A Dissemination and Implementation Science Approach to the Epidemic of Opioid Use Disorder in the United States

Universal Prevention Strategies to Prevent Opioid Misuse on a U.S. College Campus

Opioid misuse and risk of death due to overdose are critical public health issues and young adults are at risk. College campus communities are ideal settings for the prevention of opioid misuse among young adults due to high enrollment rates, the diversity and availability of resources within the campus community, and the range of risk and protective factors that can be targeted. This practitioner narrative describes a grant-funded three-year opioid misuse prevention project implemented on a U.S. college campus. In keeping with the focus of the grant, the project involved a range of universal prevention activities implemented across the campus community. Lessons learned regarding factors that facilitated implementation in this community context are discussed and may be useful for others interested in implementing prevention activities to help prevent opioid misuse among young adults in their campus communities. Additionally, a reflection on the project and the efficacy of universal prevention to prevent opioid misuse among college students are offered for consideration.

Nonmedical Use of Controlled Medications by Adolescents and Young Adults: Clinical Report

Nonmedical prescription drug use (NMPDU), the use of controlled prescription medications for purposes other than initially intended by the prescriber, is common among adolescents and young adults (AYAs). Prescription stimulants, sedatives, and opioid medications are the 3 main categories of controlled medications nonmedically used by AYAs. The intent of this clinical report is to provide an overview of the epidemiology, motives, sources, and risk factors of NMPDU among AYAs. This report also describes acute and long-term morbidity and mortality associated with NMPDU and discusses the importance of primary and secondary prevention to reduce the burden of NMPDU among AYAs. This report concludes with a series of recommendations on how pediatricians can address NMPDU with patients and their families.

When a pandemic and epidemic collide: Lessons learned about how system barriers can interrupt implementation of addiction research

Background

Telehealth technologies are now featured more prominently in addiction treatment services than prior to the COVID-19 pandemic, but system barriers should be carefully considered for the successful implementation of innovative remote solutions for medication management and recovery coaching support for people with opioid use disorder (OUD).

Method

The Centers for Disease Control and Prevention funded a telehealth trial prior to the COVID-19 pandemic with a multi-institution team who attempted to implement an innovative protocol during the height of the pandemic in 2020 in Tampa, Florida. The study evaluated the effectiveness of a mobile device application, called MySafeRx, which integrated remote motivational recovery coaching with daily supervised dosing from secure pill dispensers via videoconference, on medication adherence during buprenorphine treatment. This paper provides a participant case example followed by a reflective evaluation of how the pandemic amplified both an existing research-to-practice gap and clinical system barriers during the implementation of telehealth clinical research intervention for patients with OUD.

Findings

Implementation challenges arose from academic institutional requirements, boundaries and role identity, clinical staff burnout and lack of buy-in, rigid clinical protocols, and limited clinical resources, which hampered recruitment and intervention engagement.

Conclusions

As the urgency for feasible and effective telehealth solutions continues to rise in response to the growing numbers of opioid-related deaths, the scientific community may use these lessons learned to re-envision the relationship between intervention implementation and the role of clinical research toward mitigating the opioid overdose epidemic.

Evaluating disparities in prescribing of naloxone after emergency department treatment of opioid overdose

INTRODUCTION

Patients who initially survive opioid-related overdose are at high risk for subsequent mortality. Our health system aimed to evaluate the presence of disparities in prescribing naloxone following opioid overdose.

METHODS

This was a retrospective cohort study of patients seen in our health system, which comprises two academic centers and eight community hospitals. Eligible patients had at least one visit to any of our hospital's emergency departments (EDs) with a diagnosis code indicating opioid-related overdose between May 1, 2018, and April 30, 2021. The primary outcome measure was prescription of nasal naloxone after at least one visit for opioid-related overdose during the study period.

RESULTS

The health system had 1348 unique patients who presented 1593 times to at least one of the EDs with opioid overdose. Of included patients, 580 (43.2%) received one or more prescriptions for naloxone. The majority (68.9%, n = 925) were male. For race/ethnicity, 74.5% (1000) were Non-Hispanic White, 8.0% (n = 108) were Non-Hispanic Black, and 13.0% (n = 175) were Hispanic/Latinx. Compared with the reference age group of 16-24 years, only those 65+ were less likely to receive naloxone (adjusted odds ratio [aOR] 0.41, 95% confidence interval [CI] 0.20-0.84). The study found no difference for gender (male aOR 1.23, 95% CI 0.97-1.57 compared to female). Hispanic/Latinx patients were more likely to receive a prescription when compared to Non-Hispanic White patients (aOR 1.72, 95% CI 1.22-2.44), while no difference occurred between Non-Hispanic Black compared to Non-Hispanic White patients (aOR 1.31, 95% CI 0.87-1.98).

CONCLUSIONS

Naloxone prescribing after overdose in our system was suboptimal, with fewer than half of patients with an overdose diagnosis code receiving this lifesaving and evidence-based intervention. Patients who were Hispanic/Latinx were more likely to receive naloxone than other race and ethnicity groups, and patients who were older were less likely to receive it. Health systems need ongoing equity-informed implementation of programs to expand access to naloxone to all patients at risk.

Opioid risk screening: Program evaluation from the community pharmacists' perspective

BACKGROUND

Pharmacist-implemented screening programs can be improved through continuous program evaluation. Pharmacists are in a position to determine whether interventions are realistic and efficacious when used in practice.

OBJECTIVE

The purpose of this study is to evaluate how community pharmacists perceive the use of an opioid risk screening for patients receiving opioid prescriptions and the associated implications for improved patient-centered care.

METHODS

North Dakota community pharmacists received training on the use of an opioid risk tool for all patients filling an opioid prescription to evaluate for opioid misuse and overdose risk potential. Pharmacists then implemented the screening in their community pharmacy to screen all patients prescribed an opioid. Six months after implementation, pharmacists across the state were surveyed regarding their perception of the value of screening patients for the risk of opioid misuse and overdose. The survey questions used the Joint Committee on Standards for Educational Evaluation focusing on utility, propriety, feasibility, and accuracy.

RESULTS

All pharmacists (n = 35) indicated the opioid risk screening improved patient communication and patient-centered interventions. A total of 97% of pharmacists agreed the opioid screening tool provided an objective measure in providing care to patients and improved the potential for patient safety during prescription opioid use. Although 66% of pharmacists disagreed that the screening process was time consuming, 14% of respondents agreed with this statement indicating they may require additional assistance to optimize their workflow.

CONCLUSION

The results of this study support that opioid risk screening ensures utility for opioid risk stratification, feasibility to incorporate into existing workflow, and propriety for patient safety and well-being.

Correctly Identifying Deaths Due to Drug Toxicity Without a Forensic Autopsy

In 2005, the National Association of Medical Examiners approved the Forensic Autopsy Performance Standards. Standard B3.7 indicates that a forensic pathologist shall perform a forensic autopsy when the death is by apparent intoxication by alcohol, drugs, or poison.The Jefferson County Coroner/Medical Examiner Office has observed an increase in our caseload by 10% per year since 2012. We designed a study to determine if a pathologist could correctly classify the cause of death (COD) and manner of death (MOD) of suspected drug-related deaths without information from the internal examination. The determination of the COD and MOD was then compared with the case file, which includes information from the internal examination and microscopy, to determine agreement between the case file and the reclassification. The percent correct for COD and MOD was calculated, and kappa values were calculated for MOD.The pathologists were able to correctly classify the COD in 73% of cases. For MOD, 2 pathologists achieved substantial agreement between the test cases and the actual case file. The third pathologist had moderate agreement. These findings indicate that a full postmortem examination is necessary to correctly classify the COD/MOD in cases of suspected drug toxicity.Our null hypothesis is that a full autopsy is not necessary to correctly classify the COD and MOD in cases of drug toxicity.

Opioid-Related Education Provided by Continuing Education Divisions at US Pharmacy Schools

Objective. To quantify the number and type of new opioid-related continuing pharmacy education (CPE) activities offered by continuing education divisions (CEDs) at US schools and colleges of pharmacy from 2015 through 2018, and to determine the number of pharmacists who completed opioid-related CPE activities. Methods. Data was derived from the database of CPE activities maintained by the Accreditation Council for Pharmacy Education (ACPE), which is the sole accreditation agency for all providers of CPE, including pharmacy schools. Data were filtered to include only pharmacy school CPE providers. A search for six keywords (opiates, opioids, pain, pain management, drug overdose, and opioid antagonist) was conducted for the years 2015-2018. The data extracted included title of the CPE activity, contact hours, activity type, activity format, and the number of pharmacists who participated in the activity. Descriptive statistics were used. A content analysis of activity titles was performed. Results. Overall, the CEDs of US schools and colleges of pharmacy delivered 20.3% of all ACPE-approved opioid-related CPE activities from 2015-2018. A total of 1,237 unique opioid-related CPE activities were identified. The number of new CPE activities increased from 249 in 2015 to 297 in 2016 to 349 in 2017, then decreased to 342 in 2018. These activities reached 149,373 pharmacists and were most commonly affiliated with the following keywords: opioids (34.8%) and pain management (30.2%). Conclusion. The opioid epidemic creates an opportunity for pharmacists to increase their role in public health, but education and training are necessary. The study findings indicate that many pharmacists participate in opioid-related CPE provided by ACPE-accredited CEDs of pharmacy schools. This number is likely to increase as a growing number of states are beginning to require opioid-related CPE for pharmacist license renewal.

Applying and advancing best practices in opioid use disorder and addiction treatment: Introduction to the special issue on implementation science and quality improvement scholarship

To help realize the promise of evidence-based practices to stem the opioid crisis, there is a glaring need for descriptions of how practices are effectively disseminated and implemented. Unfortunately, addiction journals do not often publish addiction implementation science and non-research descriptions of quality improvement projects. This is unfortunate as these projects are more representative of how research is translated into practice in the real-world and offer guidance and practical information to help speed implementation of evidence-based practices. To support translation of research into practice, primary, secondary, and tertiary intervention implementation science and quality improvement projects should be disseminated. We are excited to again partner with the Providers' Clinical Support System for Opioid Therapies in presenting implementation and quality improvement demonstration projects in this special issue: "Implementation and Quality Improvement: Applying and Advancing Best Practices in Opioid Use Disorder and Addiction Treatment."

Adolescent and Parent Management of Controlled Prescription Medications

Background: Most adolescents who misuse controlled prescription medications acquire them from home settings. However, little is known regarding household management (storage, administration, and disposal) of these medications. Objective: To describe household management of controlled medications. Methods: This was a cross-sectional study with paired data using brief, online, confidential surveys of adolescents and parents via an adolescent medicine clinic associated with a large academic center. Eligible adolescents were 12-18 years with at least one controlled prescription medication in the home. Six core safe management strategies for controlled medications were identified based on current recommendations. Data were collected and analyzed in 2017. Results: Of the 243 adolescent-parent dyads, 78.2% (n = 190) dyads store medication out of sight, 68.7% (n = 167) lock up medications, 78.2% (n = 190) do not store pills besides a school nurse's office or a parent's place of work, 43.6% (n = 106) provide periodic parental monitoring, 64.6% (n = 157) frequently dispose of unused controlled medications (at least every 3-4 months), and 80.2% (n = 195) dispose of controlled medications in a prescription drug take-back program or by flushing. Families with an adolescent prescription for a controlled medication were more likely to use several core management strategies (periodic parental monitoring, frequent disposal, and appropriate disposal location). Families with a household pain reliever were 8.7 times (95% CI 3.3, 23.3) as likely to not keep spare pills in inappropriate locations. Conclusions/Importance: Most families do not practice all recommended safe management strategies for controlled medications. Healthcare professionals should promote safe management to reduce controlled prescription medication misuse.

Almost Everything We Need to Better Serve Children of the Opioid Crisis We Learned in the 80s and 90s

Opioid use disorder impedes dependent parents' abilities to care for their children. In turn, children may languish in unpredictability and persistent chaos. Societal responses to these children are often guided by a belief that unless the drug dependent parent receives treatment, there is little help for the child. While a preponderance of the drug dependence research is adult-centric, a significant body of research demonstrates the importance of not only addressing the immediate well being of the children of drug dependent caregivers but preventing the continuing cycle of drug dependence. The present commentary demonstrates through a brief review of the US history of drug dependence crises and research from the 1980s and 1990s, a range of “tried and true” family, school, and community interventions centered on children. We already know that these children are at high risk of maladjustment and early onset of drug dependence; early intervention is critical; multiple risk factors are likely to occur simultaneously; comprehensive strategies are optimal; and multiple risk-focused strategies are most protective. Where we need now to turn our efforts is on how to effectively implement and disseminate best practices, many of which we learned in the 1980s and 1990s. The greatest opportunity in both changing the nature of the opioid epidemic at scale and influencing rapid translation of existing research findings into policy and practice is not in asking what to do, but in asking how to do the right things well, and quickly.