Patterns of abuse among unintentional pharmaceutical overdose fatalities

"Fighting demons": Stigma and shifting norms in explicit mention of overdose in obituaries, 2010-2019

Obituaries are often the only published record of an individual's life and elicit community reactions, including stigmatization. Because obituaries are typically written by the bereaved, their content reflects the writer's perceptions of mores governing the social context of the next-of-kin and decedent. When a cause of death is stigmatized, it can influence the way the bereaved write the obituary. However, what constitutes a stigmatized cause of death may change as larger societal discourses of morality shift and conditions or events become framed differently. Using a sample of obituaries (N = 210) from obituary aggregator Legacy.com of "off-time," or premature, deaths in West Virginia from 2010, 2015, 2017, and 2019, this article explores whether the presentation of overdose deaths in obituaries changes alongside the shift in the public framing of the opioid crisis as medical rather than criminal. I find obituaries including terms associated with drug use and overdose become both more common and explicit over the course of the study period. This suggests that the shift in public framing of the opioid crisis from criminalization to medicalization corresponds with a decrease in drug stigmatization in obituaries. Obituary analysis can be a useful means of exploring the stigmatization of other controversial causes of death, such as suicide, cirrhosis, and lung cancer.

Predictors of engagement in screening for a hepatitis C virus (HCV) treatment trial in a rural Appalachian community

An HCV treatment trial was initiated in September 2019 to address the opioid/hepatitis C virus (HCV) syndemic in rural Kentucky. The focus of the current analysis is on participation in diagnostic screening for the trial. Initial eligibility (≥18 years of age, county resident) was established by phone followed by in-person HCV viremia testing. 900 rural residents met the inclusion criteria and comprised the analytic sample. Generalized linear models were specified to estimate the relative risk of non-attendance at the in-person visit determining HCV eligibility. Approximately one-quarter (22.1%) of scheduled participants were no-shows. People who inject drugs were no more likely than people not injecting drugs to be a no-show; however, participants ≤35 years of age were significantly less likely to attend. While the median time between phone screening and scheduled in-person screening was only 2 days, each additional day increased the odds of no-show by 3% (95% confidence interval: 2%-3%). Finally, unknown HCV status predicted no-show even after adjustment for age, gender, days between screenings and injection status. We found that drug injection did not predict no-show, further justifying expanded access to HCV treatment among people who inject drugs. Those 35 years and younger were more likely to no-show, suggesting that younger individuals may require targeted strategies for increasing testing and treatment uptake. Finally, streamlining the treatment cascade may also improve outcomes, as participants in the current study were more likely to attend if there were fewer days between phone screening and scheduled in-person screening.

Association of anabolic androgenic steroid use with perimortem polypharmacy, antemortem prescription drug use, and utilization of health care services - A Finnish triple register study of forensic autopsy cases

Anabolic androgenic steroid (AAS) use has previously been associated with complex polysubstance use that may increase morbidity and mortality among these individuals. In this study we aimed to further describe the features of perimortem polysubstance use, antemortem central nervous system (CNS) drug use and health care service utilization of AAS using males that suffer premature death. The main sample included all cases that were screened for AAS in connection with forensic autopsy between 2016-2019 and tested positive (n = 16). The control samples included autopsy cases that were screened for AAS but tested negative (n = 30) and randomly selected, age and sex matched autopsy cases not suspected of having used AAS but were otherwise fully toxicologically investigated (n = 43). Postmortem toxicological results were used for perimortem polysubstance use prevalence and severity estimation. Antemortem CNS drug use was calculated from a national register of reimbursed prescription medicines, and health care utilization from public health care registers, covering the last five years of life. Perimortem polysubstance use was prevalent in all groups, but the AAS positive had a tendency for greater CNS drug polypharmacy and the highest number of antemortem CNS drug purchases during the last five years of life, with a median of 14.5 purchases/person, vs. 1/person in the AAS negative and 0/person in the random group (Kruskal-Wallis H test, p < .001). Yearly medical contacts increased in all groups as death approached. Our findings suggest that prescription CNS drug use may play a significant role in polysubstance use disorders of AAS using males that suffer premature death.

Comprehensive Strategies in Endodontic Pain Management: An Integrative Narrative Review

This narrative review comprehensively examines the current and emerging strategies for pain management in endodontics, encompassing a wide range of pharmacological and non-pharmacological approaches. Through an extensive exploration of 20 distinct parts, the review discusses traditional analgesics, antibiotics, the use of corticosteroids, and the role of novel treatments such as platelet-rich fibrin (PRF) and cryotherapy. The review also delves into the intricacies of clinical methods, such as trephination and occlusal reduction, and discusses the potential of advanced techniques such as GABAergic signaling, acupuncture, in silico modulation, and low-level laser therapy (LLLT) for the effective management of endodontic pain. The analysis reveals a trend toward integrative methods that combine established practices with cutting-edge research, highlighting the importance of a tailored approach in endodontic pain management. The findings underscore the significance of understanding the complex nature of dental pain and the need for multifaceted treatment strategies. The review emphasizes that while traditional pharmacological methods remain foundational, emerging therapies offer promising adjuncts or alternatives, especially in cases where conventional treatments may be inadequate or unsuitable. This review aims to serve as a comprehensive resource for endodontic practitioners and researchers, offering insights into the multifarious aspects of pain management in endodontics. It underscores the ongoing evolution in the field and suggests directions for future research, particularly in refining and validating new pain management techniques.

Association of Race/Ethnicity, Persistent Poverty, and Opioid Access Among Patients with Gastrointestinal Cancer Near the End of Life

BACKGROUND

Social determinants of health (SDoH) can impact access to healthcare. We sought to assess the association between persistent poverty (PP), race/ethnicity, and opioid access among patients with gastrointestinal cancer near the end-of-life (EOL).

METHODS

SEER-Medicare patients with gastric, liver, pancreatic, biliary, colon, and rectal cancer were identified between 2008 and 2016 near EOL, defined as 30 days before death or hospice enrolment. Data were linked with county-level poverty from the American Community Survey and the US Department of Agriculture (2000-2015). Counties were categorized as never high-poverty (NHP), intermittent high-poverty (IHP) and persistent poverty (PP). Trends in opioid prescription fills and daily dosages (morphine milligram equivalents per day) were examined.

RESULTS

Among 48,631 Medicare beneficiaries (liver: n = 6551, 13.5%; pancreas: n = 13,559, 27.9%; gastric: n = 5486, 1.3%; colorectal: n = 23,035, 47.4%), there was a steady decrease in opioid prescriptions near EOL. Black, Asian, Hispanic, and other racial groups had markedly decreased odds of filling an opioid prescription near EOL (Black: OR 0.84, 95% CI 0.79-0.90; Asian: OR 0.86, 95% CI 0.79-0.94; Hispanic: OR 0.90, 95% CI 0.84-0.95; Other: OR 0.83, 95% CI 0.74-0.93; all p < 0.05). Even after filling an opioid prescription, this subset of patients received lower daily doses versus White patients (Black: -16.5 percentage points, 95% CI -21.2 to -11.6; Asian: -11.9 percentage points, 95% CI -18.5 to -4.9; Hispanic: -19.1 percentage points, 95%CI -23.5 to -14.6; all p < 0.05). The disparity in opioid access and average daily doses among was attenuated in IHP/PP areas for Asian, Hispanic, and other racial groups, yet exacerbated among Black patients.

CONCLUSIONS

Race/ethnicity-based disparities in EOL pain management persist with SDoH-based variations in EOL opioid use. In particular, PP impacted EOL opioid access and utilization.

Systematic assessment of non-medical use of prescription drugs using doctor-shopping indicators: A nation-wide, repeated cross-sectional study

AIMS

The aim of this study was to present the first nation-wide, systematic, repeated assessment of doctor-shopping (i.e. visiting multiple physicians to be prescribed the same drug) during 10 years for more than 200 psychoactive prescription drugs in the 67 million inhabitants in France.

DESIGN

This was a nation-wide, repeated cross-sectional study.

SETTING AND PARTICIPANTS

Data are from the French National Health Data System in 2010, 2015 and 2019 for 214 psychoactive prescription drugs (i.e. anaesthetics, analgesics, antiepileptics, anti-Parkinson drugs, psycholeptics, psychoanaleptics, other nervous system drugs and antihistamines for systemic use).

MEASUREMENTS

The detection and quantification of doctor-shopping relied upon an algorithm that detects overlapping prescriptions from repeated visits to different physicians. We used two doctor-shopping indicators aggregated at population level for each drug dispensed to more than 5000 patients: (i) the quantity doctor-shopped, expressed in defined daily doses (DDD), which measures the total quantity doctor-shopped by the study population for a given drug; and (ii) the proportion doctor-shopped, expressed as a percentage, which standardizes the quantity doctor-shopped according to the use level of the drug.

FINDINGS

The analyses included approximately 200 million dispensings to approximately 30 million patients each year. Opioids (e.g. buprenorphine, methadone, morphine, oxycodone and fentanyl), benzodiazepines and non-benzodiazepine hypnotics (Z-drugs) (e.g. diazepam, oxazepam, zolpidem and clonazepam) had the highest proportions doctor-shopped during the study period. In most cases, the proportion and the quantity doctor-shopped increased for opioids and decreased for benzodiazepines and Z-drugs. Pregabalin had the sharpest increase in the proportion doctor-shopped (from 0.28 to 1.40%), in parallel with a sharp increase in the quantity doctor-shopped (+843%, from 0.7 to 6.6 DDD/100 000 inhabitants/day). Oxycodone had the sharpest increase in the quantity doctor-shopped (+1000%, from 0.1 to 1.1 DDD/100 000 inhabitants/day), in parallel with a sharp increase in the proportion doctor-shopped (from 0.71 to 1.41%). Detailed results for all drugs during the study period can be explored interactively at: https://soeiro.gitlab.io/megadose/.

CONCLUSIONS

In France, doctor-shopping occurs for many drugs from many pharmacological classes, and mainly involves opioid maintenance drugs, some opioids analgesics, some benzodiazepines and Z-drugs and pregabalin.

Outcomes of an enhanced recovery after surgery (ERAS) program to limit perioperative opioid use in outpatient minimally invasive GI and hernia surgeries

BACKGROUND

Perioperative pain management is important for patient satisfaction while returning to homeostasis in the safest way possible. Studies show that patients don't require as much opioids as once thought. The benefits of ERAS pathways extend beyond enhancement of patients' perioperative experience, and include reducing opioid prescriptions in the face of the ongoing nationwide opioid crisis and evidence of prescription opioids as a contributor.

METHODS

We performed a retrospective cohort study of patients undergoing same day minimally invasive surgery (MIS) procedures for GI and hernia disease using a minimal-opioid ERAS protocol at two community hospitals between January 2020 and May 2022. We included elective laparoscopic cholecystectomy (LC), laparoscopic appendectomy (LA) for acute appendicitis without perforation, and minimally invasive (laparoscopic and robotic) inguinal and ventral hernia repair or abdominal wall reconstruction (AWR). Primary outcome was postoperative opioid use.

RESULTS

A total of 509 patients were included, undergoing procedures of MIS hernia repair (52.5%), LC (43.6%), and LA (7.9%). Only 9.4% of patients received opioid prescriptions at discharge, with no difference between groups. Among the patients receiving a prescription at discharge, there was a significant difference in morphine milligram equivalents (MME) prescribed (25.0 ± 0.0 in the LA group, 65.0 ± 41.4 in the LC group, 100.6 ± 46.2 in the MIS hernia/AWR group; P = 0.015). Nine percent of patients called with pain management concerns postoperatively. ASA score ≥ 3 was associated with increased odds for postoperative opioid prescription (OR 2.084; P = 0.014).

CONCLUSIONS

We demonstrate that an opioid-sparing ERAS program effectively manages pain for patients undergoing multiple outpatient MIS GI/hernia procedures, and suggests generalizability across a diverse range of operations. Therefore, the use of ERAS may safely and effectively expand beyond inpatient MIS and open surgeries that target reduced length of stay to also minimize opioids for outpatient procedures.

Factors associated with long-term benzodiazepine and Z-drug use across the lifespan and 5-year temporal trajectories among incident users: a Swedish nationwide register-based study

PURPOSE

Despite being discouraged by guidelines, long-term use of benzodiazepines and related Z-drugs (BZDR) remains frequent in the real-world. An improved understanding of factors associated with the transition from new to long-term BZDR use and of temporal BZDR use trajectories is needed. We aimed to assess the proportion of long-term BZDR use (> 6 months) in incident BZDR-recipients across the lifespan; identify 5-year BZDR use trajectories; and explore individual characteristics (demographic, socioeconomic and clinical) and prescribing-related factors (pharmacological properties of the initial BZDR, prescriber's healthcare level, and concurrent dispensing of other medications) associated with long-term BZDR use and distinct trajectories.

METHODS

Our nationwide register-based cohort included all BZDR-recipients in Sweden with first dispensation in 2007-2013. Trajectories of BZDR use days per year were built using group-based trajectory modelling. Cox regression and multinomial logistic regression were fitted to assess the predictors of long-term BZDR use and trajectories' membership.

RESULTS

In 930,465 incident BZDR-recipients, long-term use increased with age (20.7%, 41.0%, and 57.4% in 0-17, 18-64, and ≥ 65-year-olds, respectively). Four BZDR use trajectories emerged, labelled 'discontinued', 'decreasing', 'slow decreasing' and 'maintained'. The proportion of the 'discontinued' trajectory members was the largest in all ages, but reduced from 75.0% in the youths to 39.3% in the elderly, whereas the 'maintained' increased with age from 4.6% to 36.7%. Prescribing-related factors, in particular multiple BZDRs at initiation and concurrent dispensing of other medications, were associated with increased risks of long-term (vs short-term) BZDR use and developing other trajectories (vs 'discontinued') in all age groups.

CONCLUSIONS

The findings highlight the importance of raising awareness and providing support to prescribers to make evidence-based decisions on initiating and monitoring BZDR treatment across the lifespan.

Naloxone training and availability in the US commercial fishing industry

INTRODUCTION

Workers in physically demanding jobs with high injury rates, long hours, productivity pressures, and lack of job security, such as commercial fishing, are at higher risk for substance use and misuse. In the United States, the federal government is urging employers to consider having naloxone available to reverse the effects of an opioid overdose, especially in workplaces. This study examined naloxone training, naloxone availability, and level of concern over substance use in commercial fishing.

METHODS

As part of a larger study of commercial fishing vessel captains, we asked participants how worried they are about various potential problems, including substance use by crew members, using a five-point scale. We also asked whether they had completed naloxone training and whether their vessel was equipped with naloxone.

RESULTS

Of the 61 vessel captains who participated, 10 had naloxone training. Most were "not at all worried" about a crew member misusing alcohol (n = 52; 85.2%), a crew member using marijuana (n = 50; 82.0%), a crew member using other drugs (n = 49; 80.3%), or a crew member having a drug overdose (n = 52; 86.7%). Only five fishing vessels were equipped with naloxone.

CONCLUSION

Our results indicate that few fishing vessels are equipped with naloxone or have captains trained in its use. Fishing captains tend not to be worried about substance use in their crew. Given the higher rate of overdose deaths in the fishing industry compared to other industries, having more vessels equipped with naloxone and captains trained to administer it could save lives.

Designing a TiO2-MoO3-BMIMBr nanocomposite by a solvohydrothermal method using an ionic liquid aqueous mixture: an ultra high sensitive acetaminophen sensor

This study shows a simplistic, efficient procedure to synthesize TiO₂-MoO₃-BMIMBr nanocomposites. Powder X-ray diffraction, scanning electron microscopy, energy-dispersive X-ray spectroscopy, and X-ray photoelectron spectroscopy have all been used to completely analyse the materials. The detection of acetaminophen (AC) has been examined at a modified glassy carbon electrode with TiO₂-MoO₃-BMIMBr nanocomposites. Moreover, the electrochemical behavior of the nanocomposite modified electrode has been studied by cyclic voltammetry (CV), differential pulse voltammetry (DPV), chronoamperometry and electrochemical impedance spectroscopy (EIS). The linear response of AC was observed in the range 8.26-124.03 nM. The sensitivity and detection limits (S/N = 3) were found to be 1.16 μA L mol^-1 cm^-2 and 11.54 nM by CV and 24 μA L mol^-1 cm^-2 and 8.16 nM by DPV respectively.

Prescription drug monitoring programs use mandates and prescription stimulant and depressant quantities

BACKGROUND

While the mandate to check patients' prescription history in Prescription Drug Monitoring Program (PDMP) database before prescribing/dispensing controlled drugs has been shown to be an important tool to curb opioid abuse, less is known about whether the mandate can reduce the misuse of other commonly abused prescription drugs. We examined whether PDMP use mandates were associated with changes in prescription stimulant and depressant quantities.

METHODS

Using data from Automated Reports and Consolidate Ordering System (ARCOS), we employed difference-in-differences design to estimate the association between PDMP use mandates and prescription stimulant and depressant quantities in 50 U.S. states and the District of Columbia from 2006 to 2020. Limited PDMP use mandate was specific only to opioids or benzodiazepines. Expansive PDMP use mandate was non-specific to opioid or benzodiazepine and required prescribers/dispensers to check PDMP when prescribing/dispensing targeted controlled substances in Schedule II-V. The main outcomes were population-adjusted prescription stimulant (amphetamine, methylphenidate, lisdexamfetamine) and depressant (amobarbital, butalbital, pentobarbital, secobarbital) quantities in grams.

RESULTS

There was no evidence that limited PDMP use mandate was associated with a reduction in the prescription stimulant and depressant quantities. However, expansive PDMP use mandate that was non-specific to opioid or benzodiazepine and required prescribers/dispensers to check PDMP when prescribing/dispensing targeted controlled substances in Schedule II-V was associated with 6.2% (95% CI: -10.06%, -2.08%) decline in prescription amphetamine quantity.

CONCLUSION

Expansive PDMP use mandate was associated with a decline in prescription amphetamine quantity. Limited PDMP use mandate did not appear to change prescription stimulant and depressant quantities.

Racial and Ethnic Disparities in Opioid Access and Urine Drug Screening Among Older Patients With Poor-Prognosis Cancer Near the End of Life

PURPOSE

To characterize racial and ethnic disparities and trends in opioid access and urine drug screening (UDS) among patients dying of cancer, and to explore potential mechanisms.

METHODS

Among 318,549 non-Hispanic White (White), Black, and Hispanic Medicare decedents older than 65 years with poor-prognosis cancers, we examined 2007-2019 trends in opioid prescription fills and potency (morphine milligram equivalents [MMEs] per day [MMEDs]) near the end of life (EOL), defined as 30 days before death or hospice enrollment. We estimated the effects of race and ethnicity on opioid access, controlling for demographic and clinical factors. Models were further adjusted for socioeconomic factors including dual-eligibility status, community-level deprivation, and rurality. We similarly explored disparities in UDS.

RESULTS

Between 2007 and 2019, White, Black, and Hispanic decedents experienced steady declines in EOL opioid access and rapid expansion of UDS. Compared with White patients, Black and Hispanic patients were less likely to receive any opioid (Black, -4.3 percentage points, 95% CI, -4.8 to -3.6; Hispanic, -3.6 percentage points, 95% CI, -4.4 to -2.9) and long-acting opioids (Black, -3.1 percentage points, 95% CI, -3.6 to -2.8; Hispanic, -2.2 percentage points, 95% CI, -2.7 to -1.7). They also received lower daily doses (Black, -10.5 MMED, 95% CI, -12.8 to -8.2; Hispanic, -9.1 MMED, 95% CI, -12.1 to -6.1) and lower total doses (Black, -210 MMEs, 95% CI, -293 to -207; Hispanic, -179 MMEs, 95% CI, -217 to -142); Black patients were also more likely to undergo UDS (0.5 percentage points; 95% CI, 0.3 to 0.8). Disparities in EOL opioid access and UDS disproportionately affected Black men. Adjustment for socioeconomic factors did not attenuate the EOL opioid access disparities.

CONCLUSION

There are substantial and persistent racial and ethnic inequities in opioid access among older patients dying of cancer, which are not mediated by socioeconomic variables.

Implementation and Assessment of No Opioid Prescription Strategy at Discharge After Major Urologic Cancer Surgery

Importance

Postoperative opioid prescriptions are associated with delayed recovery, perioperative complications, opioid use disorder, and diversion of overprescribed opioids, which places the community at risk of opioid misuse or addiction.

Objective

To assess a protocol for eliminating postdischarge opioid prescriptions after major urologic cancer surgery.

Design, Setting, and Participants

This cohort study of the no opioid prescriptions at discharge after surgery (NOPIOIDS) protocol was conducted between May 2017 and June 2021 at a tertiary referral center. Patients undergoing open or minimally invasive radical cystectomy, radical or partial nephrectomy, and radical prostatectomy were sorted into the control group (usual opioids), the lead-in group (reduced opioids), and the NOPIOIDS group (no opioid prescriptions).

Interventions

The NOPIOIDS group received a preadmission educational handout, postdischarge instructions for using nonopioid analgesics, and no routine opioid prescriptions. The lead-in group received a postdischarge instruction sheet and reduced opioid prescriptions at prescribers' discretion. The control group received opioid prescriptions at prescribers' discretion.

Main Outcomes and Measures

Primary outcome measures included rate and dose of opioid prescriptions at discharge and for 30 days postdischarge. Additional outcome measures included patient-reported pain and satisfaction level, unplanned health care utilization, and postoperative complications.

Results

Of 647 opioid-naive patients (mean [SD] age, 63.6 [10.0] years; 478 [73.9%] male; 586 [90.6%] White), the rate of opioid prescriptions at discharge for the control, the lead-in, and the NOPIOIDS groups was 80.9% (157 of 194), 57.9% (55 of 95), and 2.2% (8 of 358) (Kruskal-Wallis test of medians: P < .001), and the overall median (IQR) tablets prescribed was 14 (10-20), 4 (0-5.3), and 0 (0-0) per patient in the control, lead-in, and NOPIOIDS groups, respectively (Kruskal-Wallis test of medians: P < .001). In the NOPIOIDS group, median and mean opioid dose was 0 tablets for all procedure types, with the exception of kidney procedures (mean [SD], 0.5 [1.7] tablets). Patient-reported pain surveys were received from 358 patients (72.6%) in the NOPIOIDS group, demonstrating low pain scores (mean [SD], 2.5 [0.86]) and high satisfaction scores (mean [SD], 86.6 [3.8]). There was no increase in postoperative complications in the group with no opioid prescriptions.

Conclusions and Relevance

This perioperative protocol, with emphasis on nonopioid alternatives and patient instructions, may be safe and effective in nearly eliminating the need for opioid prescriptions after major abdominopelvic cancer surgery without adversely affecting pain control, complications, or recovery.

Effects of brain-derived neurotrophic factor and adeno-associated viral vector on morphine-induced condition through target concentration changes in the ventral tegmental area and nucleus accumbens

Morphine remains the standard analgesic for severe pain. However, the clinical use of morphine is limited by the innate tendency of opiates to become addictive. Brain-derived neurotrophic factor (BDNF) is a growth factor that is protective against many mental disorders. This study aimed to evaluate the protective function of BDNF on morphine addiction based on the behavioural sensitisation (BS) model and assess potential changes in downstream molecular tropomyosin-related kinase receptor B (TrkB) and cyclic adenosine monophosphate response element binding protein (CREB) expression caused by overexpression of BDNF. We divided 64 male C57BL/6 J mice into saline, morphine, morphine plus adeno-associated viral vector (AAV), and morphine plus BDNF groups. After administering the treatments, behavioural tests were conducted during the development and expression phases of BS, followed by a western blot analysis. All data were analysed by one- or two-way analysis of variance. The overexpression of BDNF in the ventral tegmental area (VTA) caused by BDNF-AAV injection decreased the total distance of locomotion in mice who underwent morphine-induced BS and increased the concentrations of BDNF, TrkB, and CREB in the VTA and nucleus accumbens (NAc). BDNF exerts protective effects against morphine-induced BS by altering target gene expression in the VTA and NAc.

Concordance between controlled substance receipt and post-mortem toxicology in opioid-detected overdose deaths: A statewide analysis

BACKGROUND

Opioid overdoses are a leading cause of preventable death in the United States. There is limited research linking decedents' receipt of controlled substances and presence of controlled substances on post-mortem toxicology (PMT).

METHODS

We linked data on opioid-detected deaths in Connecticut between May 3, 2016, and December 31, 2017 from the Office of the Chief Medical Examiner, Department of Consumer Protection, and Department of Mental Health and Addiction Services. Exposure was defined as receipt of an opioid or benzodiazepine prescription within 90 days prior to death. Our primary outcome was concordance between medication received and metabolites in PMT.

RESULTS

Our analysis included 1412 opioid-detected overdose deaths. 47 % received an opioid or benzodiazepine 90 days prior to death; 36 % received an opioid and 27 % received a benzodiazepine. Concordance between receipt of an opioid or benzodiazepine and its presence in PMT was observed in 30 % of opioid-detected deaths. Concordance with an opioid was present in 17 % of opioid-detected deaths and concordance with a benzodiazepine was present in 21 % of opioid-detected deaths. Receipt of an opioid or benzodiazepine and concordance with PMT were less common in fentanyl or heroin-detected deaths and more common in pharmaceutical opioid-detected deaths.

DISCUSSION

Our results suggest medically supplied opioids and benzodiazepines potentially contributed to a substantial number, though minority, of opioid-detected deaths during the study period. Efforts to reduce opioid and benzodiazepine prescribing may reduce risk of opioid-detected deaths in this group, but other approaches will be needed to address most opioid-detected deaths that involved non-pharmaceutical opioids.

Unintentional drug-related deaths in people with mental illness in NSW Australia, 2012-2016: a retrospective cohort study

PURPOSE

People with mental illness are a vulnerable and stigmatised group with poor health outcomes including greater premature mortality. This study aimed to investigate trends and rates of change in unintentional drug-related deaths for people with mental illness, describe types of medicines involved, and identify populations at risk in a cohort from New South Wales, Australia.

METHODS

Features of unintentional drug-related deaths for people with mental illness between 2012 and 2016 were identified in a retrospective review of data from the National Coronial Information System.

RESULTS

A total of 495 unintentional drug-related deaths were identified (1.6 deaths/100,000 population), showing an upward trend (p < 0.01). The most common substance involved was diazepam in both genders (males 135/319, 42%, female 76/176, 43%) and more than one contributory drug was included in 80% of cases. Between 2012 and 2016, amphetamine-related deaths showed the highest increase (3.2-fold), followed by codeine (2.5-fold) and quetiapine (2.5-fold). Males (RR 1.8, 95% CI 1.5-2.2) and people aged 35-44 (RR 1.7, CI 1.3-2.2) were more likely to die from unintentional drug-related deaths compared with the reference (females and people aged 25-34).

CONCLUSION

This study found that the drugs commonly involved in deaths are also the drugs commonly used by and prescribed to people with mental illness. There were also significant differences between gender, age group, and marital status in the trend and rate of unintentional drug-related deaths for people with mental illness. A multifaceted approach encompassing both pharmaceutical prescribing and targeted public health messaging is required to inform intervention and prevention strategies.

Exploring county-level spatio-temporal patterns in opioid overdose related emergency department visits

Opioid overdoses within the United States continue to rise and have been negatively impacting the social and economic status of the country. In order to effectively allocate resources and identify policy solutions to reduce the number of overdoses, it is important to understand the geographical differences in opioid overdose rates and their causes. In this study, we utilized data on emergency department opioid overdose (EDOOD) visits to explore the county-level spatio-temporal distribution of opioid overdose rates within the state of Virginia and their association with aggregate socio-ecological factors. The analyses were performed using a combination of techniques including Moran's I and multilevel modeling. Using data from 2016-2021, we found that Virginia counties had notable differences in their EDOOD visit rates with significant neighborhood-level associations: many counties in the southwestern region were consistently identified as the hotspots (areas with a higher concentration of EDOOD visits) whereas many counties in the northern region were consistently identified as the coldspots (areas with a lower concentration of EDOOD visits). In most Virginia counties, EDOOD visit rates declined from 2017 to 2018. In more recent years (since 2019), the visit rates showed an increasing trend. The multilevel modeling revealed that the change in clinical care factors (i.e., access to care and quality of care) and socio-economic factors (i.e., levels of education, employment, income, family and social support, and community safety) were significantly associated with the change in the EDOOD visit rates. The findings from this study have the potential to assist policymakers in proper resource planning thereby improving health outcomes.

AIE-doped Poly(Ionic Liquid) Photonic Spheres for the Discrimination of Psychoactive Substances

Drugs of abuse has drawn intense attention due to increasing concerns to public health and safety. The construction of a sensing platform with the capability to identify them remains a big challenge because of the limitations of synthetic complexity, sensing scope and receptor extendibility. Here a kind of poly(ionic liquid) (PIL) photonic crystal spheres doped with aggregation-induced emission (AIE) luminogens was developed. As diverse noncovalent interactions involve in PIL moieties, the single sphere shows different binding affinity to a broad range of psychoactive substances. Furthermore, the dual-channel signals arising from photonic crystal structures and sensitive AIE-luminogens provide high-dimensional information for discriminative detection of targets, even for molecules with slight structural differences. More importantly, such single sphere sensing platform could be flexibly customized through ion-exchange, showing great extendibility to fabricate high-efficiency/high-throughput sensing arrays without tedious synthesis.

The changing epidemiology of opioid overdose in Baltimore, Maryland, 2012-2017: insights from emergency medical services

INTRODUCTION

An estimated 100,306 people died from an overdose from May 2020 to April 2021. Emergency Medical Services (EMS) are often the first responder to opioid overdose, and EMS encounter records can provide granular epidemiologic data on opioid overdose. This study describes the demographic, temporal, and geographic epidemiology of suspected opioid overdose in Baltimore City using data from Baltimore City Fire Department EMS encounters with the administration of the opioid antagonist naloxone.

METHOD

The present analyses used patient encounter data from 2012 to 2017 from the Baltimore City Fire Department, the city's primary provider of EMS services. The analytic sample included patient encounters within the city that involved naloxone administration to patients 15 years of age or older (n = 20,592). Negative binomial regression was used to calculate the incidence rates based on demographic characteristics, year, and census tract. Choropleth maps were used to show the geographic distribution of overdose incidence across census tracts in 2013, 2015, and 2017.

RESULTS

From 2012 to 2017, the annual number of EMS encounters with naloxone administrations approximately doubled every 2 years, and the temporal pattern of naloxone administration was similar to the pattern of fatal opioid-related overdoses. For most census tracts, incidence rates significantly increased over time. Population-based incidence of naloxone administration varied significantly by socio-demographic characteristics. Males, non-whites, and those 25-69 years of age had the highest incidence rates.

CONCLUSION

The incidence of naloxone administration increased dramatically over the study period. Despite significant cross-sectional variation in incidence across demographically and geographically defined groups, there were significant proportional increases in incidence rates, consistent with fatal overdose rates over the period. This study demonstrated the value of EMS data for understanding the local epidemiology of opioid-related overdose. Key MessagesPatterns of EMS encounters with naloxone administration appear to be an excellent proxy for patterns of opioid-related overdoses based on the consistency of fatal overdose rates over time.EMS plays a central role in preventing fatal opioid-related overdoses through the administration of naloxone, provision of other emergency services, and transportation to medical facilities.EMS encounters with naloxone administration could also be used to evaluate the impact of overdose prevention interventions and public health services.

U.S. Military veterans and the opioid overdose crisis: a review of risk factors and prevention efforts

U.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019. Risk for overdose among veterans is complex and influenced by ongoing interaction among physiological/biological, psychological, and socio-structural factors. A thorough understanding of opioid-related overdose among veterans, one that goes beyond simple pharmacological determinism, must examine the interplay of pain, pain treatment, and stress, as well as psychological and social experiences-before, during, and after military service. Comprehensive efforts to tackle the overdose crisis among veterans require interventions that address each of these dimensions. Promising interventions include widespread naloxone distribution and increased provision of low-threshold wrap-around services, including medications for opioid use disorder (MOUD) and holistic/complementary approaches. Interventions that are delivered by peers - individuals who share key experiential or sociodemographic characteristics with the population being served - may be ideally suited to address many of the barriers to opioid-related risk mitigation common among veterans. Community care models could be beneficial for the large proportion of veterans who are not connected to the Veterans Health Administration and for veterans who, for various reasons including mental health problems and the avoidance of stigma, are socially isolated or reluctant to use traditional substance use services. Interventions need to be tailored in such a way that they reach those more socially isolated veterans who may not have access to naloxone or the social support to help them in overdose situations. It is important to incorporate the perspectives and voices of veterans with lived experience of substance use into the design and implementation of new overdose prevention resources and strategies to meet the needs of this population. Key messagesU.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019.The risks for overdose that veterans face need to be understood as resulting from an ongoing interaction among biological/physiological, psychological, and social/structural factors.Addressing drug overdose in the veteran population requires accessible and non-judgemental, low threshold, wraparound, and holistic solutions that recognise the complex aetiology of overdose risk for veterans.

Interscalene block with liposomal bupivacaine versus continuous interscalene catheter in primary total shoulder arthroplasty

BACKGROUND

Multimodal pain regimens in total shoulder arthroplasty (TSA) now include regional anesthetic techniques. Historically, regional anesthesia for extended postoperative pain control in TSA was administered using a continuous interscalene catheter (CIC). Liposomal bupivacaine (LB) is used for its potential for similar pain control and fewer complications compared with indwelling catheters. We evaluated the efficacy of interscalene LB compared with a CIC in postoperative pain control for patients undergoing TSA.

METHODS

This was a retrospective cohort study at a tertiary-care academic medical center including consecutive patients undergoing primary anatomic or reverse TSA from 2016 to 2020 who received either single-shot LB or a CIC for perioperative pain control. Perioperative and outcome variables were collected. The primary outcome was postoperative pain control, whereas the secondary outcome was health care utilization.

RESULTS

The study included 565 patients, with 242 in the CIC cohort and 323 in the LB cohort. Demographic characteristics including sex (P = .99) and race (P = .81) were similar between the cohorts. The LB cohort had significantly lower mean pain scores at 24 hours (3 vs. 2, P < .001) and 36 hours (3 vs. 2, P < .001) postoperatively. The CIC cohort showed a higher percentage of patients experiencing a pain score of 9 or 10 postoperatively (29% vs. 17%, P = .001), whereas the LB cohort had a significantly greater proportion of opioid-free patients (32% vs. 10%, P < .001). Additionally, a greater proportion of CIC patients required opioid escalation to patient-controlled analgesia (7% vs. 2%, P = .002). The CIC cohort experienced a greater length of stay (2.3 days vs. 2.1 days, P = .01) and more 30-day emergency department visits (5% vs. 2%, P = .038).

CONCLUSIONS

LB demonstrated lower mean pain scores at 24 and 36 hours postoperatively and lower rates of severe postoperative pain. Additionally, LB patients showed significantly higher rates of opioid-free pain regimens. These results suggest that as part of a multimodal pain regimen in primary shoulder arthroplasty, LB may provide greater reductions in pain and opioid use when compared with CICs.

Real-Time Measurement of Patient Reported Outcomes and Opioid Use Following Urologic Procedures using Automated Text Messaging

OBJECTIVE

To evaluate opioid consumption and patient-reported pain intensity following urologic procedures.

METHODS

Adult patients were consented following a urologic procedure, and data was collected through post-operative day 28 in a large tertiary care academic health system. An automated text messaging platform was used to collect patient reported pain intensity, ability to manage pain, and opioid use measured in oxycodone 5 mg tablet equivalents. Outcomes were weighted based on the inverse probability of response to yield representative estimates.

RESULTS

1015 (51.8%) patients responded to the text-message survey. The median number of pills prescribed was 10 (IQR 6-10), and the median number of pills taken was 2 (IQR 0-6). By postoperative day 7, the median tablets taken overall was 0. Over the study period, 60.1% (6566) of all tablets prescribed were left unused, and 38.4% of patients did not use any of the prescribed opioids. Across urologic procedures, 6 tablets would accommodate the 75^th percentile of patient-reported use, with the exception of major open procedures.

CONCLUSIONS

In this study utilizing real-time measurement of opioid use and pain levels with text messaging, there was evidence of dramatic over-prescription of opioids relative to use and pain levels. Patient-reported data, collected via text messaging, can support clinicians and policy leaders in forming national guidelines on evidence-based best practices, personalizing prescriptions and guide shared decision making to decrease opioid excess.

The Opioid Epidemic: a Crisis Disproportionately Impacting Black Americans and Urban Communities

The heroin epidemic has existed for decades, but a sharp rise in opioid overdose deaths (OODs) jolted the nation in the mid-twenty-teens and continues as a major health crisis to this day. Although the new wave of OODs was initially approached as a rural problem impacting a White/Caucasian demographic, surveillance records suggest severe impacts on African Americans and urban-dwelling individuals, which have been largely underreported. The focus of this report is on specific trends in OOD rates in Black and White residents in states with a significant Black urban population and declared as hotspots for OOD: (Maryland (MD), Illinois (IL), Michigan (MI), and Pennsylvania (PA)), and Washington District of Columbia (DC). We compare OODs by type of opioid, across ethnicities, across city/rural demographics, and to homicide rates using 2013-2020 data acquired from official Chief Medical Examiners' or Departments of Health (DOH) reports. With 2013 or 2014 as baseline, the OOD rate in major cities (Baltimore, Chicago, Detroit, Philadelphia) were elevated two-fold over all other regions of their respective state. In DC, Wards 7 and 8 OODs were consistently greater than other jurisdictions, until 2020 when the rate of change of OODs increased for the entire city. Ethnicity-wise, Black OOD rates exceeded White rates by four- to six-fold, with fentanyl and heroin having a disproportionate impact on Black opioid deaths. This disparity was aggravated by its intersection with the COVID-19 pandemic in 2020. African Americans and America's urban dwellers are vulnerable populations in need of social and political resources to address the ongoing opioid epidemic in under-resourced communities.

Nationwide study of the characteristics of frequent attenders with multiple emergency department attendance patterns

INTRODUCTION

The burden of frequent attenders (FAs) of emergency departments (EDs) on healthcare resources is underestimated when single-centre analyses do not account for utilisation of multiple EDs by FAs. We aimed to quantify the extent of multiple ED use by FAs and to characterise FAs.

METHODS

We reviewed nationwide ED attendance in Singapore data from 1 January 2006 to 31 December 2018 (13 years). FAs were defined as patients with ≥4 ED visits in any calendar year. Single ED FAs and multiple ED FAs were patients who attended a single ED exclusively and ≥2 distinct EDs within the year, respectively. Mixed ED FAs were patients who attended a mix of a single ED and multiple EDs in different calendar years. We compared the characteristics of FAs using multivariable logistic regression.

RESULTS

We identified 200,130 (6.3%) FAs who contributed to1,865,704 visits (19.6%) and 2,959,935 (93.7%) non-FAs who contributed to 7,671,097 visits (80.4%). After missing data were excluded, the study population consisted of 199,283 unique FAs. Nationwide-linked data identified an additional 15.5% FAs and 29.7% FA visits, in addition to data from single centres. Multiple ED FAs and mixed ED FAs were associated with male sex, younger age, Malay or Indian ethnicity, multiple comorbidities, median triage class of higher severity, and a higher frequency of ED use.

CONCLUSION

A nationwide approach is needed to quantify the national FA burden. The multiple comorbidities and higher frequency of ED use associated with FAs who visited multiple EDs and mixed EDs, compared to those who visited a single ED, suggested a higher level of ED burden in these subgroups of patients. The distinct characteristics and needs of each FA subgroup should be considered in future healthcare interventions to reduce FA burden.

Trends in Prescriptions for Non-opioid Pain Medications Among U.S. Adults With Moderate or Severe Pain, 2014-2018

As opioid prescribing has declined, it is unclear how the landscape of prescription pain treatment across the U.S. has changed. We used nationally-representative data from the Medical Expenditure Health Survey, 2014 to 2018 to examine trends in prescriptions for opioid and non-opioid pain medications, including acetaminophen, non-steroidal anti-inflammatory drugs, gabapentinoids, and antidepressants among U.S. adults with self-reported pain. Overall, from 2014 to 2018, the percentage of participants receiving a prescription for opioids declined, (38.8% vs 32.8%), remained stable for non-steroidal anti-inflammatory drugs (26.8% vs 27.7%), and increased for acetaminophen (1.6% vs 2.3%), antidepressants (9.6% vs 12.0%) and gabapentinoids (13.2% vs 19.0%). In this period, the adjusted odds of receiving an opioid prescription decreased (aOR = .93, 95% CI = .90-.96), while the adjusted odds of receiving antidepressant, gabapentinoid and acetaminophen prescriptions increased (antidepressants: aOR = 1.08, 95% CI = 1.03-1.13 gabapentinoids: aOR = 1.11, 95% CI = 1.06-1.17; acetaminophen: aOR = 1.10, 95% CI: 1.02-1.20). Secondary analyses stratifiying within the 2014 to 2016 and 2016 to 2018 periods revealed particular increases in prescriptions for gabapentinoids (aOR = 1.13, 95% CI = 1.05-1.21) and antidepressants (aOR = 1.23, 95% CI = 1.12-1.35) since 2016. PERSPECTIVE: These data demonstrate that physicians are increasingly turning to CDC-recommended non-opioid medications for pain management, particularly antidepressants and gabapentinoids. However, evidence for these medications' efficacy in treating numerous common pain conditions, including low back pain, remains limited.

Health harms of non-medical prescription opioid use: A systematic review

ISSUES

Non-medical prescription opioid use (NMPOU) contributes substantially to the global burden of morbidity. However, no systematic assessment of the scientific literature on the associations between NMPOU and health outcomes has yet been undertaken.

APPROACH

We undertook a systematic review evaluating health outcomes related to NMPOU based on ICD-10 clinical domains. We searched 13 electronic databases for original research articles until 1 July 2021. We employed an adaptation of the Oxford Centre for Evidence-Based Medicine 'Levels of Evidence' scale to assess study quality.

KEY FINDINGS

Overall, 182 studies were included. The evidence base was largest on the association between NMPOU and mental and behavioural disorders; 71% (129) studies reported on these outcomes. Less evidence exists on the association of NMPOU with infectious disease outcomes (26; 14%), and on external causes of morbidity and mortality, with 13 (7%) studies assessing its association with intentional self-harm and 1 study assessing its association with assault (<1%).

IMPLICATIONS

A large body of evidence has identified associations between NMPOU and opioid use disorder as well as on fatal and non-fatal overdose. We found equivocal evidence on the association between NMPOU and the acquisition of HIV, hepatitis C and other infectious diseases. We identified weak evidence regarding the potential association between NMPOU and intentional self-harm, suicidal ideation and assault.

DISCUSSION AND CONCLUSIONS

Findings may inform the prevention of harms associated with NMPOU, although higher-quality research is needed to characterise the association between NMPOU and the full spectrum of physical and mental health disorders.

Effects of County-Level Opioid Dispensing Rates on Individual-Level Patterns of Prescription Opioid and Heroin Consumption: Evidence From National U.S. Data

OBJECTIVE

The authors examined directly whether county-level changes in opioid dispensing rates affect individual-level prescription opioid misuse, frequency of use, and dependence, as well as the same outcomes for heroin.

METHODS

Using data from the restricted-access National Survey on Drug Use and Health, the Centers for Disease Control and Prevention's retail opioid prescription database, the Prescription Drug Abuse Policy System, and the U.S. Census, the authors applied fixed-effects models to determine whether county-level dispensing rates affected prescription opioid outcomes as intended and whether changes in rates adversely affected heroin use outcomes. Bayes factors were used to confirm evidence for null findings.

RESULTS

The sample included 748,800 respondents age 12 and older from 2006 to 2016. The odds of prescription opioid misuse, increased frequency of misuse, and dependence were 7.2%, 3.5%, and 10.4% higher, respectively, per standard deviation increase in the county-level opioid dispensing rate per 100 persons. There was no evidence for any association between opioid dispensing rates and the three heroin outcomes. The odds ratio was nonsignificant according to frequentist techniques in fixed-effects models, and Bayesian techniques confirmed very strong support for the null hypothesis.

CONCLUSIONS

County-level opioid dispensing rates are directly associated with individual-level prescription opioid misuse, frequency of misuse, and dependence. Changes in dispensing were not associated with population shifts in heroin use. Reductions in opioid dispensing rates have contributed to stemming prior increases in prescription opioid misuse while not adversely affecting heroin use. Physicians and other health care providers can take action to minimize opioid dispensing for tangible benefits regarding prescription opioid misuse without adverse effects on heroin use.

Mental disorder and opioid overdose: a systematic review

PURPOSE

This systematic review summarizes and presents the current state of research quantifying the relationship between mental disorder and overdose for people who use opioids.

METHODS

The protocol was published in Open Science Framework. We used the PECOS framework to frame the review question. Studies published between January 1, 2000, and January 4, 2021, from North America, Europe, the United Kingdom, Australia, and New Zealand were systematically identified and screened through searching electronic databases, citations, and by contacting experts. Risk of bias assessments were performed. Data were synthesized using the lumping technique.

RESULTS

Overall, 6512 records were screened and 38 were selected for inclusion. 37 of the 38 studies included in this review show a connection between at least one aspect of mental disorder and opioid overdose. The largest body of evidence exists for internalizing disorders generally and mood disorders specifically, followed by anxiety disorders, although there is also moderate evidence to support the relationship between thought disorders (e.g., schizophrenia, bipolar disorder) and opioid overdose. Moderate evidence also was found for the association between any disorder and overdose.

CONCLUSION

Nearly all reviewed studies found a connection between mental disorder and overdose, and the evidence suggests that having mental disorder is associated with experiencing fatal and non-fatal opioid overdose, but causal direction remains unclear.

Did prescribing laws disproportionately affect opioid dispensing to Black patients?

OBJECTIVE

To evaluate whether pain management clinic laws and prescription drug monitoring program (PDMP) prescriber check mandates, two state opioid policies with relatively rapid adoption across states, reduced opioid dispensing more or less in Black versus White patients.

DATA SOURCES

Pharmacy claims data, US sample of commercially insured adults, 2007-2018.

STUDY DESIGN

Stratifying by race, we used generalized estimating equations with an event-study specification to estimate time-varying effects of each policy on opioid dispensing, comparing to the four pre-policy quarters and states without the policy. Outcomes included high-dosage opioids, overlapping opioid prescriptions, concurrent opioid/benzodiazepines, opioids from >3 prescribers, opioids from >3 pharmacies.

DATA EXTRACTION METHODS

We identified all prescription opioid dispensing to Black and White adults aged 18-64 without a palliative care or cancer diagnosis code.

PRINCIPAL FINDINGS

Exactly 7,096,592 White and 1,167,310 Black individuals met inclusion criteria. Pain management clinic laws were associated with reductions in two outcomes; their association with high-dosage receipt was larger among White patients. In contrast, reductions due to PDMP mandates appeared limited to, or larger in, Black patients compared with White patients in four of five outcomes. For example, PDMP mandates reduced high-dosage receipt in Black patients by 0.7 percentage points (95% CI: 0.36-1.08 ppt.) over 4 years: an 8.4% decrease from baseline; there was no apparent effect in White patients. Similarly, while there was limited evidence that mandates reduced overlapping opioid receipt in White patients, they appeared to reduce overlapping opioid receipt in Black patients by 1.3 ppt. (95% CI: -1.66--1.01 ppt.) across post-policy years-a 14.4% decrease from baseline.

CONCLUSIONS

PDMP prescriber check mandates but not pain management clinic laws appeared to reduce opioid dispensing more in Black patients than White patients. Future research should discern the mechanisms underlying these disparities and their consequences for pain management.

Exploring Differences in Baseline Characteristics among Adults Entering Integrated Residential Treatment for Co-occurring Disorders in 2013 and 2017

Little is known about patients' addiction severity, substance use, or mental health symptoms upon entering integrated treatment. This is the first study to compare baseline characteristics among cohorts of patients with co-occurring disorders entering a private integrated residential treatment program in 2013 and 2017; a period when severe and persistent mental illness diagnoses, mental health service use, and overdose deaths increased. Our sample includes 3400 patients entering private, integrated residential treatment during 2013 (n = 1535) and 2017 (n = 1865). Trained staff completed admission interviews of all participants that included the Addiction Severity Index (ASI), a semi-structured interview to evaluate the past 30-day functioning of the following domains: medical, employment, alcohol, drug, legal, family or social support systems, and psychiatric. We used a p-value of 0.05 to assess significance. With the exception of the drug composite score, the 2017 cohort scored higher than the 2013 cohort on all other composite scores. Compared to the 2013 cohort, the 2017 cohort reported more days using alcohol, cocaine, amphetamines, and engaging in polysubstance use. Conversely, the 2017 cohort reported fewer days using other prescription opioids and sedatives than the 2013 cohort. After controlling for age, the 2017 cohort reported more days of marijuana use than the 2013 cohort. The 2017 cohort reported higher rates of the following symptoms: depression, anxiety, hallucinations, and suicidal ideation. Findings underscore differences among integrated treatment patient cohorts for baseline addiction severity, substance use, or mental health symptoms.

Decreasing Post-Operative Opioid Prescriptions Following Orthopedic Trauma Surgery: The "Lopioid" Protocol

OBJECTIVE

To assess the effectiveness of a multimodal analgesic regimen containing "safer" opioid and non-narcotic pain medications in decreasing opioid prescriptions following surgical fixation in orthopedic trauma.

DESIGN

Retrospective cohort study.

SETTING

One urban, academic medical center.

SUBJECTS

Traumatic fracture patients from 2018 (848) and 2019 (931).

METHODS

In 2019 our orthopedic trauma division began a standardized protocol of post-operative pain medications that included: 50 mg of tramadol four times daily, 15 mg of meloxicam once daily, 200 mg gabapentin twice daily, and 1 g of acetaminophen every 6 hours as needed. This multimodal regimen was dubbed the "Lopioid" protocol. We compared this protocol to all patients from the prior year who followed a standard protocol that included Schedule II narcotics.

RESULTS

Greater mean MME were prescribed at discharge from fracture surgery under the standard protocol compared to the Lopioid protocol (252.3 vs 150.0; p < 0.001) and there was a difference in the type of opioid medication prescribed (p < 0.001). There was a difference in the number of refills filled for patients discharged with opioids after surgical treatment between standard and Lopioid cohorts (0.31 vs 0.21; p = 0.002). There was no difference in the types of medication-related complications (p = 0.710) or the need for formal pain management consults (p = 0.199), but patients in the Lopioid cohort had lower pain scores at discharge (2.2 vs 2.7; p = 0.001).

CONCLUSIONS

The Lopioid protocol was effective in decreasing the amount of Schedule II narcotics prescribed at discharge and the number of opioid refills following orthopedic surgery for fractures.

New means, new measures: assessing prescription drug-seeking indicators over 10 years of the opioid epidemic

BACKGROUND AND AIMS

Prescription drug-seeking (PDS) from multiple prescribers is a primary means of obtaining prescription opioids; however, PDS behavior has probably evolved in response to policy shifts, and there is little agreement about how to operationalize it. We systematically compared the performance of traditional and novel PDS indicators.

DESIGN

Longitudinal study using a de-identified commercial claims database.

SETTING

United States, 2009-18.

PARTICIPANTS

A total of 318 million provider visits from 21.5 million opioid-prescribed patients.

MEASUREMENTS

We applied binary classification and generalized linear models to compare predictive accuracy and average marginal effect size predicting future opioid use disorder (OUD), overdose and high morphine milligram equivalents (MME). We compared traditional indicators of PDS to a network centrality measure, PageRank, that reflects the prominence of patients in a co-prescribing network. Analyses used the same data and adjusted for patient demographics, region, SES, diagnoses and health services.

FINDINGS

The predictive accuracy of a widely used traditional measure (N + unique doctors and N + unique pharmacies in 90 days) on OUD, overdose and MME decreased between 2009 and 2018, and performed no better than chance (50% accuracy) after 2015. Binarized PageRank measures however exhibited higher predictive accuracy than the traditional binary measures throughout 2009-2018. Continuous indicators of PDS performed better than binary thresholds, with days of Rx performing best overall with 77-93% predictive accuracy. For example, days of Rx had the highest average marginal effects on overdose and OUD: a 1 standard deviation increase in days of Rx was associated with a 6-8% [confidence intervals (CIs) = 0.058-0.061 and 0.078-0.082] increase in the probability of overdose and a 4-5% (CIs = 0.038-0.043 and 0.047-0.053) increase in the probability of OUD. PageRank performed nearly as well or better than traditional indicators of PDS, with predictive performance increasing after 2016.

CONCLUSIONS

In the United States, network-based measures appear to have increasing promise for identifying prescription opioid drug-seeking behavior, while indicators based on quantity of providers or pharmacies appear to have decreasing utility.

Predictive Modelling of Susceptibility to Substance Abuse, Mortality and Drug-Drug Interactions in Opioid Patients

Objective: Opioids are a class of drugs that are known for their use as pain relievers. They bind to opioid receptors on nerve cells in the brain and the nervous system to mitigate pain. Addiction is one of the chronic and primary adverse events of prolonged usage of opioids. They may also cause psychological disorders, muscle pain, depression, anxiety attacks etc. In this study, we present a collection of predictive models to identify patients at risk of opioid abuse and mortality by using their prescription histories. Also, we discover particularly threatening drug-drug interactions in the context of opioid usage.

Methods and Materials: Using a publicly available dataset from MIMIC-III, two models were trained, Logistic Regression with L2 regularization (baseline) and Extreme Gradient Boosting (enhanced model), to classify the patients of interest into two categories based on their susceptibility to opioid abuse. We’ve also used K-Means clustering, an unsupervised algorithm, to explore drug-drug interactions that might be of concern.

Results: The baseline model for classifying patients susceptible to opioid abuse has an F1 score of 76.64% (accuracy 77.16%) while the enhanced model has an F1 score of 94.45% (accuracy 94.35%). These models can be used as a preliminary step towards inferring the causal effect of opioid usage and can help monitor the prescription practices to minimize the opioid abuse.

Discussion and Conclusion: Results suggest that the enhanced model provides a promising approach in preemptive identification of patients at risk for opioid abuse. By discovering and correlating the patterns contributing to opioid overdose or abuse among a variety of patients, machine learning models can be used as an efficient tool to help uncover the existing gaps and/or fraudulent practices in prescription writing. To quote an example of one such incidental finding, our study discovered that insulin might possibly be interacting with opioids in an unfavourable way leading to complications in diabetic patients. This indicates that diabetic patients under long term opioid usage might need to take increased amounts of insulin to make it more effective. This observation backs up prior research studies done on a similar aspect. To increase the translational value of our work, the predictive models and the associated software code are made available under the MIT License.

Defining "Doctor shopping" with Dispensing Data: A Scoping Review

BACKGROUND

"Doctor shopping" typically refers to patients that seek controlled substance prescriptions from multiple providers with the presumed intent to obtain these medications for non-medical use and/or diversion. The purpose of this scoping review is to document and examine the criteria used to identify "doctor shopping" from dispensing data in the United States.

METHODS

A scoping review was conducted on "doctor shopping" or analogous terminology from January 1, 2000 through December 31, 2020 using the Web of Science Core Collection (7 citation indices). Our search was limited to U.S. only, English-language, peer-reviewed and U.S. federal government studies. Studies without explicit "doctor shopping" criteria were excluded. Key components of these criteria included the number of prescribers and dispensers, dispensing period, and drug class (e.g., opioids).

RESULTS

Of 9,845 records identified, 95 articles met the inclusion criteria and our pool of studies ranged from years 2003 to 2020. The most common threshold-based or count definition was [≥4 Prescribers (P) AND ≥4 Dispensers (D)] (n = 12). Thirty-three studies used a 365-day detection window. Opioids alone were studied most commonly (n = 69), followed by benzodiazepines and stimulants (n = 5 and n = 2, respectively). Only 39 (41%) studies provided specific drug lists with active ingredients.

CONCLUSION

Relatively simple P × D criteria for identifying "doctor shopping" are still the dominant paradigm with the need for on-going validation. The value of P × D criteria may change through time with more diverse methods applied to dispensing data emerging.

Association of Preoperative Opioid Use With Complication Rates and Resource Use in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement

Background

Preoperative opioid use has been shown to be a negative predictor of patient outcomes, complication rates, and resource utilization in a variety of different orthopaedic procedures. To date, there are no studies investigating its effect on outcomes after hip arthroscopy in the setting of femoroacetabular impingement (FAI).

Purpose

To determine the association of preoperative opioid use with postoperative outcomes after hip arthroscopy in patients with FAI.

Study Design

Cohort study; Level of evidence, 3.

Methods

The Truven Health MarketScan Commercial Claims and Encounters Database was queried for all patients who underwent hip arthroscopy for FAI between 2011 and 2018. Opioid prescriptions filled in the 6 months preceding surgery were queried, and the average daily oral morphine equivalents (OMEs) in this period were computed for each patient. Patients were divided into 4 cohorts: opioid naïve, <1 OME per day, 1 to 5 OMEs per day, and >5 OMEs per day. Postoperative 90-day complications, health care utilization, perioperative costs, postoperative opioid use, and 1- and 3-year revision rates were then compared among cohorts.

Results

A total of 22,124 patients were ultimately included in this study; 31.2% of these patients were prescribed opioids preoperatively. Overall, the percentage of preoperative opioid-naïve patients increased from 64.5% in 2011 to 78.9% in 2018. Patients who received preoperative opioids had a higher rate of complications, increased resource utilization, and increased revision rates. Specifically, on multivariate analysis, patients taking >5 OMEs per day (compared with patients who were preoperatively opioid naïve) had increased odds of a postoperative emergency department visit (Odds Ratio, 2.23; 95% confidence interval [CI], 1.94-2.56; P < .001), 90-day readmission (OR, 2.25; 95% CI, 1.77-2.87; P < .001), increased acute postoperative opioid use (OR, 25.56; 95% CI, 22.98-28.43; P < .001), prolonged opioid use (OR, 10.45; 95% CI, 8.92-12.25; P < .001), and 3-year revision surgery (OR, 2.14; 95% CI, 1.36-3.36; P < .001). Perioperative adjusted costs were increased for all preoperative opioid users and were highest for the >5 OMEs per day cohort ($6255; 95% CI, $5143-$7368).

Conclusion

A large number of patients with FAI are prescribed opioids before undergoing hip arthroscopy, and use of these pain medications is associated with increased health care utilization, increased costs, prolonged opioid use, and early revision surgery.

Medical and Non-Medical Opioid Use at the Intersection of Gender and Sexual Identity: Associations with State Medical Cannabis Law Status in a U.S. National Sample of Adults

At the structural level, medical cannabis laws (MCLs) have been negatively associated with opioid prescribing practices, and sexual minority adults report disproportionately high non-medical prescription opioid use. We examined medical/non-medical prescription opioid use by intersecting sexual identity and gender and explored associations with MCLs using the 2015-2017 National Survey on Drug Use and Health, which captured sexual identity and MCL state residence for adults 18 + years (N = 126,463). Survey-weighted gender-stratified multinomial logistic models estimated adjusted relative risk ratios (aRRR) of medical vs. no prescription opioid use, and any non-medical vs. no prescription opioid use, by sexual identity and MCL, and tested moderation by MCL. Past-year medical prescription opioid use was higher among women than men across sexual identities (e.g., bisexual: 38.5% women vs. 30.2% men). Non-medical prescription opioid use was lower among women than men, except for bisexual adults (12.4% women vs. 7.6% men). MCL was associated with lower medical prescription opioid vs. no use among heterosexual women (aRRR = 0.86, 95% confidence interval [CI] = 0.81-0.91), bisexual women (aRRR = 0.74, 95% CI = 0.62-0.89), and heterosexual men (aRRR = 0.91, 95% CI = 0.85-0.97). Living in an MCL state was associated with lower non-medical vs. no use among heterosexual and bisexual women, but not among men or lesbian/gay women. MCL status did not moderate associations between sexual identity and prescription opioid outcomes. Future studies should assess whether implementing MCLs could particularly affect bisexual women who reported the highest prescription opioid use and may need targeted services.

Doctor shopping among chronic noncancer pain patients treated with opioids in the province of Quebec (Canada): incidence, risk factors, and association with the occurrence of opioid overdoses

Opioid doctor shopping was a rare phenomenon among people living with chronic noncancer pain but was associated with the occurrence of opioid overdoses.

Introduction:

Prescription opioids continue to be involved in the opioid crisis, and a better understanding of factors associated with problematic opioid use is needed.

Objectives:

The aim of this study was to assess the incidence of opioid doctor shopping, a proxy for problematic opioid use, to identify associated risk factors, and to assess its association with the occurrence of opioid overdoses.

Methods:

This was a retrospective cohort study of people living with chronic noncancer pain (CNCP) and treated with opioids for at least 6 months between 2006 and 2017 in the province of Quebec (Canada). Data were drawn from the Quebec health administrative databases. Doctor shopping was defined as overlapping prescriptions written by ≥ 2 prescribers and filled in ≥3 pharmacies.

Results:

A total of 8,398 persons with CNCP were included. The median age was 68.0 (Q1: 54; Q3: 82) years, and 37.1% were male. The 1-year incidence of opioid doctor shopping was 7.8%, 95% confidence interval (CI): 7.2–8.5. Doctor shopping was associated with younger age (hazard ratio [HR] 18–44 vs ≥65 years: 2.22, 95% CI: 1.77–2.79; HR 45–64 vs ≥65 years: 1.34, 95% CI: 1.11–1.63), male sex (HR = 1.20, 95% CI: 1.01–1.43), history of substance use disorder (HR = 1.32, 95% CI: 1.01–1.72), and anxiety (HR = 1.41, 95% CI: 1.13–1.77). People who exhibited doctor shopping were 5 times more likely to experience opioid overdoses (HR = 5.25, 95% CI: 1.44–19.13).

Conclusion:

Opioid doctor shopping is a marginal phenomenon among people with CNCP, but which is associated with the occurrence of opioid overdoses. Better monitoring of persons at high risk to develop doctor shopping could help prevent opioid overdoses.

Primary Care and Mental Health Prescribers, Key Clinical Leaders, and Clinical Pharmacist Specialists' Perspectives on Opioids and Benzodiazepines

OBJECTIVE

Due to increased risks of overdose fatalities and injuries associated with coprescription of opioids and benzodiazepines, healthcare systems have prioritized deprescribing this combination. Although prior work has examined providers' perspectives on deprescribing each medication separately, perspectives on deprescribing patients with combined use is unclear. We examined providers' perspectives on coprescribed opioids and benzodiazepines and identified barriers and facilitators to deprescribing.

DESIGN

Qualitative study using semistructured interviews.

SETTING

One multisite Veterans Affairs (VA) healthcare system in the United States of America.

SUBJECTS

Primary care and mental health prescribers, key clinical leaders, clinical pharmacist specialists (N = 39).

METHODS

Interviews were audio-recorded, transcribed, and analyzed using thematic analysis. Themes were identified iteratively, through a multidisciplinary team-based process.

RESULTS

Analyses identified four themes related to barriers and facilitators to deprescribing: inertia, prescriber self-efficacy, feasibility of deprescribing/tapering, and promoting deprescribing, as well as a fifth theme, consequences of deprescribing. Results highlighted the complexity of deprescribing when multiple prescribers are involved, a need for additional support and time, and concerns about patients' reluctance to discontinue these medications. Facilitators included agreement with the goal of deprescribing and fear of negative consequences if medications are continued. Providers spoke to how deprescribing efforts impaired patient-provider relationships and informed their decisions not to start patients on these medications.

CONCLUSIONS

Although providers agree with the goal, prescribers' belief in a limited deprescribing role, challenges with coordination among prescribers, concerns about insufficient time and patients' resistance to discontinuing these medications need to be addressed for efforts to be successful.

Longitudinal Dose Trajectory Among Patients Tapering Long-Term Opioids

OBJECTIVE

To evaluate the dose trajectory of new opioid tapers and estimate the percentage of patients with sustained tapers at long-term follow-up.

DESIGN

Retrospective cohort study.

SETTING

Data from the OptumLabs Data Warehouse® which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees, representing a diverse mixture of ages, ethnicities, and geographical regions across the United States.

SUBJECTS

Patients prescribed stable, higher-dose opioids for ≥12 months from 2008 to 2018.

METHODS

Tapering was defined as ≥15% relative reduction in average MME/day during any of six overlapping 60-day periods in the initial 7 months of follow-up after the period of stable baseline dosing. Average monthly dose was ascertained during consecutive 60-day periods up to 16 months of follow-up. Linear regression estimated the geometric mean relative dose by tapering status and follow-up duration. Poisson regression estimated the percentage of tapered patients with sustained dose reductions at follow-up and patient-level predictors of failing to sustain tapers.

RESULTS

The sample included 113,618 patients with 203,920 periods of stable baseline dosing (mean follow-up = 13.7 months). Tapering was initiated during 37,170 follow-up periods (18.2%). After taper initiation, patients had a substantial initial mean dose reduction (geometric mean relative dose .73 [95% CI: .72-.74]) that was sustained through 16 months of follow-up; at which point, 69.8% (95% CI: 69.1%-70.4%) of patients who initiated tapers had a relative dose reduction ≥15%, and 14.2% (95% CI: 13.7%-14.7%) had discontinued opioids. Failure to sustain tapers was significantly less likely among patients with overdose events during follow-up (adjusted incidence rate ratio [aIRR]: .56 [95% CI: .48-.67]) and during more recent years (aIRR: .93 per year after 2008 [95% CI: .92-.94]).

CONCLUSIONS

In an insured and Medicare Advantage population, over two-thirds of patients who initiated opioid dose tapering sustained long-term dose reductions, and the likelihood of sustaining tapers increased substantially from 2008 to 2018.

Primary prevention of prescription opioid diversion: a systematic review of medication disposal interventions

Background: In the U.S., 50-75% of nonmedical users of prescription opioids obtain their pills through diversion by friends or relatives. Increasing disposal of unused opioid prescriptions is a fundamental primary prevention strategy in combatting the opioid epidemic.Objectives: To identify interventions for disposal of unused opioid pills and assess the evidence of their effectiveness on disposal-related outcomes.Methods: A search of four electronic databases was conducted (October 2019). We included all empirical studies, systematic literature reviews, and meta-analyses about study medication disposal interventions in the U.S. Studies of disposal interventions that did not include opioids were excluded. We abstracted data for the selected articles to describe the study design, and outcomes. Further, we assessed the quality of each study using the NIH Study Quality Assessment Tools.Results: We identified 25 articles that met our inclusion criteria. None of the 13 studies on drug take-back events or the two studies on donation boxes could draw conclusions about their effectiveness. Although studies on educational interventions found positive effects on knowledge acquisition, they did not find differences in disposal rates. Two randomized controlled trials on drug disposal bags found higher opioid disposal rates in their intervention arms compared to the control arms (57.1% vs 28.6% and 33.3%, p = .01; and 85.7% vs 64.9%, p = .03).Conclusions: Peer-reviewed publications on opioid disposal interventions are limited and either do not address effectiveness or have conflicting findings. Future research should address these limitations and further evaluate implementation and cost-effectiveness.

US Trends in Opioid Access Among Patients With Poor Prognosis Cancer Near the End-of-Life

PURPOSE

Heightened regulations have decreased opioid prescribing across the United States, yet little is known about trends in opioid access among patients dying of cancer.

METHODS

Among 270,632 Medicare fee-for-service decedents with poor prognosis cancers, we used part D data to examine trends from 2007 to 2017 in opioid prescription fills and opioid potency (morphine milligram equivalents per day [MMED]) near the end-of-life (EOL), defined as the 30 days before death or hospice enrollment. We used administrative claims to evaluate trends in pain-related emergency department (ED) visits near EOL.

RESULTS

Between 2007 and 2017, the proportion of decedents with poor prognosis cancers receiving ≥ 1 opioid prescription near EOL declined 15.5% (relative percent difference [RPD]), from 42.0% (95% CI, 41.4 to 42.7) to 35.5% (95% CI, 34.9 to 36.0) and the proportion receiving ≥ 1 long-acting opioid prescription declined 36.5% (RPD), from 18.1% (95% CI, 17.6 to 18.6) to 11.5% (95% CI, 11.1 to 11.9). Among decedents receiving opioids near EOL, the mean daily dose fell 24.5%, from 85.6 MMED (95% CI, 82.9 to 88.3) to 64.6 (95% CI, 62.7 to 66.6) MMED. Overall, the total amount of opioids prescribed per decedent near EOL (averaged across those who did and did not receive an opioid) fell 38.0%, from 1,075 morphine milligram equivalents per decedent (95% CI, 1,042 to 1,109) to 666 morphine milligram equivalents per decedent (95% CI, 646 to 686). Simultaneously, the proportion of patients with pain-related ED visits increased 50.8% (RPD), from 13.2% (95% CI, 12.7 to 13.6) to 19.9% (95% CI, 19.4 to 20.4). Sensitivity analyses demonstrated similar declines in opioid utilization in the 60 and 90 days before death or hospice, and suggested that trends in opioid access were not confounded by secular trends in hospice utilization.

CONCLUSION

Opioid use among patients dying of cancer has declined substantially from 2007 to 2017. Rising pain-related ED visits suggests that EOL cancer pain management may be worsening.

Patient-Reported Pain and Opioid Use After Ambulatory Head and Neck Surgery

Objective

The main objective of this study was to quantify daily pain and opioid use in patients after hemithyroidectomy and cervical lymph node biopsy (CLNB). The secondary objective was to identify factors associated with decreased pain and opioid use.

Study Design

Prospective cohort study from June 2017 to February 2019. Patients were given paper surveys to record daily postoperative opioid use and maximal pain on a visual analog scale.

Setting

Single institution (NewYork-Presbyterian/Weill Cornell Medical Center).

Methods

All adult patients undergoing hemithyroidectomy and CLNB by a single surgeon were consecutively selected for participation. Patients recorded daily pain and opioid analgesic use over a 2-week postoperative period.

Results

Of 33 patients enrolled, 29 (87.9%) returned a survey. Thirteen underwent CLNB, and 16 underwent hemithyroidectomy. Pain resolved after both procedures by the end of the 2-week period. CLNB patients used a median (interquartile range) of 15.0 (0-41.2) morphine milligram equivalents (MME), and 95% used 70 or fewer MME. Hemithyroidectomy patients used a median of 8.2 (4.5-13.9) MME, and 95% used 30 or fewer MME. Use of nonopioid analgesics was associated with a statistically significant decrease in pain (56.1 vs 171 visual analog scale, 95% confidence interval [CI] of Δ = [12.0 to 217.8]) and opioid use (12.2 vs 48.8 MME, 95% CI of Δ = [5.0 to 68.1 MME]) in CLNB but not in hemithyroidectomy.

Conclusion

Patients have low pain and opioid requirements after hemithyroidectomy and CLNB. Head and neck surgeons should evaluate their opioid-prescribing patterns for opportunities to safely decrease postoperative prescriptions.

Is Europe facing an opioid crisis like the United States? An analysis of opioid use and related adverse effects in 19 European countries between 2010 and 2018

Background

Given the ongoing opioid crisis in the United States (US), we investigated the opioid situation in Europe. The aims of the study are to provide an overview of trends in prescription opioid (PO) use and opioid-related adversities between 2010 and 2018 for different opioids in 19 European countries and to present a comparison with similar data from the US.

Methods

A multisource database study with national data from 19 European countries evaluating trends between 2010 and 2018 in (a) PO consumption, (b) high-risk (HR) opioid users, (c) opioid-related hospital admissions, (d) opioid-related overdose deaths, (e) opioid use disorder treatment entries, and (f) patients in opioid substitution therapy (OST). Within and between-country comparisons and comparisons with data from the US were made.

Results

There was considerable variation between European countries. Most countries showed increased PO consumption with the largest increase and the highest consumption in the United Kingdom (UK) compared to the rest of Europe and the US in 2018 (UK: 58,088 defined daily doses for statistical purposes/1000 population/day). In 2018, Scotland had the highest rates (per 100,000 population) of HR opioid users (16·2), opioid-related hospital admissions (118), opioid-related deaths (22·7), opioid use disorder treatment admissions (190), and OST patients (555) of all included European countries. These rates were similar or even higher than those in the US in 2018. Other countries with high rates of opioid-related adversities were Northern Ireland (synthetic and “other” opioids), Ireland (heroin and methadone), and England (all opioids). All other countries had no or little increase in opioid-related adversities.

Conclusions

Apart from the British Isles and especially Scotland, there is no indication of an opioid crisis comparable to that in the US in the 19 European countries that were part of this study. More research is needed to identify drivers and develop interventions to stop the emerging opioid crisis in the UK and Ireland.

Opioid Doctor Shopping: A Rare Phenomenon Among Patients with Chronic Non-Cancer Pain Followed in Tertiary Care Settings

Background

Opioid doctor shopping has not yet been investigated in patients followed in tertiary care settings. This study aimed at assessing the prevalence of opioid doctor shopping among patients with chronic non-cancer pain (CNCP) (ie, pain lasting ≥3 months) attending multidisciplinary pain clinics in Quebec, Canada.

Patients and Methods

This was a retrospective cohort study of patients with CNCP enrolled in the Quebec Pain Registry (QPR) between 2008 and 2014. QPR data were linked to the Quebec health insurance databases. The index date was the date of the first visit at the pain clinic. Prevalence of doctor shopping was assessed within the 12 months following the index date. Doctor shopping was defined as at least 1 day of overlapping opioid prescriptions from ≥2 prescribers and filled in ≥3 pharmacies.

Results

A total of 2191 patients with CNCP with at least one opioid dispensation within the 12 months following the index date were included. The mean age was 58.6±14.9 years and 41.3% were men. The median pain duration was 4 years, and 13.3% of patients were diagnosed with neuropathic pain. Regarding past year comorbidities, 15.0% presented anxiety, 16.8% depression and 6.4% substance use disorder. Among the included patients, 15 (0.7%) presented at least one episode of doctor shopping. Among these doctor-shoppers, 9 (60.0%) exhibited only 1 episode.

Conclusion

Opioid doctor shopping is a rare phenomenon among patients with CNCP treated in tertiary care settings. Opioids should remain a drug option for patients without substance use disorder, and who have persistent pain despite optimized nonopioid therapy.

Associations between spouse and service member prescriptions for high-risk and long-term opioids: A dyadic study

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Military spouses were more likely to have risky opioid Rx if their spouse did.

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High-risk opioid therapy was linked to pain, disability, smoking, and ACES

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Reducing risky opioid Rx for service members may reduce similar risky Rx for spouses.

Background

Estimates suggest approximately 2.4% of service members, and 15% of service members who have engaged in recent combat, report misusing pain relievers in the past year. This study explores the extent to which military spouses’ obtainment of opioids is associated with their service member partners’ obtainment of opioid prescriptions, in addition to other factors such as service member health, state prescribing patterns, and sociodemographic characteristics.

Methods

Data were drawn from the Millennium Cohort Family Study, a large, longitudinal survey of married spouses of service members from all service branches, and archival data analyzed from 2018 to 2020. The dependent variables were spouse long-term opioid therapy and spouse opioid prescriptions that pose a high risk of adverse outcomes.

Results

Seven percent of spouse and service member dyads met the criteria for high-risk opioid use, generally because they had purchased a prescription for a ≥90 Morphine Milligram Equivalents daily dose (76.7% for spouses, 72.8% for service members). Strong associations were found between spouse and service member opioid therapies (OR = 5.53 for long-term; OR = 2.20 for high-risk).

Conclusions

Findings suggest that reducing the number of long-term and high-risk opioid prescriptions to service members may subsequently reduce the number of similar prescriptions obtained by their spouses. Reducing the number of service members and spouses at risk for adverse events may prove to be effective in stemming the opioid epidemic and improve the overall health and safety of military spouses and thus, the readiness of the U.S. Armed Forces.

Psychological interventions to reduce postoperative pain and opioid consumption: a narrative review of literature

BACKGROUND

Evidence suggests that over half of patients undergoing surgical procedures suffer from poorly controlled postoperative pain. In the context of an opioid epidemic, novel strategies for ameliorating postoperative pain and reducing opioid consumption are essential. Psychological interventions defined as strategies targeted towards reducing stress, anxiety, negative emotions and depression via education, therapy, behavioral modification and relaxation techniques are an emerging approach towards these endpoints.

OBJECTIVE

This review explores the efficacy of psychological interventions for reducing postoperative pain and opioid use in the acute postoperative period.

EVIDENCE REVIEW

An extensive literature search was conducted in MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Medline In-Process/ePubs, Embase, Ovid Emcare Nursing, and PsycINFO, Web of Science (Clarivate), PubMed-NOT-Medline (NLM), CINAHL and ERIC, and two trials registries, ClinicalTrials.Gov (NIH) and WHO ICTRP. Included studies were limited to those investigating adult human subjects, and those published in English.

FINDINGS

Three distinct forms of psychological interventions were identified: relaxation, psychoeducation and behavioral modification therapy. Study results showed a reduction in both postoperative opioid use and pain scores (n=5), reduction in postoperative opioid use (n=3), reduction in postoperative pain (n=5), no significant reduction in pain or opioid use (n=7), increase in postoperative opioid use (n=1) and an increase in postoperative pain (n=1).

CONCLUSION

Some preoperative psychological interventions can reduce pain scores and opioid consumption in the acute postoperative period; however, there is a clear need to strengthen the evidence for these interventions. The optimal technique, strategies, timing and interface requires further investigation.