Prevention of Prescription Opioid Misuse and Projected Overdose Deaths in the United States

Ketamine and hydroxynorketamine as novel pharmacotherapies for the treatment of Opioid-Use Disorders

Opioid use disorder (OUD) has reached epidemic proportions, with many countries facing high opioid use and related fatalities. Although currently-prescribed medications for OUD (MOUD) are considered life-saving, they inadequately address negative affect and cognitive impairment, resulting in high relapse rates to non-medical opioid use, even years after drug cessation (protracted abstinence). Evidence supports the notion that ketamine, an anesthetic and rapid-acting antidepressant drug, holds promise as a candidate for OUD treatment, including the management of acute withdrawal somatic symptoms, negative affect during protracted opioid abstinence and prevention of re-taking non-medical opioids. In this review, we comprehensively discuss preclinical and clinical research evaluating ketamine and its metabolites as potential novel therapeutic strategies for treating OUDs. We further examine evidence supporting the relevance of the molecular targets of ketamine and its metabolites in relation to their potential effects and therapeutic outcomes in OUDs. Overall, existing evidence demonstrates that ketamine and its metabolites can effectively modulate pathophysiological processes affected in OUD, suggesting their promising therapeutic role in the treatment of OUD and the prevention of return to opioid use during abstinence.

Improving Estimates of the Prevalence of Opioid Use Disorder in the United States: Revising Keyes et al

OBJECTIVES

The United States faces an ongoing drug overdose crisis, but accurate information on the prevalence of opioid use disorder (OUD) remains limited. A recent analysis by Keyes et al used a multiplier approach with drug poisoning mortality data to estimate OUD prevalence. Although insightful, this approach made stringent and partly inconsistent assumptions in interpreting mortality data, particularly synthetic opioid (SO)-involved and non-opioid-involved mortality. We revise that approach and resulting estimates to resolve inconsistencies and examine several alternative assumptions.

METHODS

We examine 4 adjustments to Keyes and colleagues' estimation approach: (A) revising how the equations account for SO effects on mortality, (B) incorporating fentanyl prevalence data to inform estimates of SO lethality, (C) using opioid-involved drug poisoning data to estimate a plausible range for OUD prevalence, and (D) adjusting mortality data to account for underreporting of opioid involvement.

RESULTS

Revising the estimation equation and SO lethality effect (adj. A and B) while using Keyes and colleagues' original assumption that people with OUD account for all fatal drug poisonings yields slightly higher estimates, with OUD population reaching 9.3 million in 2016 before declining to 7.6 million by 2019. Using only opioid-involved drug poisoning data (adj. C and D) provides a lower range, peaking at 6.4 million in 2014-2015 and declining to 3.8 million in 2019.

CONCLUSIONS

The revised estimation equation presented is feasible and addresses limitations of the earlier method and hence should be used in future estimations. Alternative assumptions around drug poisoning data can also provide a plausible range of estimates for OUD population.

Nor-LAAM loaded PLGA microparticles for treating opioid use disorder

The treatment landscape for opioid use disorder (OUD) faces challenges stemming from the limited efficacy of existing medications, poor adherence to prescribed regimens, and a heightened risk of fatal overdose post-treatment cessation. Therefore, there is a pressing need for innovative therapeutic strategies that enhance the effectiveness of interventions and the overall well-being of individuals with OUD. This study explored the therapeutic potential of nor-Levo-α-acetylmethadol (nor-LAAM) to treat OUD. We developed sustained release nor-LAAM-loaded poly (lactic-co-glycolic acid) (PLGA) microparticles (MP) using a hydrophobic ion pairing (HIP) approach. The nor-LAAM-MP prepared using HIP with pamoic acid had high drug loading and exhibited minimal initial burst release and sustained release. The nor-LAAM-MP was further optimized for desirable particle size, drug loading, and release kinetics. The lead nor-LAAM-MP (F4) had a relatively high drug loading (11 wt%) and an average diameter (19 μm) and maintained a sustained drug release for 4 weeks. A single subcutaneous injection of nor-LAAM-MP (F4) provided detectable nor-LAAM levels in rabbit plasma for at least 15 days. We further evaluated the therapeutic efficacy of nor-LAAM-MP (F4) in a well-established fentanyl-addiction rat model, and revealed a marked reduction in fentanyl choice and withdrawal symptoms in fentanyl-dependent rats. These findings provide insights into further developing long-acting nor-LAAM-MP for treating OUD. It has the potential to offer a new effective medication to the existing sparse armamentarium of products available to treat OUD.

Opioid prescribing requirements to minimize unused medications after an emergency department visit for acute pain: a prospective cohort study

BACKGROUND

Unused opioid prescriptions can be a driver of opioid misuse. Our objective was to determine the optimal quantity of opioids to prescribe to patients with acute pain at emergency department discharge, in order to meet their analgesic needs while limiting the amount of unused opioids.

METHODS

In a prospective, multicentre cohort study, we included consecutive patients aged 18 years and older with an acute pain condition present for less than 2 weeks who were discharged from emergency department with an opioid prescription. Participants completed a pain medication diary for real-time recording of quantity, doses, and names of all analgesics consumed during a 14-day follow-up period.

RESULTS

We included 2240 participants, who had a mean age of 51 years; 48% were female. Over 14 days, participants consumed a median of 5 (quartiles, 1-14) morphine 5 mg tablet equivalents, with significant variation across pain conditions (p < 0.001). Most opioid tablets prescribed (63%) were unused. To meet the opioid need of 80% of patients for 2 weeks, we found that those experiencing renal colic or abdominal pain required fewer opioid tablets (8 morphine 5 mg tablet equivalents) than patients who had fractures (24 tablets), back pain (21 tablets), neck pain (17 tablets), or other musculoskeletal pain (16 tablets).

INTERPRETATION

Two-thirds of opioid tablets prescribed at emergency department discharge for acute pain were unused, whereas opioid requirements varied significantly based on the cause of acute pain. Smaller, cause-specific opioid prescriptions could provide adequate pain management while reducing the risk of opioid misuse.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT03953534.

Pain management inequities by demographic and geriatric-related variables in older adult inpatients

BACKGROUND

Pain is ubiquitous, yet understudied. The objective of this study was to analyze inequities in pain assessment and management for hospitalized older adults focusing on demographic and geriatric-related variables.

METHODS

This was a retrospective cohort study from January 2013 through September 2021 of all adults 65 years or older on the general medicine service at UCSF Medical Center. Primary exposures included (1) demographic variables including race/ethnicity and limited English proficiency (LEP) status and (2) geriatric-related variables including age, dementia or mild cognitive impairment diagnosis, hearing or visual impairment, end-of-life care, and geriatrics consult involvement. Primary outcomes included (1) adjusted odds of numeric pain assessment versus other assessments and (2) adjusted opioids administered, measured by morphine milligram equivalents (MME).

RESULTS

A total of 15,809 patients were included across 27,857 hospitalizations with 1,378,215 pain assessments, with a mean age of 77.8 years old. Patients were 47.4% White, 26.3% with LEP, 49.6% male, and 50.4% female. Asian (OR 0.75, 95% CI 0.70-0.80), Latinx (OR 0.90, 95% CI 0.83-0.99), and Native Hawaiian or Pacific Islander (OR 0.77, 95% CI 0.64-0.93) patients had lower odds of a numeric assessment, compared with White patients. Patients with LEP (OR 0.70, 95% CI 0.66-0.74) had lower odds of a numeric assessment, compared with English-speaking patients. Patients with dementia, hearing impairment, patients 75+, and at end-of-life were all less likely to receive a numeric assessment. Compared with White patients (86 MME, 95% CI 77-96), Asian patients (55 MME, 95% CI 46-65) received fewer opioids. Patients with LEP, dementia, hearing impairment and those 75+ years old also received significantly fewer opioids.

CONCLUSION

Older, hospitalized, general medicine patients from minoritized groups and with geriatric-related conditions are uniquely vulnerable to inequitable pain assessment and management. These findings raise concerns for pain underassessment and undertreatment.

Exploring Opioid Prescription Patterns and Overdose Rates in South Carolina (2017-2021): Insights into Rising Deaths in High-Risk Areas

With opioid overdose rates on the rise, we aimed to develop a county-level risk stratification that specifically focused on access to medications for opioid use disorder (MOUDs) and high overdose rates. We examined over 15 million records from the South Carolina Prescription Tracking System (SCRIPTS) across 46 counties. Additionally, we incorporated data from opioid treatment programs, healthcare professionals prescribing naltrexone, clinicians with buprenorphine waivers, and county-level overdose fatality statistics. To assess the risk of opioid misuse, we classified counties into high-risk and low-risk categories based on their prescription rates, overdose fatalities, and treatment service availability. Statistical methods employed included the two-sample t-test and linear regression. The t-test assessed the differences in per capita prescription rates between high-risk and low-risk counties. Linear regression was used to analyze the trends over time. Our study showed that between 2017 and 2021, opioid prescriptions decreased from 64,223 to 41,214 per 100,000 residents, while fentanyl-related overdose deaths increased by 312%. High-risk counties had significantly higher rates of fentanyl prescriptions and relied more on out-of-state doctors. They also exhibited higher instances of doctor shopping and had fewer medical doctors per capita, with limited access to MOUDs. To effectively combat the opioid crisis, we advocate for improved local healthcare infrastructure, broader treatment access, stricter management of out-of-state prescriptions, and vigilant tracking of prescription patterns. Tailored local strategies are essential for mitigating the opioid epidemic in these communities.

Telehealth Utilization for Opioid Use Disorder: A Nationwide Analysis Before and After the COVID-19 Public Health Emergency Declaration

Introduction: The COVID-19 pandemic has led to the rapid and widespread adoption of telehealth services. Telehealth may aid in bridging gaps in access to care. The specific impact of telehealth on opioid use disorder (OUD) and its treatment remains uncertain. Methods: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of(a) OUD treatments with and without telehealth support and (b) prescriptions for medications for opioid use disorder (MOUD) with and without telehealth support among individuals diagnosed with OUD. Results: In a study population of 1,340,506 individuals, OUD diagnosis rates were 5 per 1,000 in-person and 1 per 1,000 via telehealth. COVID-19 decreased in-person OUD diagnoses by 0.89 per 1,000, while telehealth diagnoses increased by 0.83 per 1,000. In-person MOUD treatment rates increased by 0.07 per 1,000 during COVID-19, while telehealth rates remained low. The onset of COVID-19 saw a 1.13 per 1,000 higher increase in telehealth-supported MOUD treatment compared to solely in-person treatment. Conclusions: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of (a) OUD treatments with and without telehealth support and (b) prescriptions for MOUD with and without telehealth support among individuals diagnosed with OUD.

Understanding Public Perception of Naloxone: A Study of FAQs and Answer Source Credibility

PURPOSE

The most commonly used intervention for opioid overdoses is naloxone. With naloxone soon to be sold over-the-counter in the United States, the goal of this paper is to categorize frequently asked questions (FAQs) and answers about naloxone using internet sources in a cross-sectional fashion.

METHODS

Terms "narcan" and "naloxone" were searched on a clean Google Chrome browser using the "People also asked" tab to find FAQs and their answer sources. We classified questions and sources and assessed each website's quality and credibility grading with JAMA benchmark criteria. The Kruskal-Wallis H test was used to determine variance of mean JAMA score by source type and Post-Hoc Dunn's test with Bonferroni corrected alpha of 0.005 used to compare source types.

RESULTS

Of the 305 unique questions, 202 (66.2%) were classified as facts, 78 (25.6%) were policy, and 25 (8.2%) were value. Of the 144 unique answer sources, the two most common included 55 (38.2%) which were government entities and 47 (32.6%) which were commercial entities. Ninety-two (of 144, 63.9%) sources met three or more JAMA benchmark criteria. Statistical analysis showed a significant difference between the JAMA benchmark scores by source type H(4) = 12.75, p = 0.0126 and between the mean rank of academic and government sources (p = 0.0036).

CONCLUSION

We identified FAQs and their citations about naloxone, highlighting potential lack of understanding and knowledge of this important intervention. We recommend updating websites to accurately reflect current and useful information for those that may require naloxone.

Nor-LAAM loaded PLGA Microparticles for Treating Opioid Use Disorder

The treatment landscape for opioid use disorder (OUD) faces challenges stemming from the limited efficacy of existing medications, poor adherence to prescribed regimens, and a heightened risk of fatal overdose post-treatment cessation. Therefore, there is a pressing need for innovative therapeutic strategies that enhance the effectiveness of interventions and the overall well-being of individuals with OUD. This study explored the therapeutic potential of nor-Levo-α-acetylmethadol (nor-LAAM) to treat OUD. We developed sustained release nor-LAAM-loaded poly (lactic-co-glycolic acid) (PLGA) microparticles (MP) using a hydrophobic ion pairing (HIP) approach. The nor-LAAM-MP prepared using HIP with pamoic acid had high drug loading and exhibited minimal initial burst release and sustained release. The nor-LAAM-MP was further optimized for desirable particle size, drug loading, and release kinetics. The lead nor-LAAM-MP (F4) had a relatively high drug loading (11 wt.%) and an average diameter (19 µm) and maintained a sustained drug release for 4 weeks. A single subcutaneous injection of nor-LAAM-MP (F4) provided detectable nor-LAAM levels in rabbit plasma for at least 15 days. We further evaluated the therapeutic efficacy of nor-LAAM-MP (F4) in a well-established fentanyl-addiction rat model, and revealed a marked reduction in fentanyl choice and withdrawal symptoms in fentanyl-dependent rats. These findings provide insights into further developing long-acting nor-LAAM-MP for treating OUD. It has the potential to offer a new effective medication to the existing sparse armamentarium of products available to treat OUD.

Identifying patterns of pain, depression, anxiety, interpersonal trauma exposure, and nonmedical prescription opioid use: Latent class analysis among patients with chronic pain

BACKGROUND

Chronic pain in the context of certain factors may be associated with potential for nonmedical prescription opioid use; however, identifying this risk can be challenging and complex. Several variables alone have been associated with non-prescribed opioid use, including depression, anxiety, pain interference, and trauma exposure. Prior research has often failed to integrate these assessments together, which is important as these factors may cluster together in important and complex ways. The current study aimed to identify classes of patients with chronic pain who have differential risk for use of nonmedical prescription opioid use, depression and anxiety, and pain severity, interference, and catastrophizing, and interpersonal violence exposure.

METHODS

Self-report and medical record data from patients (N = 211; Mage = 48, 69.0% women, 69.0% white) at a pain management center were collected.

RESULTS

Latent class analysis revealed 3 classes with (1) low probability of clinically significant depression, anxiety, pain, and nonmedical prescription opioid use (44.7%), (2) high probability of clinically significant depression, anxiety, pain, pain catastrophizing, trauma, and nonmedical prescription opioid use (41.3%), and (3) high probability of severe pain and nonmedical prescription opioid use (14.0%).

CONCLUSIONS

High-risk classes had either high levels of depression and anxiety, pain catastrophizing, and interpersonal violence exposure, or pain severity and interference. Future research should continue to explore these classes in large, diverse samples, and prospective study designs. Finally, results underscore that opioid use is complex, not easily identified by a single factor, and may be motivated by complex unmet clinical needs.

Public Health Interventions and Overdose-Related Outcomes Among Persons With Opioid Use Disorder

Importance

Given the high number of opioid overdose deaths in the US and the complex epidemiology of opioid use disorder (OUD), systems models can serve as a tool to identify opportunities for public health interventions.

Objective

To estimate the projected 3-year association between public health interventions and opioid overdose-related outcomes among persons with OUD.

Design, Setting, and Participants

This decision analytical model used a simulation model of the estimated US population aged 12 years and older with OUD that was developed and analyzed between January 2019 and December 2023. The model was parameterized and calibrated using 2019 to 2020 data and used to estimate the relative change in outcomes associated with simulated public health interventions implemented between 2021 and 2023.

Main Outcomes and Measures

Projected OUD and medications for OUD (MOUD) prevalence in 2023 and number of nonfatal and fatal opioid-involved overdoses among persons with OUD between 2021 and 2023.

Results

In a baseline scenario assuming parameters calibrated using 2019 to 2020 data remained constant, the model projected more than 16 million persons with OUD not receiving MOUD treatment and nearly 1.7 million persons receiving MOUD treatment in 2023. Additionally, the model projected over 5 million nonfatal and over 145 000 fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. When simulating combinations of interventions that involved reducing overdose rates by 50%, the model projected decreases of up to 35.2% in nonfatal and 36.6% in fatal opioid-involved overdoses among persons with OUD. Interventions specific to persons with OUD not currently receiving MOUD treatment demonstrated the greatest reduction in numbers of nonfatal and fatal overdoses. Combinations of interventions that increased MOUD initiation and decreased OUD recurrence were projected to reduce OUD prevalence by up to 23.4%, increase MOUD prevalence by up to 137.1%, and reduce nonfatal and fatal opioid-involved overdoses among persons with OUD by 6.7% and 3.5%, respectively.

Conclusions and Relevance

In this decision analytical model study of persons with OUD, findings suggested that expansion of evidence-based interventions that directly reduce the risk of overdose fatality among persons with OUD, such as through harm reduction efforts, could engender the highest reductions in fatal overdoses in the short-term. Interventions aimed at increasing MOUD initiation and retention of persons in treatment projected considerable improvement in MOUD and OUD prevalence but could require a longer time horizon for substantial reductions in opioid-involved overdoses.

Evaluation of the Functionality in an Emergency Department Setting of an Intravenous Protection Device to Prevent Self-Injection

Background

The United States has an opioid abuse crisis that has been increasing exponentially since 2013. In 2021, there were 220 deaths each day from opioid overdoses in the United States alone. Patients suffering from addiction often present to the emergency department (ED) anticipating that an intravenous (IV) catheter will be placed. This catheter is then accessible for patients to self-inject illicit drugs while under medical care or elope from the facility with the IV in place to self-inject. The misuse of medical IV access is a potential source of prolonged hospitalizations and fatal overdoses nationwide. On two separate occasions, patients were found dead in our ED bathroom after overdosing by accessing their IV site for self-injection. These events prompted the development of the IV SafeLock prototype. The IV SafeLock is designed to prevent intravenous access by the patient while allowing access by specified providers to administer medications. This study aims to investigate prototype usability and functionality by nursing staff in the ED.

Methods

A prospective study was performed with twenty ED nurses in a clinical trial to use the IV SafeLock in the clinical setting. Each nurse was given two months to complete an evaluation of 20 patients requiring IV access. They used the IV SafeLock on infusion ports and Intermittent Needle Therapy (INT) access sites. A Likert scale was used to measure the ease of function and use of the IV SafeLock.

Results and conclusion

The nurses felt that the IV SafeLock was easy to use and achieved its function of protecting the intravenous access site from self-injection. The IV SafeLock prototypes used in the trial were easy to use and functioned as intended most of the time. The IV SafeLock can be used by nursing staff in a clinical setting to help prevent self-injection.

Clinical Trial Registration

NCT05695183 enrolled 01/12/2023.

Opioid Prescription and Long-Term Survival Outcomes in Adults: A Nationwide Cohort Study in Korea

BACKGROUND

We aimed to investigate the association between short- and long-term opioid use and long-term mortality in Korea.

METHODS

In this population-based retrospective cohort study, data were obtained from the National Health Insurance Service of South Korea. The study included all adult individuals who were prescribed opioids in 2016. The control group comprised adults not prescribed opioids in 2016 selected using a 1:1 stratified random sampling technique. Participants were categorized into three groups: non-user, opioid 1-89 days user (short-term), and opioid ≥ 90 days user (long-term) groups. The primary endpoint in this study was 5-year all-cause mortality, evaluated from January 1, 2017 to December 31, 2021.

RESULTS

In total, 4,556,606 adults were included in this study. Of these, 2,070,039 were prescribed opioids at least once. Specifically, 1,592,883 adult individuals were prescribed opioids for 1-89 days, while 477,156 adults were prescribed opioid for ≥ 90 days. In the multivariable Cox regression modelling, the opioid user group had a 28% (hazard ratio [HR], 1.28; 95% confidence interval [95% CI], 1.26-1.29; P < 0.001) higher risk of 5-year all-cause mortality than had the non-user group. Moreover, the opioid 1-89 days and opioid ≥ 90 days user groups had 15% (HR, 1.15; 95% CI, 1.14-1.17; P < 0.001) and 49% (HR, 1.49; 95% CI, 1.47-1.51; P < 0.001) higher risks of 5-year all-cause mortality than had the non-user group, respectively.

CONCLUSION

Both short and long-term opioid prescriptions were associated with increased long-term mortality among the Korean adult population.

Development of a Medical Device in Response to a Fatal Self-Injection of Non-prescribed Opioids: A Case Report

Patients who inject drugs (PWID) pose unique challenges in their medical care due to risks of increased infection and overdose. There are no known commercially available devices to prevent patients from self-injecting non-prescribed substances into vascular access devices (VADs). A patient in the emergency department (ED) of a midsized suburban hospital self-injected an opioid in the ED restroom after the placement of a vascular catheter by the nursing staff as part of her ED care. Despite precautions taken for a patient with a known opioid use disorder (OUD) and a history of self-injecting non-prescribed substances into VADs, the patient suffered a self-induced fatal overdose. PWID are at significant risk of self-injection when requiring intravenous medications as part of their medical care. This case highlighted the need for formal reporting for patients who self-inject non-prescribed substances into VADs. It revealed a lack of medical devices to help providers ensure that PWID cannot access their medical devices when intravenous therapy is indicated.

Trends in Healthy Life Expectancy (HALE) and Disparities by Income and Region in Korea (2008-2020): Analysis of a Nationwide Claims Database

BACKGROUND

Healthy life expectancy is a well-recognized indicator for establishing health policy goals used in Korea's Health Plan. This study aimed to explore Koreans' healthy life expectancy and its gender, income, and regional disparities from 2008 to 2020.

METHODS

This study was conducted on the entire population covered by health insurance and medical aid program in Korea. The incidence-based "years lived with disability" for 260 disease groups by gender, income level, and region was calculated employing the methodology developed in the Korean National Burden of Disease Study, and it was used as the number of healthy years lost to calculate health-adjusted life expectancy (HALE).

RESULTS

Koreans' HALE increased from 68.89 years in 2008 to 71.82 years in 2020. Although the gender disparity in HALE had been decreasing, it increased to 4.55 years in 2020. As of 2020, 5.90 years out of 8.67 years of the income disparity (Q5-Q1) in HALE were due to the disparity between Q1 and Q2, the low-income groups. Income and regional disparities in HALE exhibited an increasing trend, and these disparities were higher in men than in women.

CONCLUSION

A subgroup with a low health level was identified through the HALE results, and it was confirmed that improving the health level of this population can reduce health inequalities and improve health at the national level. Further exploration of the HALE calculation methodology may help in the development of effective policies such as prioritizing interventions for health risk factors.

Determinants of prescription opioid misuse among Black Americans: Evidence from the 2019 National Survey on Drug Use and Health

BACKGROUND

Opioid misuse, including prescription opioid misuse, remains a significant public health concern impacting various ethnoracial groups in the United States, including non-Hispanic Black Americans. This study provides more recent evidence on prescription opioid misuse among Black Americans.

METHODS

We used data from the 2019 National Survey on Drug Use and Health to examine the prevalence and determinants of prescription opioid misuse among Black American adults aged 18 and older. We compared these findings to non-Hispanic White American adults.

RESULTS

The prevalence rate of past-year prescription opioid misuse was very similar among Black (3.4%) and White respondents (3.8%). Adjusted multivariate logistic regression analyses found no significant racial differences in prescription opioid misuse. Religious importance and rurality were negatively associated with misuse only among Black respondents. Depressive episodes, other drug use, age, and risk-taking behaviors were associated with prescription opioid misuse among both Black and White respondents.

CONCLUSION

Black and White Americans remain at risk for prescription opioid-related problems. Religiosity and rurality require further investigation to understand how they may impact misuse among Black Americans.

Opioid use disorder: current trends and potential treatments

Opioid use disorder (OUD) is a major public health threat, contributing to morbidity and mortality from addiction, overdose, and related medical conditions. Despite our increasing knowledge about the pathophysiology and existing medical treatments of OUD, it has remained a relapsing and remitting disorder for decades, with rising deaths from overdoses, rather than declining. The COVID-19 pandemic has accelerated the increase in overall substance use and interrupted access to treatment. If increased naloxone access, more buprenorphine prescribers, greater access to treatment, enhanced reimbursement, less stigma and various harm reduction strategies were effective for OUD, overdose deaths would not be at an all-time high. Different prevention and treatment approaches are needed to reverse the concerning trend in OUD. This article will review the recent trends and limitations on existing medications for OUD and briefly review novel approaches to treatment that have the potential to be more durable and effective than existing medications. The focus will be on promising interventional treatments, psychedelics, neuroimmune, neutraceutical, and electromagnetic therapies. At different phases of investigation and FDA approval, these novel approaches have the potential to not just reduce overdoses and deaths, but attenuate OUD, as well as address existing comorbid disorders.

Opioid Prescribing Patterns After Imposition of Setting-Specific Limits on Prescription Duration

Importance

Despite their widespread adoption across the US, policies imposing one-size-fits-all limits on the duration of prescriptions for opioids have shown modest and mixed implications for prescribing.

Objective

To assess whether a prescription duration limit policy tailored to different clinical settings was associated with shorter opioid prescription lengths.

Design, Setting, and Participants

This cross-sectional study examined changes in opioid prescribing patterns for opioid-naive Medicaid enrollees aged 12 to 64 years before and after implementation of a statewide prescription duration limit policy in West Virginia in June 2018. Patients with cancer or Medicare coverage were excluded. The policy assigned a 7-day duration limit to opioid prescriptions for adults treated in outpatient hospital- or office-based practices, a 4-day limit for adults treated in emergency departments, and a 3-day limit for pediatric patients younger than 18 years regardless of clinical setting. Data were examined from January 1, 2017, through September 30, 2019, and data were analyzed from June 12 to October 30, 2023.

Main Outcomes and Measures

Whether a patient's initial opioid prescription was longer in days than the June 2018 policy limit for a given care setting before and after policy implementation. Interrupted time series models were used to calculate the association between the policy's implementation and outcomes.

Results

The analytic sample included 44 703 Medicaid enrollees (27 957 patients [62.5%] before policy implementation and 16 746 patients [37.5%] after policy implementation; mean [SD] age, 33.9 [13.4] years; 27 461 females [61.4%]). Among adults treated in outpatient hospital- or office-based settings, the duration limit policy was associated with a decrease of 8.83 (95% CI, -10.43 to -7.23) percentage points (P < .001), or a 56.8% relative reduction, in the proportion of prescriptions exceeding the 7-day limit. In the emergency department setting, the policy was associated with a decrease of 7.03 (95% CI, -10.38 to -3.68) percentage points (P < .001), a 37.5% relative reduction, in the proportion of prescriptions exceeding the 4-day limit. The proportion of pediatric opioid prescriptions longer than the 3-day limit decreased by 12.80 (95% CI, -17.31 to -8.37) percentage points (P < .001), a 26.5% relative reduction, after the policy's implementation.

Conclusions and Relevance

Results of this cross-sectional study suggest that opioid prescription duration limits tailored to different clinical settings are associated with reduced length of prescriptions for opioid-naive patients. Additional research is needed to evaluate whether these limits are associated with reductions in the incidence of opioid use disorder or with unintended consequences, such as shifts to illicit opioids.

Post-Operative Complications Associated with Long-Term NSAID or Long-Term Opioid Use Prior to Lumbar Spinal Fusion Surgery

OBJECTIVE

Lower back pain (LBP) has been implicated as a significant cause of chronic pain in the United States, often requiring analgesic use. In this study, we investigate the trends in long-term preoperative NSAID (LTN) and Opioid (LTO) use in patients with low back pain in the United States, and the resultant postoperative complications following lumbar fusion.

METHODS

In this retrospective cohort study of patients with lumbar pathologies, multivariate population-based regression models were developed using the 2010-2017 National Readmission Database. Short-term complications (30-, 90-day) and long-term complications (180-, 300-day) were analyzed at readmission.

RESULTS

Of patients diagnosed with LBP (N = 1427,190) we found a rise in LTO users and a fall in LTN users following 2015. We identified 654,264 individuals who received a lumbar spine fusion, of which 22,975 were LTN users and 11,213 were LTO users. LTO users had significantly higher total inpatient charges (p-value<0.0001) and LOS (p-value<0.0001), while LTN users had lower rates of acute infection (OR: 0.993, 95% CI: 0.987-0.999, p = 0.017) and acute posthemorrhagic anemia (OR: 0.957, 95% CI: 0.935-0.979, p < 0.001) at primary admission. Readmission analysis showed that LTN use had significantly lower odds of readmission compared to LTO use at all time points (p < 0.01 for all). LTN use had significantly higher odds of hardware failure (OR: 1.134, 95% CI: 1.039-1.237, p = 0.005) within 300-days of receiving a lumbar fusion.

CONCLUSIONS

LTO users had significantly higher readmission rates compared to LTN. In addition, we found that LTN use was associated with significantly higher odds of hardware failure at long-term follow-up in patients receiving lumbar fusion surgery.

The effects of (2R,6R)-hydroxynorketamine on oxycodone withdrawal and reinstatement

Despite the thousands of lives lost during the ongoing opioid crisis, a scarcity of new and effective clinical treatments for opioid use disorder (OUD) remains. To address this unmet need, some researchers have turned to dissociative and psychedelic drugs to treat multiple psychiatric conditions. In particular, low doses of ketamine have been shown to attenuate opioid withdrawal and drug use in clinical and preclinical studies. However, ketamine has misuse liability and dissociative side effects that may limit its widespread application as a treatment for OUD. More recently, (2R,6R)-hydroxynorketamine (HNK), a ketamine metabolite that lacks misuse potential, has gained attention for its effectiveness in depression and stress models. To uncover its role in OUD, we tested the time-dependent effects of (2R,6R)-HNK on oxycodone withdrawal and reinstatement of oxycodone conditioned place preference (CPP). In male and female oxycodone-dependent mice, we found that 24h pretreatment with (2R,6R)-HNK (10 or 30mg/kg, s.c.) reduced the frequency of withdrawal-like behaviors and global withdrawal scores during naloxone-precipitated withdrawal, whereas 1h pretreatment with (2R,6R)-HNK only reduced paw tremors and the sum of global withdrawal scores but not GWS Z-scores. In other experiments, both 1h and 24h pretreatment with (2R,6R)-HNK (30mg/kg, s.c.) blocked drug-induced reinstatement of oxycodone CPP. Finally, we found (2R,6R)-HNK (30mg/kg, sc) had no effect on locomotor activity and thigmotaxis. Together, these results indicate that acute (2R,6R)-HNK has efficacy in some preclinical models of OUD without producing locomotor or anxiety-like side effects.

Impact of opioid law on prescriptions and satisfaction of pediatric burn and orthopedic patients: An epidemiologic study

OBJECTIVES

The objective of this study was to determine the reduction in prescribed opioid pain dosage units to pediatric patients experiencing acute pain and to assess patient satisfaction with pain control 90-day post discharge following the 2017 Ohio opioid prescribing cap law.

METHODS

The retrospective chart review included 960 pediatric (age 0-18 years) burn injury and knee arthroscopy patients treated between August 1, 2015-August 31, 2019. Prospectively, legal guardians completed a survey for a convenience sample of 50 patients. Opioid medications (days and morphine milligram equivalents (MMEs)/kg) prescribed at discharge before and after the Ohio law implementation were collected. Guardians reported experience and satisfaction with their child's opioid prescription at 90-days post discharge.

RESULTS

From pre-law to post-law, there was a significant decrease (p<0.001) within the burn and knee cohorts in the median days (1.7 to 1.0 and 5.0 to 3.8, respectively) and median total MMEs prescribed (15.0 to 2.5 and 150.0 to 90.0, respectively). An interrupted time series analysis revealed a statistically significant decrease in MMEs/kg and days prescribed at discharge when the 2017 Ohio opioid prescription law went into effect, with an abrupt level change. Prospectively, more than half of participants were satisfied (72% burn and 68% knee) with their pain control and felt they received the right amount of medication (84% burn and 56% knee). Inpatient opioid use was not changed pre- and post-law.

CONCLUSIONS

Discharge opioids prescribed for pediatric burn and knee arthroscopy procedures has decreased from 2015-2019. Caregivers varied greatly in their satisfaction with pain control and the amount of opioid prescribed.

Determining the Impact of Opioid Policy on Substance Use and Mental Health-Related Harms: Protocol for a Data Linkage Study

BACKGROUND

Increasing harms related to prescription opioids over the past decade have led to the introduction of a range of key national and state policy initiatives across Australia. These include introducing a mandatory real-time prescription drug-monitoring program in the state of Victoria from April 2020 and a series of changes to subsidies for opioids on the Pharmaceutical Benefit Scheme from June 2020. Together, these changes aim to influence opioid supply and reduce harms related to prescription opioids, yet few studies have specifically explored how these policies have influenced opioid prescribing and related harms in Australia.

OBJECTIVE

The aim of this study is to examine the impact of a range of opioid-related policies on hospital admissions and emergency department (ED) presentations in Victoria, Australia. In particular, the study aims to understand the effect of various opioid policies and opioid-prescribing changes on (1) the number and rates of ED presentations and hospital admissions attributed to substance use (ie, opioid and nonopioid related) or mental ill-health (eg, suicide, self-harm, anxiety, and depression), (2) the association between differing opioid dose trajectories and the likelihood of ED presentations and hospital admissions related to substance use and mental ill-health, and (3) whether changes in an individual's opioid prescribing change the risk related to ED presentations and hospital admissions related to substance use and mental ill-health.

METHODS

We will conduct a population-level linked data study. General practice health records obtained from the Population Level Analysis and Reporting platform are linked with person-level data from 3 large hospital networks in Victoria, Australia. Interrupted time series analysis will be used to examine the impact of opioid policies on a range of harms, including the rates of presentations related to substance use (opioid and nonopioid) and mental ill-health among the primary care cohort. Group-based trajectory modeling and a case-crossover design will be used to further explore the impact of changes in opioid dosage and other covariates on opioid and nonopioid poisonings and mental ill-health-related presentations at the patient level.

RESULTS

Given that this paper serves as a protocol, there are currently no results available. The deidentified primary health data were sourced from electronic medical records of approximately 4,717,000 patients from 542 consenting general practices over a 6-year period (2017-2022). The submission of results for publication is planned for early 2024.

CONCLUSIONS

This study will add to the limited evidence base to help understand the impact of opioid policies in Australia, including whether intended or unintended outcomes are occurring as a result.

TRIAL REGISTRATION

EU PAS Register EUPAS104005; https://www.encepp.eu/encepp/viewResource.htm?id=104006.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51825.

Developing the Opioid Rapid Response System™ for Lay Citizen Response to the Opioid Overdose Crisis: a Randomized Controlled Trial

Emergency responders face challenges in arriving timely to administer naloxone in opioid overdoses. Therefore, interest in having lay citizens administer naloxone nasal spray has emerged. These citizens, however, must be recruited and trained, and be in proximity to the overdose. This study aimed to develop the Opioid Rapid Response System (ORRS)tm to meet this need by developing a system to recruit and train citizen responders and evaluate outcomes in a randomized clinical trial. ORRS recruitment messages and training platform were developed iteratively and then outcomes for each were evaluated in a randomized, unblinded two-arm waitlist-controlled trial. ORRS was field tested in 5 Indiana counties, recruiting adult citizen responders (age 18 or older) who did not self-identity as a certified first responder. Participants were recruited using either personal or communal messages and then randomly assigned to online naloxone training and waitlisted-control conditions. Pre- and post-surveys were administered online to measure the exposure to recruitment messages and training effects on knowledge of opioid overdose, confidence responding, concerns about responding, and intent to respond. Of the 220 randomized participants (114 training, 106 waitlisted-control), 140 were analyzed (59 training, 81 waitlisted-control). Recruited participants more frequently identified with communal appeal than with the personal appeal (chi-square = 53.5; p < 0.0001). Between-group differences for intervention effects were significant for knowledge of overdose signs (Cohen's d = 1.17), knowledge of overdose management (d = 1.72), self-efficacy (d = 1.39), and concerns (d = 1.31), but not for intent (d = 0.17), which suffered from a ceiling effect. ORRS provides stronger support for efficacy than that reported for other training interventions and the digital modality eases rapid dissemination.Trial Registration: NCT04589676.

MedSMA℞T Adventures in PharmaCity Game: Youth Experiences and Recommendation for Use in Opioid Safety Education

Adolescents are often excluded from the creation of opioid safety interventions; therefore, it is crucial to design evidence-based interventions tailored for and with youth. Video games are ubiquitous and approachable to adolescents making them an accessible educational modality. MedSMA℞T: Adventures in PharmaCity is a serious game that educates adolescents and their families on the safe, appropriate, and responsible use of opioid prescriptions. The first objective of the study was to elucidate adolescents' experiences and perceptions of the game. The second objective was to elicit their recommendations for use and suggestions for improvement. Adolescents were recruited through Qualtrics research panels, social media, listservs, and snowball sampling. Recruitment occurred between April 2021 and October 2021. Eligible adolescents played the game and completed a follow-up virtual semi-structured interview with a study team member. Interviews were transcribed verbatim and uploaded to NVivo for data analysis. A thematic content analysis was performed. A total of seventy-two adolescents participated. Analysis yielded four themes: prior gaming experience, educational salience, game design impressions, and recommendations for improvement. Most adolescents approached MedSMA℞T with prior gaming experience. The youth correctly identified the game's intended objective: the promotion of opioid medication safety. Adolescents had overarchingly positive impressions of the game's levels, characters, and graphics. Study participants suggested expanded game levels, improved controls, and more instructions for gameplay. In summary, adolescents had favorable experiences using the MedSMA℞T game which allude to the wide-spread acceptability of this intervention among young people.

Patient-Reported Outcomes in Pain Management After Ambulatory Pediatric General and Urologic Surgery

BACKGROUND

Many studies evaluating opioid stewardship interventions' effects on postoperative pain rely on emergency department (ED) visits or readmissions, but patient-reported pain scores represent a more complete picture of the postoperative experience. This study compares patient-reported pain scores after ambulatory pediatric and urologic procedures and the effect of an opioid stewardship intervention that nearly eliminated the use of outpatient narcotics.

METHODS

This is a retrospective comparative study including 3173 pediatric patients who underwent ambulatory procedures from 2015 to 2019, during which there was an intervention to reduce narcotic prescriptions. Postoperative day one phone calls assessed pain levels using a four-point scale (no pain, mild pain, moderate pain controlled with medication, or severe pain uncontrolled with medication). We quantified the proportion of patients prescribed opioids pre-versus post-intervention and compared pain scores for patients receiving opioid versus non-opioid regimens.

RESULTS

Opioid prescription rates demonstrated a 6.5-fold reduction after opioid stewardship efforts. The majority of patients (2838) received non-opioids, with only 335 patients receiving opioids. Opioid patients reported moderate/severe pain slightly more than non-opioid patients (14.1% vs. 10.4%, p = 0.04). On by-procedure analyses, there were no subgroups in which non-opioid patients reported significantly higher pain scores.

CONCLUSIONS

Non-opioid postoperative pain regimens appear to be effective, with only 10.4% of patients reporting moderate/severe pain after ambulatory procedures. Future studies assessing patient-reported outcomes are necessary to optimize pain control for all patients and to determine whether there is ever an indication for opioid prescription after ambulatory general pediatric or urologic surgery.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Effect of Peripheral Magnetic Stimulation on Acute and Chronic Pain After Surgery: A Systematic Review and Meta-Analysis

Peripheral magnetic stimulation (PMS) is a potentially promising modality to help manage postoperative pain. We systematically reviewed the effect of PMS on acute and chronic postoperative pain. MEDLINE, Cochrane CENTRAL, EMBASE, ProQuest Dissertations, and clinical trials.gov were searched from inception until May 2021. We included studies of any study design that included patients ≥18 years of age undergoing any type of surgery that administered PMS within the perioperative period and evaluated postoperative pain. Seventeen randomized controlled trials and 1 nonrandomized clinical trial were included into the review. Thirteen out of the 18 studies found a positive effect with PMS on postoperative pain scores. In our meta-analysis, peripheral magnetic stimulation was more efficacious than sham or no intervention within the first 7 postoperative days (mean difference [MD] -1.64 on a 0 to 10 numerical rating score, 95% confidence interval [CI] -2.08 to -1.20, I2 = 77%, 6 studies, 231 patients). This was also true at 1 and 2 months after surgery (MD -1.82, 95% CI -2.48 to -1.17, I2 = 0%, 3 studies, 104 patients; and MD -1.96, 95% CI -3.67 to -.26, I2 = 84%, 3 studies, 104 patients, respectively). A difference was not seen with persistent pain at 6 and 12-months after surgery, acute postoperative opioid consumption, or adverse events between groups. Results are limited by heterogeneity and generally low-quality studies, as well as low or very low quality of evidence. High-quality and adequately blinded trials are needed to definitively confirm the benefits of peripheral magnetic stimulation administered in the perioperative period. PERSPECTIVE: This review evaluates the efficacy and safety of PMS on postoperative pain. The results help elucidate PMS' role in postoperative pain management and identify gaps where more research is required.

A Challenging Case of Managing Septic Arthritis of the Sternoclavicular Joint in a Patient With a History of Intravenous Opioid Use Disorder: A Case Report and Literature Review

Septic arthritis of the sternoclavicular joint (SCJ) is a rare condition with limited literature available. We present a case of a 31-year-old female patient with a history of opioid drug use who presented with septic arthritis of the left SCJ. The patient exhibited chest wall pain; imaging revealed septic arthritis with an associated retrosternal abscess. Treatment with antibiotics alone resulted in the resolution of the abscess, highlighting the potential for medical management without surgical intervention. This case report and literature review emphasizes the importance of considering septic arthritis in patients with vague chest pain, particularly those with a history of intravenous drug use, and raise awareness about the complications associated with opioid use.

A Bayesian Spatio-temporal Model to Optimize Allocation of Buprenorphine in North Carolina

The opioid epidemic is an ongoing public health crisis. In North Carolina, overdose deaths due to illicit opioid overdose have sharply increased over the last 5-7 years. Buprenorphine is a U.S. Food and Drug Administration approved medication for treatment of opioid use disorder and is obtained by prescription. Prior to January 2023, providers had to obtain a waiver and were limited in the number of patients that they could prescribe buprenorphine. Thus, identifying counties where increasing buprenorphine would yield the greatest overall reduction in overdose death can help policymakers target certain geographical regions to inform an effective public health response. We propose a Bayesian spatiotemporal model that relates yearly, county-level changes in illicit opioid overdose death rates to changes in buprenorphine prescriptions. We use our model to forecast the statewide count and rate of illicit opioid overdose deaths in future years, and we use nonlinear constrained optimization to identify the optimal buprenorphine increase in each county under a set of constraints on available resources. Our model estimates a negative relationship between death rate and increasing buprenorphine after accounting for other covariates, and our identified optimal single-year allocation strategy is estimated to reduce opioid overdose deaths by over 5.

Estimated Reductions in Opioid Overdose Deaths With Sustainment of Public Health Interventions in 4 US States

Importance

In 2021, more than 80 000 US residents died from an opioid overdose. Public health intervention initiatives, such as the Helping to End Addiction Long-term (HEALing) Communities Study (HCS), are being launched with the goal of reducing opioid-related overdose deaths (OODs).

Objective

To estimate the change in the projected number of OODs under different scenarios of the duration of sustainment of interventions, compared with the status quo.

Design, Setting, and Participants

This decision analytical model simulated the opioid epidemic in the 4 states participating in the HCS (ie, Kentucky, Massachusetts, New York, and Ohio) from 2020 to 2026. Participants were a simulated population transitioning from opioid misuse to opioid use disorder (OUD), overdose, treatment, and relapse. The model was calibrated using 2015 to 2020 data from the National Survey on Drug Use and Health, the US Centers for Disease Control and Prevention, and other sources for each state. The model accounts for reduced initiation of medications for OUD (MOUDs) and increased OODs during the COVID-19 pandemic.

Exposure

Increasing MOUD initiation by 2- or 5-fold, improving MOUD retention to the rates achieved in clinical trial settings, increasing naloxone distribution efforts, and furthering safe opioid prescribing. An initial 2-year duration of interventions was simulated, with potential sustainment for up to 3 additional years.

Main Outcomes and Measures

Projected reduction in number of OODs under different combinations and durations of sustainment of interventions.

Results

Compared with the status quo, the estimated annual reduction in OODs at the end of the second year of interventions was 13% to 17% in Kentucky, 17% to 27% in Massachusetts, 15% to 22% in New York, and 15% to 22% in Ohio. Sustaining all interventions for an additional 3 years was estimated to reduce the annual number of OODs at the end of the fifth year by 18% to 27% in Kentucky, 28% to 46% in Massachusetts, 22% to 34% in New York, and 25% to 41% in Ohio. The longer the interventions were sustained, the better the outcomes; however, these positive gains would be washed out if interventions were not sustained.

Conclusions and Relevance

In this decision analytical model study of the opioid epidemic in 4 US states, sustained implementation of interventions, including increased delivery of MOUDs and naloxone supply, was found to be needed to reduce OODs and prevent deaths from increasing again.

Changes in opioid and other analgesic prescribing following voluntary and mandatory prescription drug monitoring program implementation: A time series analysis of early outcomes

BACKGROUND

Australian prescription drug monitoring programs (PDMPs) provide information about a patient's recent medication history for controlled drugs at the point of prescribing and dispensing. Despite their increasing use, the evidence for PDMPs is mixed, and is almost exclusively from the United States. This study examined the impact of PDMP implementation on opioid prescribing among general practitioners in Victoria, Australia.

METHOD

We examined data on analgesic prescribing using electronic records of 464 medical practices in the Australian state of Victoria between 01/04/2017 and 31/12/ 2020. We used interrupted time series analyses, to examine immediate and longer-term trends in medication prescribing following voluntary (from April 2019) and mandatory PDMP implementation (from April 2020). We examined changes in three outcomes (i) 'high' opioid dose (50-100mg oral morphine equivalent daily dose (OMEDD) and over 100mg (OMEDD) prescribing (ii) prescribing of high-risk medication combinations (opioids with either benzodiazepines or pregabalin), and (iii) initiation of non-controlled pain medications (tricyclic antidepressants, pregabalin and tramadol).

RESULTS

We found no effect of voluntary or mandatory PDMP implementation on 'high-dose' opioid prescribing with reductions only seen in those prescribed <20mg OMEDD (i.e., the lowest dose category). Co-prescribing of opioids with benzodiazepines (additional 11.87 [95%CI 2.04 to 21.67] patients/10,000 and pregabalin (additional 3.54 [95% CI 0.82 to 6.26] patients/10,000 increased following mandatory PDMP implementation among those prescribed opioids. In contrast to trends of reduced initiation prior to PDMP implementation, we found increased new initiation of non-monitored medications following PDMP implementation (e.g., an immediate increase of 2.32 [95%CI 0.02 to 4.54], patients/10,000 received pregabalin and 3.06 [95%CI 0.54 to 5.5] patients/10,000 received tricyclic antidepressants after mandatory PDMP implementation), and increased tramadol initiation during the voluntary PDMP period (an increase of 11.26 [95%CI: 5.84, 16.67] patients /10,000).

CONCLUSION

PDMP implementation did not appear to reduce prescribing of high opioid doses or high-risk combinations. Increased initiation of tricyclic antidepressants, pregabalin and tramadol may indicate a possible unintended effect.

Impact of unsolicited reporting notifications on providers' prescribing behavior: An experimental study on Maryland PDMP data

BACKGROUND

Unsolicited Reporting Notifications(URNs) have been a component of Maryland's Prescription Drug Monitoring Program (PDMP) since 2016. We evaluated the effect of URNs on providers' prescription behaviors.

METHODS

This is a quasi-experimental study of providers who were issued at least one URN from January 2018 to April 2021. Providers for whom URNs were not successfully delivered were designated as a comparison group. The outcome variables were average daily opioid and benzodiazepine prescriptions, average morphine milligram equivalents per patient, and proportion of overlapping opioid and benzodiazepine, either with or without muscle relaxant prescriptions. Changes were compared before versus after the issuance of a URN among the intervention and comparison groups using "Generalized Estimation Equation" and "Generalized Linear" Models. We also conducted stratified analyses by types of URN, including notifications for multiple provider episodes (MPE), overdose fatality (ODF), and dangerous drug combinations (DDC).

RESULTS

The average daily number of opioids prescriptions (3.3% decrease in the intervention group vs 22.7% increase in the comparison group, P<0.001), co-prescription of opioids and benzodiazepines either with muscle relaxants (68.0% decrease vs. 36.1% decrease, P<0.001), or without muscle relaxants (6.0% decrease vs. 16.3% increase, P<0.001), significantly reduced after the first URN regardless of the type of URN. Stratified analysis by types of URNs showed that ODF and DDC URNs had a significant effect on most of the outcomes of interest.

CONCLUSION

The findings suggest that unsolicited reporting, especially particular types of URNs including ODF and DDC, is associated with subsequent changes in unsafe prescribing behaviors.

Modeling Opioid Abuse: A Case Study of the Opioid Crisis in New England

For the past two decades, the USA has been embroiled in a growing prescription drug epidemic. The ripples of this epidemic have been especially apparent in the state of Maine, which has fought hard to mitigate the damage caused by addiction to pharmaceutical and illicit opioids. In this study, we construct a mathematical model of the opioid epidemic incorporating novel features important to better understanding opioid abuse dynamics. These features include demographic differences in population susceptibility, general transmission expressions, and combined consideration of pharmaceutical opioid and heroin abuse. We demonstrate the usefulness of this model by calibrating it with data for the state of Maine. Model calibration is accompanied by sensitivity and uncertainty analysis to quantify potential error in parameter estimates and forecasts. The model is analyzed to determine the mechanisms most influential to the number of opioid abusers and to find effective ways of controlling opioid abuse prevalence. We found that the mechanisms most influential to the overall number of abusers in Maine are those involved in illicit pharmaceutical opioid abuse transmission. Consequently, preventative strategies that controlled for illicit transmission were more effective over alternative approaches, such as treatment. These results are presented with the hope of helping to inform public policy as to the most effective means of intervention.

Interprofessional Naloxone Student Training to Manage Suspected Opioid Overdose

PURPOSE

The study purpose was to examine the effect of interprofessional naloxone training on students' knowledge, confidence, and interprofessional collaboration competency. The overarching goal was to decrease mortality related to opioid overdoses.

DESIGN/METHODS

A training session for interprofessional students consisted of a lecture presentation, demonstration, and hands-on practice regarding appropriate administration of naloxone for suspected opioid overdose. A questionnaire elicited baseline and change in knowledge, confidence, and interprofessional collaboration competency scores at pretraining and posttraining. In addition, changes in knowledge and confidence were also measured 3 weeks after the training. Thematic analysis explored training components that students perceived as valuable or needing improvement.

RESULTS

Participants (N = 100) were nursing (n = 33), physician assistant (n = 37), and pharmacy (n = 30) students. Pretraining and posttraining comparison demonstrated increased knowledge (P < .001), confidence (P < .001), and collaboration scores (P < .001). At 3 weeks, knowledge and confidence remained higher than pretraining (P < .001). Knowledge was trending downward compared with posttraining (P = .09). Thematic analysis identified 4 themes: (a) indications for administration of different naloxone types, (b) learning modalities, (c) knowledge application, and (d) improvements.

CONCLUSIONS

An interprofessional naloxone administration training resulted in increased knowledge, confidence, and interprofessional teamwork. Educators can adapt this training for a variety of future or current healthcare professionals to improve immediate intervention and outcomes in suspected opioid overdoses.

Human-centered design development of mHealth patient-to-peer referral tool in the emergency department

Background

Given the steady increase of emergency department (ED) visits related to opioid overdoses, this study aims to determine the design and usability of an ED-centered mHealth patient-to-peer referral prototype tool that allows patients to refer peers to comprehensive HIV/HCV and opioid misuse prevention services.

Methods

Two iterative focus group discussion (FDG) sessions and one use-case session were conducted. Eligible participants who were ≥18 years, had a history of injection drug use (IDU), and had utilized the ED in the past year were recruited through the distribution of flyers at the study institution, including the study ED. Human-centered design process was completed by using participant feedback on perceived utility, usability/accessibility, tool design, and clarity/readability to fine-tune prototype version and drive subsequent discussion sessions.

Results

Sixteen consented individuals participated in at least one of the sessions. Feedback revealed that participants favored the inclusion of the webpage link on the referral card as means to bypass QR code if needed, more descriptions highlighting the exact services offered, and the fact that no personal information was required to complete the referral process. The prototype underwent several adjustments between user-centered FDG sessions, which ultimately ended in including features such as an online webpage with educational videos, SMS text-message communication system, and QR code usage into the final patient-to-peer referral tool prototype.

Conclusion

The findings of this study suggest a human-centered designed patient-to-peer referral tool could be a feasible approach to linking community members at risk of IDU to HIV/HCV and opioid use-related preventive services from ED patients.

Conceptualizing and Measuring Abatement from the Opioid Epidemic: A Case Study from Pennsylvania

Policy Points In 2021, four major pharmaceutical manufacturers and distributors reached a proposed settlement agreement with 46 state Attorneys General of $26 billion to address their liabilities in fueling the US opioid epidemic. It raises important questions about abatement conceptualization and measurement for allocating settlement funds among substate entities. We outline the political economy tensions undergirding the settlement and allocation, introduce an abatement conceptual framework, describe how an abatement formula was developed for Pennsylvania to allocate settlement funds, and summarize considerations for future settlement allocation efforts. Documenting the challenges and experiences of this task is essential to inform future efforts.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Virtual Reality Animal Rescue World: Pediatric virtual reality analgesia during just noticeable pressure pain in children aged 2-10 years old (crossover design)

BACKGROUND AND AIMS

Excessive pain during medical procedures is a worldwide medical problem. Most scald burns occur in children under 6, who are often undermedicated. Adjunctive Virtual Reality (VR) distraction has been shown to reduce pain in children aged 6-17, but little is known about VR analgesia in young children. This study tests whether desktop VR (VR Animal Rescue World) can reduce the just noticeable pressure pain of children aged 2-10.

METHODS

A within-subject repeated measures design was used. With treatment order randomized, each healthy volunteer pediatric participant underwent brief cutaneous pressure stimuli under three conditions: (1) no distraction, (2) a verbal color naming task (no VR), and (3) a large TV-based desktop VR distraction. A hand-held Wagner pressure pain stimulation device was used to generate just noticeable pain sensations. Participants indicated when a steadily increasing non-painful pressure stimulus first turned into a painful pressure sensation (just noticeable pain).

RESULTS

A total of 40 healthy children participated (43% aged 2-5 years; and 57% aged 6-10 years). Compared to the no distraction condition, the 40 children showed significant VR analgesia (i.e., a significant reduction in pain sensitivity during the VR Animal Rescue World condition), t(39) = 9.83, p < 0.001, SD = 6.24. VR was also significantly more effective at reducing pain sensitivity vs. an auditory color naming task, t(39) = 5.42, p < 0.001, SD = 5.94. The subset of children aged 2-5 showed significant reductions in pain during VR. Children under 6 showed greater sensitivity to pain during no distraction than children aged 6-10.

CONCLUSION

During no distraction, children under 6 years old were significantly more sensitive to pain than children aged 6-10. Virtual reality (VR) significantly reduced the "just noticeable" pressure pain sensitivity of children in both age groups.

A novel long-acting formulation of oral buprenorphine/naloxone produces prolonged decreases in fentanyl self-administration by rhesus monkeys

BACKGROUND

Due to the poor oral bioavailability of buprenorphine, an oral formulation has not been thought possible. Lyndra Therapeutics is developing a once-weekly long-acting oral product containing buprenorphine. We evaluated the efficacy of this formulation in reducing intravenous (i.v.) fentanyl self-administration by three male and three female rhesus monkeys.

METHODS

Buprenorphine HCl and naloxone HCl were co-formulated using an 11:1 ratio of buprenorphine:naloxone in a controlled-release gastric residence formulation administered in an oral capsule (LYN-013). Naloxone was included to determine the feasibility of combining naloxone with buprenorphine in the formulation as an abuse deterrent. Complete fentanyl dose-response functions were determined during each session. The efficacy of single doses of 56/5, 112/10 and 168/15 mg buprenorphine/naloxone in reducing fentanyl self-administration was examined over 13 days.

RESULTS

LYN-013 significantly decreased the rate of responding for fentanyl for 3 days and significantly reduced total intake of fentanyl for 8 days. Time to maximal buprenorphine levels (Tmax) ranged between 56 and 68 h for all 3 doses. The maximal buprenorphine level (Cmax) following 168 mg was 2.3 ng/ml which was significantly greater that those observed for 56 mg (1.22 ng/ml) and 112 mg (1.35 ng/ml). Finally, the area-under-curves (AUCtau) were buprenorphine dose-dependently increased from 88 to 127-265 h*ng/ml. There were no signs of non-specific changes in behavior.

CONCLUSIONS

A once-weekly oral buprenorphine/naloxone formulation produced sustained suppression of fentanyl self-administration in monkeys suggesting that oral delivery of buprenorphine with this formulation could provide a new opportunity to treat opioid use disorders (OUD).

Intra-Articular Magnesium Plus Bupivacaine Is the Most Effective and Safe Postoperative Analgesic Option Following Knee Arthroscopy: A Network Meta-analysis

PURPOSE

To evaluate the comparative efficacy and safety of single-dose intra-articular injection of commonly used analgesics after knee arthroscopy.

METHODS

A systematic literature review was done to search for randomized controlled trials (RCTs) published from database inception to October 1, 2020, that compared analgesics (i.e., morphine, bupivacaine, ropivacaine, and magnesium alone or in combination) with placebo or each other after knee arthroscopy. The primary outcomes were postoperative pain intensity at 2 hours and 24 hours. Secondary outcomes included the time to first analgesic request, number of patients requiring supplementary analgesics and side effects. We estimated summary standardized mean differences (SMDs) or odds ratios with 95% credible intervals (95% CrIs) using Bayesian network meta-analysis with random effects.

RESULTS

In total, 78 randomized controlled trials comprising 4,425 participants were included. Compared with placebo, magnesium plus bupivacaine was most likely to be effective in relieving pain at both 2-hour (SMD = -3.81, 95% CrI -5.28 to -2.35) and 24-hour after surgery (SMD = -2.81, 95% CrI: -4.29 to -1.30). Following was morphine plus bupivacaine (2-hour: SMD = -2.19, 95% CrI -3.05 to -1.31; 24-hour: SMD = -1.44, 95% CrI -2.14 to -0.73) and bupivacaine alone (2-hour: SMD = -1.66, 95% CrI -2.33 to -0.98; 24-hour: SMD = -0.67, 95% CrI -1.22 to -0.07); ropivacaine alone and magnesium alone were not effective on pain relief. The interval time to first analgesic request was significantly extended compared with placebo except for ropivacaine alone and magnesium alone. The number of patients requiring supplementary analgesics was reduced in all groups except ropivacaine alone. No statistically significant difference was found between any studied analgesics or placebo with regard to side effects.

CONCLUSIONS

Of 6 common postoperative intra-articular analgesics, magnesium plus bupivacaine provides the most effective pain relief without increasing short-term side effects after knee arthroscopy.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and II studies.

A pilot study of a mixed-method approach to design an ED-based peer mHealth referral tool for HIV/HCV and opioid overdose prevention services

BACKGROUND

The intersecting epidemics of opioid misuse, injection drug use, and HIV/HCV have resulted in record overdose deaths and sustained high levels of HIV/HCV transmissions. Literature on social networks suggests opportunities to connect people who use drugs (PWUD) and their peers to HIV/HCV and opioid overdose prevention services. However, little evidence exists on how to design such peer referral interventions in emergency department (ED) settings.

METHODS

A mixed-method study was conducted to assess the feasibility of an mHealth-facilitated 'patient to peer social network referral program' for PWUD. In-depth interviews (IDIs) and quantitative surveys were conducted with urban ED patients (n = 15), along with 3 focus group discussions (FGDs) (n = 19).

RESULTS

Overall, 34 participants were enrolled (71 % males, 53 % Black). 13/15 IDI participants reported a history of opioid overdose; all had witnessed overdose events; all received HIV/HCV testing. From survey responses, most would invite their peers for HIV/HCV testing and naloxone training; and anticipated peers to accept referrals (HIV: 60 %, HCV: 73 %, naloxone: 93 %). Qualitative data showed PWUD shared health-related information with each other but preferred word of mouth rather than text messages. Participants used smartphones regularly and suggested using Internet advertising for prevention services. Participants expressed enthusiasm for ED-based peer mHealth referral platform to prevention services, as well as referring their peers to proposed services, with monetary incentives.

CONCLUSION

ED-based peer referral intervention to HIV/HCV testing and naloxone training was viewed favorably by PWUD. Frequent smartphone use among PWUD suggests that the medium could be a promising mode for peer referral.

Oxycodone decreases anxiety-like behavior in the elevated plus-maze test in male and female rats

The prescription opioid oxycodone is widely used for the treatment of pain in humans. Oxycodone misuse is more common among people with an anxiety disorder than those without one. Therefore, oxycodone might be misused for its anxiolytic properties. We investigated if oxycodone affects anxiety-like behavior in adult male and female rats. The rats were treated with oxycodone (0.178, 0.32, 0.56, or 1 mg/kg), and anxiety-like behavior was investigated in the elevated plus-maze test. Immediately after the elevated plus-maze test, a small open field test was conducted to determine the effects of oxycodone on locomotor activity. In the elevated plus-maze test, oxycodone increased the percentage of time spent on the open arms, the percentage of open arm entries, time on the open arms, open arm entries, and the distance traveled. The males treated with vehicle had a lower percentage of open arm entries than the females treated with vehicle, and oxycodone treatment led to a greater increase in the percentage of open arm entries in the males than females. Furthermore, the females spent more time on the open arms, made more open arm entries, spent less time in the closed arms, and traveled a greater distance than the males. In the small open field test, treatment with oxycodone did not affect locomotor activity or rearing. Sex differences were observed; the females traveled a greater distance and displayed more rearing than the males. In conclusion, oxycodone decreases anxiety-like behavior in rats, and oxycodone has a greater anxiolytic-like effect in males than females.

Efficacy of non-pharmacological interventions in pain relief and opioid consumption after cardiac surgery: A systematic review and Bayesian network meta-analysis

OBJECTIVE

To investigate and rank the evidence for the efficacy of non-pharmacological interventions in relieving pain after cardiac surgery using comprehensive comparisons.

BACKGROUND

Although several previous systematic reviews and meta-analyses showed that non-pharmacological interventions effectively control and reduce pain after cardiac surgery, none quantitatively compared the effect of these different types of interventions.

DESIGN

Systematic review and Bayesian network meta-analysis based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Network Meta-Analysis guidelines.

METHODS

Six databases were searched from inception to April 2021 to collect all published evidence from randomised clinical trials. One author extracted the relevant information from the eligible trials; a second author independently reviewed the data. Before analysing the extracted data, two investigators independently assessed the quality of the included studies. Conventional meta-analysis was conducted using either fixed- or random-effects models according to statistical heterogeneity. The Bayesian network meta-analysis was conducted using the consistency model.

RESULTS

We identified 42 randomised clinical trials comparing 14 groups with 4253 patients. Transcutaneous electrical nerve stimulation, acupressure, music and massage were effective for pain relief, with transcutaneous electrical nerve stimulation being associated with the best probability of successful pain relief after cardiac surgery (cumulative ranking curve surface, 0.97; probability, 77.03%). Acupressure (cumulative ranking curve surface, 0.79; probability, 30.69%) was the second-best option. However, there was no evidence that any pair-up intervention significantly reduced opioid use or anxiety.

CONCLUSIONS

These findings suggest that transcutaneous electrical nerve stimulation, acupressure, music and massage may effectively alleviate postoperative cardiac pain, with transcutaneous electrical nerve stimulation representing the best choice for pain relief.

RELEVANCE TO CLINICAL PRACTICE

The results of this network meta-analysis can guide patients after cardiac surgery and healthcare providers to make optimal decisions in managing postoperative cardiac pain.

TRIAL REGISTRATION

PROSPERO CRD42021246183.

Overdose, opioid treatment admissions and prescription opioid pain reliever relationships: United States, 2010-2019

Background

"As part of the U.S. government's urgent response to the epidemic of overdose deaths (1)" the United States Centers for Disease Control and Prevention (CDC) issued the "CDC Guideline for Prescribing Opioids for Chronic Pain-United States, 2016 (2)" (guideline) followed by the "CDC Clinical Practice Guideline for Prescribing Opioids-United States, 2022 (3) (guideline update). " The guideline and guideline update cite a direct correlation between prescription opioids sales (POS) and opioid treatment admissions (OTA) and prescription opioid deaths (POD), which was based on data from 1999 to 2010. This paper updates those relationships and includes the correlations between prescription opioid sales (POS) and any opioid deaths (AOD) and total overdose deaths (TOD) from 2010 to 2019.

Methods

Linear regression models were fit to each response separately. Opioid sales (measured as MME (morphine milligram equivalent) per capita) was the independent variable. Total overdose deaths (TOD), any opioid overdose deaths (AOD), prescription opioid overdose deaths (POD) and opioid treatment admissions (OTA) were the dependent, response variables. The models were assessed using three criteria: the statistical significance of the model (Overall P-Value), the quality of the fit (R 2), and the sign of the slope coefficient (positive or negative).

Results

The analyses revealed that the direct correlations (i.e., significant, positive slopes) reported by the CDC based on data from 1999 to 2010 no longer exist. Based on data from 2010 to 2019, the relationships either have reversed (i.e., significant, negative slopes) or are non-existent (i.e., no significant model).

Conclusions

The guideline, guideline update, CDC's public, medical profession, and intergovernmental communications should be corrected/updated to state no direct correlation has existed between POS to OTA, POD, AOD, and TOD since 2010. Individualized patient care and public health policy should be amended accordingly.

Evaluation of a Program to Screen Patients in Community Pharmacies for Opioid Misuse and Accidental Overdose

Introduction

Community pharmacies nationwide have adopted new strategies to combat the opioid epidemic. One strategy to prevent opioid misuse and accidental overdose is patient screening to identify those at risk. The purpose of our study was to determine whether such screening in community pharmacies led pharmacy personnel to intervene with patients at risk and to describe the proportion of patients they identified as at risk.

Methods

We implemented the Opioid and Naloxone Education (ONE) program in North Dakota to give community pharmacies and pharmacists training and tools to provide preventive screening for opioid misuse and accidental overdose before dispensing a prescribed opioid. Data were collected and analyzed from September 15, 2018, through May 15, 2021, to evaluate overall patient risk characteristics for opioid misuse and accidental overdose.

Results

Of 8,217 patients screened, 3.9% were identified as at high risk for opioid misuse, and 18.3% at risk for accidental overdose. Nearly 1 of 3 screenings (31.7%) indicated opioid medication use in the past 60 days. Pharmacists delivered 1 or more risk-factor–dependent interventions to 41.1% of patients in the study. Following screening, naloxone dispensing in pharmacies increased to 6 times the national average.

Conclusion

Pharmacy-based patient screening for risk of opioid misuse and accidental overdose led to risk-dependent interventions targeted to individual patients. The tools and risk-dependent interventions applied in the ONE program increased patient awareness of opioid risks and ways to reduce risk. Future studies should examine long-term outcomes, including reduction in overdose, treatment of opioid use disorder, and reduced opioid-related acute care.

SRS-22r question 11 is a valid opioid screen and stratifies opioid consumption

PURPOSE

To validate the Scoliosis Research Society-22r (SRS-22r) question 11 (Q11) response as a measure to assess and quantify opioid consumption.

METHODS

A post hoc analysis of a prospective study regarding opioid use during ASD surgery was performed. Data were collected at enrollment and 2-year follow-up including the SRS-22r and a standardized data collection form (CRF) for self-reported opioid consumption. Responses to Q11 of the SS-22r were compared with responses to the opioid consumption CRF (as measured by morphine equivalent dose (MED)). Inter-rater agreement was calculated. Sensitivity and specificity for the Q11 (+) responses were calculated using MED reports as the "true" value.

RESULTS

Cohen's kappa indicated almost perfect agreement between the MED CRF and Q11 (k = 0.878, p < 0.001). Mean daily MED consumption for patients reporting "Daily Narcotic" use was 62.0 (Median: 38.7, SD 87.5) mg; for patients reporting "Narcotics weekly or less", mean daily MED consumption was 21.6 (15.0, 29.0) mg. The positive Q11 responses were 96% sensitive and 92% specific for opioid users.

CONCLUSION

SRS-22r Q11 exhibits almost perfect agreement with an independent questionnaire designed to assess opioid consumption in this cohort. "Daily narcotic" users report nearly three times the mean daily MED of "Weekly or less" users (62.0 ± 87.5 mg vs 21.6 ± 29 mg, p = 0.037). Q11 exhibited excellent sensitivity and specificity for determining opioid users and non-users. Given the need for opioid research in ASD, Q11 may be useful to use existing registries and observational cohorts to design more definitive studies regarding opioid consumption.

LEVEL OF EVIDENCE

III.

Risk Attenuation and Amplification in the U.S. Opioid Crisis

The evolution of risk identification and ultimately the public and private responses that have become known collectively as the "opioid crisis" is an important case study in risk management due to the reach and magnitude of its impacts. This article examines a number of "signals" related to opioid risks using the social amplification of risk framework (SARF) to investigate a limited set of public-sector activities and policy responses. We evaluate whether the SARF presents an effective lens to examine the serious shortcomings of risk management of opioid use, which has a history of risk attenuation and, more recently, evidence of risk amplification. Our goal in this article is limited to addressing "goodness of fit" of the SARF as a descriptive tool. We consider whether the SARF effectively reveals important gaps in public risk management responses for the opioid example and other similarly situated societal risk problems. Applying SARF supports that its suggested relationship between risk signals and inappropriate attenuated public response does generate useful insights into regulatory efficacy for examples of public risk management. Similar such conclusions about inappropriate public responses stemming from the amplification factors are less supported because, in this case, the risk is, and continues to be, large. Overall, we find that the SARF's particular focus on the signaling function of risk information performs best as an organizational aid to study historical information rather than as a predictive tool for determining inappropriate risk management responses.