Abstract available through Pharmacotherapy.

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This thesis discusses the evolution of the role of the pharmacist in U.S. health care delivery from its early origins to modern day practice. Public policy, education and licensing requirements, and technological advances have substantially shaped the role of the pharmacist and what health care services they provide. Where pharmacists once provided direct patient care when formal modes of pharmacist professionalization did not exist, post-WWII mass production of pharmaceuticals confined pharmacists to dispensing and distribution duties that did not fully utilize their drug knowledge. Consequently, pharmacy educators and leaders have pushed pharmacy practice into an era of “pharmaceutical care,” emphasizing direct patient care activities and the employment of pharmacists’ drug expertise. Pharmacists today have moved back into clinical roles, participating in patient care activities alongside other health care professionals—sometimes even providing primary care services. Due to the U.S.’s growing dependence of prescription drugs and the American public’s continuous demands for high quality care, greater access to health care services, and containment of health care costs, pharmacists will likely acquire greater responsibilities in direct patient care.

Made available in DSpace on 2015-12-06T23:46:14Z (GMT). No. of bitstreams: 0 Previous issue date: 2013 / Associação Fundo de Incentivo à Psicofarmacologia (AFIP) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Introdução: O uso nao prescrito de medicamentos psicotropicos entre jovens tem crescido mundialmente e se tornado objeto de preocupacao nos ultimos anos. Os tranquilizantes estao entre os medicamentos mais utilizados, com grande potencial para uso inadequado, abuso e dependencia, especialmente em populacoes mais vulneraveis como os adolescentes. Este estudo descreve o padrao de uso de tranquilizantes sem receita medica por estudantes brasileiros e identifica caracteristicas dos adolescentes e da exposicao a essas substancias que estao associadas ao consumo nao prescrito. Metodos: As analises foram realizadas a partir de uma amostra randomizada e estratificada de 47979 estudantes de 10 a 18 anos de nivel fundamental e medio da rede publica e privada de ensino nas 27 capitais brasileiras. Os dados foram obtidos por meio da aplicacao de um questionario de autopreenchimento sobre uso de tranquilizantes sem receita medica e demais substancias psicotropicas (alcool, tabaco, maconha, cocaina/crack, ecstasy, Benflogin®, anabolizantes, anfetaminas e opioides), variaveis sociodemograficas (idade, genero, classe socioeconomica, tipo de escola e regiao do pais), indicadores de acesso (ja ter recebido prescricao medica e uso de tranquilizantes por familiar ou amigo) e tambem percepcao de risco. Modelos de regressao logistica foram realizados para verificar associacao entre uso na vida nao prescrito de tranquilizantes e os fatores previamente mencionados. Resultados: O uso na vida de tranquilizantes sem receita medica foi relatado por 3,9% dos participantes, sendo o diazepam o medicamento mais consumido. O principal motivo de uso foi automedicacao e mais de 80% mencionou ter obtido o medicamento atraves da familia ou disponivel em ambiente familiar. O consumo foi duas vezes mais prevalente entre meninas e alunos provenientes de classes socioeconomicas mais favorecidas e escolas privadas. Houve associacao entre uso nao prescrito de tranquilizantes e uso na vida de alcool, de tabaco, de drogas ilicitas e de outros medicamentos sem receita medica. O uso sem prescricao medica de tranquilizantes pelos adolescentes tambem foi associado ao uso de tranquilizantes por algum parente ou amigo, ja ter recebido uma prescricao medica anterior de tranquilizantes e a uma baixa percepcao de risco de uso regular da substancia. A prescricao medica tambem esteve associada a uma baixa percepcao de risco do adolescente ao uso regular nao prescrito. Conclusao: O uso de tranquilizantes sem receita medica por adolescentes pode indicar o consumo de outras substancias, incluindo combinacoes de risco, como o uso concomitante com alcool. Ha influencia direta (oferta) e indireta (acesso e uso) da familia, e a prescricao medica tem um papel reforcador sobre o uso nao prescrito, inclusive reduzindo a percepcao de risco dos adolescentes. Os riscos decorrentes do uso de tranquilizantes sem prescricao medica devem ser abordados em fases iniciais de programas preventivos sobre drogas, e maior atencao pode ser dada aos grupos de maior risco ao consumo, como meninas e adolescentes com maior poder aquisitivo. Os medicos devem ser alertados sobre o efeito da prescricao medica de tranquilizantes acerca de um eventual uso nao prescrito entre adolescentes, sendo judiciosos ao prescrever para esta faixa etaria. Da mesma forma, adultos devem ser orientados quanto a importancia de nao compartilhar seus psicotropicos ou deixa-los acessiveis para adolescentes / Background: The use of a psychotropic medication without a prescription among young people appears to be a growing global problem. Tranquilizers are used in large scale, with great potential of misuse, abuse and dependence, especially in more vulnerable populations such as adolescents. This study aims to describe the patterns of nonprescribed use of tranquilizers by Brazilian students and to identify these adolescents' characteristics as well as the exposure variables (characteristics) that may lead to (may imply) the use of tranquilizers without a proper prescription. Methods: Analyses were made from a dataset of a randomized and stratified sample of 47979 students aged 10 to 18, attending middle and high school in private and public schools, from the 27 Brazilian state capitals. We used a self-report questionnaire to obtain information regarding the nonprescribed use of tranquilizers and other substances (alcohol, tobacco, marijuana, cocaine/ crack, ecstasy, Benflogin®, amphetamines and opioids), sociodemographic variables (age, gender, socioeconomic status, type of school and country region), access indicators (having received a medical prescription for tranquilizers and use of these substances by a relative or a close friend) and risk perception. Logistic regression models were performed to verify association between nonprescribed lifetime use and the factors we mention above. Results: Nonprescribed lifetime use of tranquilizers was reported by 3.9% of respondents and diazepam was the most cited drug. The main reason to use tranquilizers without a prescription was self-medication and more than 80% of adolescents had obtained them within their own home or by means of a relative. Girls were twice more likely than boys to report the use, as well as adolescents from private schools and higher socioeconomic status. Nonprescribed lifetime use of tranquilizers was associated with lifetime use of alcohol, tobacco, illicit drugs and nonprescribed use of other medications. The nonprescribed use was also associated with having received a medical prescription in the past, the use of tranquilizers by a relative or close friend, as well as low risk perception to the regular nonprescribed use of tranquilizers. Medical prescription was likewise associated with low risk perception among those who ever used tranquilizers. Conclusions: Adolescents’ non-medical use of prescription tranquilizers might indicate the use of other substances including risky combinations such as prescription tranquilizers and alcohol. Family may act directly, by offering, or indirectly, by allowing access and self use. Prior medical prescription might reinforce this behaviour, as well as reduce adolescents’ risk perception. The risks that result from nonmedical use of prescription anxiolytics should be addressed during the early stages of drug prevention programs, and more attention should be given to high risk groups, including girls and adolescents with higher purchasing power. Physicians should be warned about the effect of prescription tranquilizers regarding possible misuse among adolescents, and ought to be judicious when prescribing for this age group. Likewise, adults should be counselled about the importance of not sharing their psychotropic drugs and not leaving them accessible to adolescents. / BV UNIFESP: Teses e dissertações

Dr. Robert Pack is Professor of Community and Behavioral Health, Associate Dean for Academic Affairs in the College of Public Health at East Tennessee State University, and Director of the new ETSU Center for Prescription Drug Abuse Prevention and Treatment. The Center grew out of a university and community collaborative that was started in 2012 to address the regional problem of prescription opioid abuse. At least five funded projects and dozens of other academic products have grown out of the Working Group. Dr. Pack is currently PI of the NIH/NIDA-funded Diversity Promoting Institutions Drug Abuse Research Program at ETSU, the research component of which is the five-year set of three studies titled Inter-professional Communication to Prevent Prescription Drug Abuse and Misuse. He was trained in health education/health promotion at the UAB Royals School of Public Health and is experienced in designing, running and disseminating theory-based intervention studies. In 2014, he was trained at the NIH-funded Training Institute for Dissemination and Implementation Research in Health (TIDIRH, Boston, 2014).

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Background Gabapentinoids (gabapentin and pregabalin), a class of FDA-approved antiepileptic medications with expanded indications for certain neuropathic pain conditions, have been prescribed off-label for almost all types of pain in the US opioid epidemic. Methods We used IBM® MarketScan® Research Databases (2015-2018) and collected primary data. In Aim 1, we described the geographic variation in gabapentinoids and opioids for pain by US state and metropolitan statistical area (MSA). In Aim 2, we implemented a controlled multiple baseline interrupted time series analysis and assessed the impact of including gabapentin in states’ prescription drug monitoring programs (PDMP) and listing gabapentin as a Schedule V controlled substance. In Aim 3, we developed an algorithm to identify potential gabapentin misuse and/or abuse in administrative claims data. Results The pattern of the geographic variation in gabapentinoids was similar to that of opioids across states and MSAs. Including gabapentin in PDMPs and Schedule V controlled ABSTRACT viii substance classification were effective in curbing the growth of gabapentin use and reducing opioid-related adverse events. Our algorithm identified approximately one in six patients with gabapentin use as having potentially misused and/or abused gabapentin. Multiple comorbidities and drug use were associated with gabapentin misuse and/or abuse. Conclusions Gabapentinoids may have been widely used as alternative or adjuvant analgesics to opioids for pain across the US. Policy makers should consider including gabapentin in proactive PDMPs and scheduling of gabapentin. Monitoring requirements and individualized safety measures should be put in place for patients who potentially misuse and/or abuse gabapentin.

BACKGROUND AND OBJECTIVES: Sexual minority individuals demonstrate disparate rates of substance use. Research suggests that bisexual women are vulnerable to substance use disorders when compared to other sexual minority groups. This study explored differences in prevalence of past-year alcohol use disorder (AUD) with and without concurrent past-year opioid and/or benzodiazepine misuse. METHODS: The present study utilized responses from the National Survey on Drug Use and Health (NSDUH) public dataset between the years 2015-2019 (N = 16,002) to examine the association between sexual orientation and concurrent misuse of opioids and/or benzodiazepines among individuals with past-year AUD, stratified by sex. RESULTS: Bisexual females demonstrated higher rates of concurrent opioid and benzodiazepine use compared to all other groups. Although there was no association between sexual orientation and concurrent substance use patterns among males, female respondents with past-year AUD endorsing past-year misuse of opioids and benzodiazepines, both alone and in combination, were more likely to be bisexual compared to heterosexual. Lesbians were less likely to endorse concurrent misuse of opioids and benzodiazepines compared to bisexual females. DISCUSSION AND CONCLUSIONS: In a national sample, bisexual females demonstrated higher odds of risky concurrent substance use patterns. Identifying sexual minority individuals who exhibit elevated risk of co-occurring alcohol, opioid, and/or benzodiazepine misuse is an important step to targeted prevention efforts and allocation of resources to combat rising overdose deaths. SCIENTIFIC SIGNIFICANCE: For the first time, this study explored risky concurrent alcohol, opioid, and benzodiazepine misuse patterns among individuals of different sexual orientations.

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