eight trials, 1,222 women) for IoL compared with EM.

CONCLUSIONS:

In women whose pregnancy is complicated by late PPROM, neither our trial nor the updated meta-analysis indicates that IoL substantially improves pregnancy outcomes compared with EM.

TRIAL REGISTRATION:

Current Controlled Trials ISRCTN29313500 Please see later in the article for the Editors’ Summary.

A recent article from American Medical News highlighted two situations where a patient made a significant negative impact on the practice of a doctor. Both doctors were forced to file defamation suits.

Dr. Albert Carlotti III, MD, DDS, spent 3 years fighting the online attacks of a former patient. During the course of this battle, the cosmetic surgeon lost hundreds of patients, dropped 35 pounds, and was forced to sell his home.

“I was dealing with somebody who had the intent of destroying us professionally, personally and on every level. I went from a very successful surgeon to pretty much out of business,” said Dr. Carlotti

The patient had created her own website posting claims that Dr. Carlotti was being investigated by the state medical board and was not board certified. The Arizona Board of Medical Examiners showed no record of any disciplinary action against Dr. Carlotti and his practice. In the end, the suit went to a three-week trial in which the jury found in favor of Dr. Carlotti, awarding him $12 million.

Neurologist David McKee, MD, was in a similar situation and an appeals court ruled that he may sue a former patient’s son for defamation. The lower court had originally ruled that online comments made by the patient’s son were not defamation. However, the Minnesota Court of Appeals decided that the comments carried weight in terms of their defamatory nature.

Dr. McKee’s reputation suffered as a result of the online comments.

“I think people feel they are unrestrained on the Internet and they think they can get away with anything. I think this decision shows there are limits to what you can say,” said Marshall Tanick, the doctor’s attorney.

The moral of the story? Online review sites and comments can be a double-edged sword. While some comments may be accurate and reliable, others can emanate from a frustrated individual venting and lying.

In the generation or so since cardiac angioplasty has become a widely used alternative to bypass surgery, standards of care required that a cardiac surgeon be on call at the hospital in case of major problems with the procedure. In such cases, the surgeon would take over, open the patient’s chest, and complete a surgical bypass. Because smaller hospitals can’t afford the financial and logistical commitments of on-call cardiac surgeons, this has meant that angioplasties are typically done in large referral hospitals.

This week’s paper confirms a longstanding hunch: With the right contingency plans in place, doing angioplasties in hospitals without cardiac surgeons on call is no riskier than doing them in larger hospitals. The contingency plans are not trivial, and it’s worth reading the full article to appreciate how much planning and staff education is needed to get them in place. However, for a lot of patients, this could mean having this important procedure closer to home, or in a hospital that’s in their insurance plan’s network — less hassle and maybe less expense as a result.

Because this article appeared in the august New England Journal of Medicine, it could be the last word. Until the next last word, of course.

Check out the abstract below or go right to the free full text.

PubMed Citation:

N Engl J Med. 2012 Mar 25. [Epub ahead of print]

Outcomes of PCI at Hospitals with or without On-Site Cardiac Surgery.

Aversano T, Lemmon CC, Liu L; the Atlantic CPORT Investigators.

Source

From Johns Hopkins University, Baltimore (T.A., C.C.L.); and Clinical Trials and Surveys, Owings Mills, MD (L.L.).

Abstract

Background Performance of percutaneous coronary intervention (PCI) is usually restricted to hospitals with cardiac surgery on site. We conducted a noninferiority trial to compare the outcomes of PCI performed at hospitals without and those with on-site cardiac surgery. Methods We randomly assigned participants to undergo PCI at a hospital with or without on-site cardiac surgery. Patients requiring primary PCI were excluded. The trial had two primary end points: 6-week mortality and 9-month incidence of major adverse cardiac events (the composite of death, Q-wave myocardial infarction, or target-vessel revascularization). Noninferiority margins for the risk difference were 0.4 percentage points for mortality at 6 weeks and 1.8 percentage points for major adverse cardiac events at 9 months. Results A total of 18,867 patients were randomly assigned in a 3:1 ratio to undergo PCI at a hospital without on-site cardiac surgery (14,149 patients) or with on-site cardiac surgery (4718 patients). The 6-week mortality rate was 0.9% at hospitals without on-site surgery versus 1.0% at those with on-site surgery (difference, -0.04 percentage points; 95% confidence interval [CI], -0.31 to 0.23; P=0.004 for noninferiority). The 9-month rates of major adverse cardiac events were 12.1% and 11.2% at hospitals without and those with on-site surgery, respectively (difference, 0.92 percentage points; 95% CI, 0.04 to 1.80; P=0.05 for noninferiority). The rate of target-vessel revascularization was higher in hospitals without on-site surgery (6.5% vs. 5.4%, P=0.01). Conclusions We found that PCI performed at hospitals without on-site cardiac surgery was noninferior to PCI performed at hospitals with on-site cardiac surgery with respect to mortality at 6 weeks and major adverse cardiac events at 9 months. (Funded by the Cardiovascular Patient Outcomes Research Team [C-PORT] participating sites; ClinicalTrials.gov number, NCT00549796 .).

This gave me the opportunity to post a comment on his blog and point out that about 17% of the articles indexed in Medline are available for free on the Internet. But that still means access to 83% of the articles is controlled by the publishers and aggregators, and most of them charge for access to the full text. However, MedInfoNow does give some subscribers the ability to link to the full text of an article in their institution’s library.

My comment led to a couple of phone conversations, during which I discovered that, like many MedInfoNow subscribers, Dr. Fahrni was not taking advantage of all the features MedInfoNow offers. Most subscribers use MedInfoNow to stay current with the literature; few realize what a powerful information management tool the MedInfoNow website is. Dr. Fahrni was intrigued, and agreed to let me give him a 20-minute webinar to orient him to some of the more powerful information management tools at MedInfoNow, what I call the “hidden gems.” We did the webinar recently, and he agreed that I should blog about these hidden gems so that more MedInfoNow subscribers can unleash the full power of their subscriptions.

In that 20-minute webinar, I reviewed 29 features. Here’s a brief description of the 10 that Dr. Fahrni found most useful — including one that may address his frustration about not getting access to the full text of articles (see “hidden gem” no. 3 below).

10. Help videos. We’ve loaded about a dozen short videos on the website, each designed to show you how to use a valuable feature of MedInfoNow. Basically these videos capture the on-screen process subscribers go through to access different parts of the site and customize it to their preferences. To get to these videos at the MedInfoNow website, click on the “Help” link in the upper right corner of any page, then click on the “Videos” tab on the Help page.

9. Order a book. Each book record includes price and availability information from two Internet booksellers, including Amazon, as well as information about the Kindle version if it’s available. Clicking on the link to a bookseller brings you right to an order page at the bookseller’s website.

8. MedInfoNow Pearl. In the Weekly Literature Update email, we frequently publish a brief tip, trick, or pearl about a MedInfoNow feature. You can get to the tip instantly by clicking on the New and Noteworthy tab at the top of each weekly email.

7. Adding relevant topics to your profile. When you are reading an abstract of an article, a box to the right displays the MedInfoNow topics that are related to that article. You can check any of these topics and add them to your profile with one click…an instant way of refining your journal article profile so that it includes subjects you may have overlooked when you first set it up.

6. Enhanced quick search. We’ve just enhanced the experience of conducting a quick search of the MedInfoNow journal article database. For a full description, check out our blog post about it.

5. Print or export. When examining articles in a search results list, you can print the citations of selected articles or the entire page. Similarly, an export tool allows you to export your selection of articles into a csv file or into a bibliographic citation tool, EndNote or RefWorks.

4. Update your profile. As most subscribers know, keeping an accurate profile ensures that MedInfoNow delivers the most relevant information to them. So this is not a hidden gem as much as it’s an underused tool that can greatly enhance the flow of valuable information to you. “Update my profile” links appear in the navigation bar and in multiple places on the web version of your Weekly Literature Update.

3. Get full text from your library. If your library participates in PubMed’s LinkOut program and you are looking at a citation of an article from a journal that’s in your library’s collection, you are just one click away from getting access to that article. Use the “My Library Link for Full Text” link under the Journal Articles tab at the MedInfoNow website to determine whether your institution is among the 3,000 participants in the LinkOut program.

2. Embed MIN abstracts at your blog/web site. Dr. Fahrni was glad to learn about the “Share” button on the article abstract and book detail page. Each abstract and book record comes with a URL that, when copied, allows subscribers to post the abstract or book detail page on their own blog or web site. Just click “Share” and a box will pop up asking you where you’d like to post the information. It’s that simple.

And the #1 hidden gem?

1. Posting articles to your own article list(s). See something that’s worth another look later? You can post articles to a list you create at the website for easy reference later. You can add/delete articles, and then print, export, or email the list to others. With just a little effort you can keep important information readily available so you don’t have to search for it at a later date.

As both a top-tier literature update service and information management service, MedInfoNow is simply the most time efficient way for healthcare professionals to save time, stay informed, and always be prepared.

Know of any “hidden gems” we missed? Tell us! We’d love to hear more about the unique ways our subscribers use our service.

View the video below to see demonstrations of a few of MedInfoNow’s hidden gems.

Glucophage and its generic equivalent metformin have been mainstays for treating type 2 diabetes, the most common form, for well over a decade. The drug reliably reduces blood sugar, which is the most obvious finding in diabetes, and it’s relatively safe. So it works, right?

Well, not so fast. This week’s paper studies the evidence that metformin actually keeps people healthier — for instance, by lowering the incidence of vascular disease or by lowering the death rate, particularly from cardiovascular disease. Unfortunately, according to the authors, there’s not enough evidence after all this time to support these expectations.

The strongest endorsement the authors can give is: “Compared with other antidiabetic treatments, metformin may be the one with the least disadvantages.”
Check out the abstract below or go right to the free full text.

PubMed Citation

PLoS Med. 2012 Apr;9(4):e1001204. Epub 2012 Apr 10.

Reappraisal of metformin efficacy in the treatment of type 2 diabetes: a meta-analysis of randomised controlled trials.

Boussageon R, Supper I, Bejan-Angoulvant T, Kellou N, Cucherat M, Boissel JP, Kassai B, Moreau A, Gueyffier F, Cornu C.

Source

Department of General Medicine, Université Claude Bernard Lyon 1, Lyon, France.

Abstract

BACKGROUND:

The UK Prospective Diabetes Study showed that metformin decreases mortality compared to diet alone in overweight patients with type 2 diabetes mellitus. Since then, it has been the first-line treatment in overweight patients with type 2 diabetes. However, metformin-sulphonylurea bitherapy may increase mortality.

METHODS AND FINDINGS:

This meta-analysis of randomised controlled trials evaluated metformin efficacy (in studies of metformin versus diet alone, versus placebo, and versus no treatment; metformin as an add-on therapy; and metformin withdrawal) against cardiovascular morbidity or mortality in patients with type 2 diabetes. We searched Medline, Embase, and the Cochrane database. Primary end points were all-cause mortality and cardiovascular death. Secondary end points included all myocardial infarctions, all strokes, congestive heart failure, peripheral vascular disease, leg amputations, and microvascular complications. Thirteen randomised controlled trials (13,110 patients) were retrieved; 9,560 patients were given metformin, and 3,550 patients were given conventional treatment or placebo. Metformin did not significantly affect the primary outcomes all-cause mortality, risk ratio (RR) = 0.99 (95% CI: 0.75 to 1.31), and cardiovascular mortality, RR = 1.05 (95% CI: 0.67 to 1.64). The secondary outcomes were also unaffected by metformin treatment: all myocardial infarctions, RR = 0.90 (95% CI: 0.74 to 1.09); all strokes, RR = 0.76 (95% CI: 0.51 to 1.14); heart failure, RR = 1.03 (95% CI: 0.67 to 1.59); peripheral vascular disease, RR = 0.90 (95% CI: 0.46 to 1.78); leg amputations, RR = 1.04 (95% CI: 0.44 to 2.44); and microvascular complications, RR = 0.83 (95% CI: 0.59 to 1.17). For all-cause mortality and cardiovascular mortality, there was significant heterogeneity when including the UK Prospective Diabetes Study subgroups (I(2) = 41% and 59%). There was significant interaction with sulphonylurea as a concomitant treatment for myocardial infarction (p = 0.10 and 0.02, respectively).

CONCLUSIONS:

Although metformin is considered the gold standard, its benefit/risk ratio remains uncertain. We cannot exclude a 25% reduction or a 31% increase in all-cause mortality. We cannot exclude a 33% reduction or a 64% increase in cardiovascular mortality. Further studies are needed to clarify this situation. Please see later in the article for the Editors’ Summary.

For a long time, we have known that men have a higher incidence of coronary artery disease than women of the same age. This is serious stuff, of course, since coronary artery disease can lead to heart attacks and strokes. Is it something in our genes? This study says yes.

The authors focused on the Y chromosome, the one that determines male sex. On the Y chromosome, they found a specific grouping of genes that is associated strongly with the development of coronary artery disease. Moreover, in working through the function of this group of genes, they learned that the genes affect immunity and inflammation. The latter observation ties in with current thinking that inflammation of blood vessel walls is often the key culprit in triggering heart attacks, which is scientifically satisfying.

Like all genetic studies, this one won’t influence clinical care in the near future. Eventually, if it’s possible to develop a reasonably-priced diagnostic test for this gene grouping, it could help to identify men at higher risk for coronary artery disease and influence how aggressively patients take preventive measures.

Check out the abstract below or go right to the free full text.

PubMed Citation:

Lancet. 2012 Mar 10;379(9819):915-22. Epub 2012 Feb 9.

Inheritance of coronary artery disease in men: an analysis of the role of the Y chromosome.

Charchar FJ, Bloomer LD, Barnes TA, Cowley MJ, Nelson CP, Wang Y, Denniff M, Debiec R, Christofidou P, Nankervis S, Dominiczak AF, Bani-Mustafa A, Balmforth AJ, Hall AS, Erdmann J, Cambien F, Deloukas P, Hengstenberg C, Packard C, Schunkert H, Ouwehand WH, Ford I, Goodall AH, Jobling MA, Samani NJ, Tomaszewski M.

Source

School of Health Sciences, University of Ballarat, Ballarat, VIC, Australia.

Abstract

BACKGROUND:

A sexual dimorphism exists in the incidence and prevalence of coronary artery disease–men are more commonly affected than are age-matched women. We explored the role of the Y chromosome in coronary artery disease in the context of this sexual inequity.

METHODS:

We genotyped 11 markers of the male-specific region of the Y chromosome in 3233 biologically unrelated British men from three cohorts: the British Heart Foundation Family Heart Study (BHF-FHS), West of Scotland Coronary Prevention Study (WOSCOPS), and Cardiogenics Study. On the basis of this information, each Y chromosome was tracked back into one of 13 ancient lineages defined as haplogroups. We then examined associations between common Y chromosome haplogroups and the risk of coronary artery disease in cross-sectional BHF-FHS and prospective WOSCOPS. Finally, we undertook functional analysis of Y chromosome effects on monocyte and macrophage transcriptome in British men from the Cardiogenics Study.

FINDINGS:

Of nine haplogroups identified, two (R1b1b2 and I) accounted for roughly 90% of the Y chromosome variants among British men. Carriers of haplogroup I had about a 50% higher age-adjusted risk of coronary artery disease than did men with other Y chromosome lineages in BHF-FHS (odds ratio 1·75, 95% CI 1·20-2·54, p=0·004), WOSCOPS (1·45, 1·08-1·95, p=0·012), and joint analysis of both populations (1·56, 1·24-1·97, p=0·0002). The association between haplogroup I and increased risk of coronary artery disease was independent of traditional cardiovascular and socioeconomic risk factors. Analysis of macrophage transcriptome in the Cardiogenics Study revealed that 19 molecular pathways showing strong differential expression between men with haplogroup I and other lineages of the Y chromosome were interconnected by common genes related to inflammation and immunity, and that some of them have a strong relevance to atherosclerosis.

INTERPRETATION:

The human Y chromosome is associated with risk of coronary artery disease in men of European ancestry, possibly through interactions of immunity and inflammation.

FUNDING:

British Heart Foundation; UK National Institute for Health Research; LEW Carty Charitable Fund; National Health and Medical Research Council of Australia; European Union 6th Framework Programme; Wellcome Trust.

Copyright © 2012 Elsevier Ltd. All rights reserved.

A recent interesting article in Time suggested that “Googling Symptoms Helps Patients and Doctors.” The article, written by Dr. Zachary F. Meisel, points out that sometimes when patients are correct, the diagnosis can be determined more quickly than if the doctor were to work it out alone.

Most interesting, though, were the author’s 3 tips for doctors when patients do make their way into your office with a Google stack:

1. Embrace patient self-education. Patients are more empowered when they have taken the time to understand what is happening to them and what their various choices are. As a doctor you can help promote this by steering them to good, reliable sources, including tools, videos, and decision-making surveys.
2. Point them in the right direction. There are a lot of poor sources for health information on the Internet. You’d rather have your patients on reliable, peer-reviewed, and evidence-based sites that offer good information than on Yahoo Answers, where anyone can give their opinion about what might be wrong. Provide your patients, particularly the ones who come in citing bad sources, with a list of better sites to check when they have questions about their health.
3. Get over the idea that the Internet is a nuisance when it comes to patient care. Patients will go online. Many patients will self-diagnose. Doctors can’t continue to roll their eyes at this behavior. Instead, their attitude should shift to, “What can I do to help patients do this in a more productive way?” Finally, doctors shouldn’t be surprised when their patients are sometimes correct.

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But, MedInfoNow is much more than that. It also offers our readers the fastest and most intuitive search of Medline® for those times they need to quickly locate information on topics outside of their profile.

Now, furthering our mission to find ways to save our subscribers time while keeping them informed, we are adding a powerful new enhancement to the search experience at MedInfoNow.  The technical name for this new feature is faceted searching, but what it means is that when readers do a quick search or advanced search, in addition to presenting a list of articles that match the search terms, MedInfoNow will display right alongside them a list of topics represented by the search results.

The juxtaposition of the search results with the topics gives our users the ability to instantly drill down to the topic that best matches their interests, narrowing their results from dozens or hundreds of articles to just the few that are most relevant for them.

With this enhancement, busy healthcare professionals can find useful, timely articles on a topic in just two steps and a matter of seconds:

1. They type search terms in the Quick Search box at the top of the page. A list of articles matching those terms instantly appears, but now alongside the search results is a listing of all the topics represented by those articles. Each topic will display the number of articles in parentheses.
2. They click on a topic to immediately narrow their search results to articles related to that specific topic – and they can quickly move through the topics to see different, targeted subsets of their results.

Take a look at the step by step video to see just how quick and easy it is to use MedInfoNow’s Enhanced Search.

MedInfoNow is committed to providing our users the tools they need to save time … stay informed … be prepared. Take a free trial and check it out for yourself.

Pain management is a well-known clinical challenge. Pain is hard to define, there’s no laboratory test to clarify how much someone actually hurts, and individuals seem to vary in the amount of pain they can live with. Looming over the clinical challenge is the specter of drug abuse, real or suspected, with prescribing regulations and a veritable law enforcement industry.

This study examines the use of the most potent pain killers in managing back pain, perhaps the poster child for difficult challenges in pain management. The setting is Kaiser Permanente Northwest, an enormous multispecialty practice that prides itself on evidence-based treatment. Even here, though, patients taking opioid pain killers are problematical. The more opioids they take, they more they visit both clinic offices and emergency departments. The authors note that these patients have a higher incidence of psychological distress, and their lifestyles tend to be less healthy than people who are not taking opioids. What’s the cause, and what’s the effect? This retrospective review of patient records can’t say.

Another concern is that even in this salary-based system replete with clinical guidelines, physicians do a sloppy job of monitoring opioid use among their patients. They seem to give prescription refills more or less on autopilot, for instance.

This paper doesn’t try to offer solutions, only to identify the nature and extent of the problem. I hope this health system is now working prospectively to understand how to keep patients with back pain healthier in all respects. If it were easy, someone would have done it by now.

Check out the abstract below or go right to the free full text.

PubMed Citation:

Opioids for back pain patients: primary care prescribing patterns and use of services.

BACKGROUND:

Opioid prescribing for noncancer pain has increased dramatically. We examined whether the prevalence of unhealthy lifestyles, psychologic distress, health care utilization, and co-prescribing of sedative-hypnotics increased with increasing duration of prescription opioid use.

METHODS:

We analyzed electronic data for 6 months before and after an index visit for back pain in a managed care plan. Use of opioids was characterized as “none,” “acute” (≤90 days), “episodic,” or “long term.” Associations with lifestyle factors, psychologic distress, and utilization were adjusted for demographics and comorbidity.

RESULTS:

There were 26,014 eligible patients. Of these, 61% received a course of opioids, and 19% were long-term users. Psychologic distress, unhealthy lifestyles, and utilization were associated incrementally with duration of opioid prescription, not just with chronic use. Among long-term opioid users, 59% received only short-acting drugs; 39% received both long- and short-acting drugs; and 44% received a sedative-hypnotic. Of those with any opioid use, 36% had an emergency visit.

CONCLUSIONS:

Prescription of opioids was common among patients with back pain. The prevalence of psychologic distress, unhealthy lifestyles, and health care utilization increased incrementally with duration of use. Coprescribing sedative-hypnotics was common. These data may help in predicting long-term opioid use and improving the safety of opioid prescribing.