Patterns of prescription opioid abuse and comorbidity in an aging treatment population

Impact of Enhanced Recovery After Surgery Protocols on Outcomes Up to Two Years After Adult Structural Spine Disorder Surgery

STUDY DESIGN

Retrospective cohort study of prospectively enrolled database.

OBJECTIVE

We analyze the recovery pattern of patients with adult structural spine disorder (ASD) who underwent corrective surgery with enhanced recovery after surgery (ERAS+) protocol, including physical and psychological prehabilitation components, compared with a non-ERAS protocol (ERAS-) up to 2 years (2Y) after surgery.

BACKGROUND

Spine surgery for ASD is often highly invasive, which can contribute to prolonged recovery. The trajectory of recovery may be accelerated by the application of enhanced recovery principles.

MATERIALS AND METHODS

Inclusion criteria were operative patients with ASD older than 18 years with complete baseline, 90 days perioperative, and 2Y postoperative data. We assessed differences in baseline demographics, surgical details, baseline health-related quality of life (HRQL), and surgical outcomes between ERAS+ and ERAS- patients. Outcomes included adverse events, reoperations, and radiographic parameters such as sacral slope, pelvic tilt, pelvic incidence-lumbar lordosis mismatch, sagittal vertical axis, lumbar lordosis, T2 to T12 kyphosis, and maximum Cobb angle. In addition, HRQL measures included the physical component summary, Oswestry Disability Index, Neck Disability Index, EuroQol 5 dimensions, Scoliosis Research Society Questionnaire 22r total and domain scores, Numeric Pain Rating Scale-back, and Numeric Pain Rating Scale-leg. We used multivariable logistic regression and analysis of covariance to adjust for confounding.

RESULTS

A total of 471 patients with ASD met the inclusion criteria, with 59 designated ERAS+. Those individuals with ERAS+ were older (64.1 ± 13.0 vs. 58.0 ± 16.0; P = 0.005), had a higher Charlson Comorbidity Index, (2.4 ± 1.8 vs. 1.4 ± 1.6; P < 0.001), and exhibited a higher modified ASD frailty index (8.2 ± 5.4 vs. 6.3 ± 4.9; P = 0.019). The adjusted analysis demonstrated the ERAS+ cohort demonstrated a lower likelihood of overall reoperations (Odds ratio (OR): 0.3; 95% CI: 0.13-0.89), and a lower likelihood of overall adverse events (OR: 0.4; 95% CI: 0.19-0.93). ERAS+ was more likely to achieve the minimal clinically important difference in the Scoliosis Research Society Questionnaire 22r total scores at 6 months (6M; OR: 3.1; 95% CI: 1.2-8.4), self-image domain at 6M (OR: 9.0; 95% CI: 1.6-50.0), in the pain domain at 6M (OR: 3.5; 95% CI: 1.01-11.9) and 1 year postoperatively (OR: 2.6; 95% CI: 1.03-6.7), and in the SF-36's physical component summary (PCS) scores at 1 year (OR: 2.1; 95% CI: 1.05-4.2). No other statistically significant differences in HRQL were observed at the remaining time points (P > 0.05).

CONCLUSION

Our work is the first to evaluate HRQL metrics and complications over 2Y following ASD correction with ERAS. Despite presenting with more severe baseline frailty and higher comorbidity profiles, patients with ASD who underwent corrective surgery with an ERAS protocol experienced fewer short-term adverse events and improved HRQL. We believe ERAS following ASD surgery leads to faster functional recovery, reduced postoperative deconditioning, and improved quality of life.

Predictors of Multiwave Opioid Use Among Older American Adults

Background and Objectives

Despite limited analgesic benefits, long-term opioid therapy (L-TOT) is common among older adults with chronic pain. Extended opioid use poses a threat to older adults as aging metabolisms retain opioids for longer, increasing the risk of injury, overdose, and other negative health outcomes. In contrast to predictors of general opioid use, predictors of L-TOT in older adults are not well documented. We aimed to identify such predictors using all available data on self-reported opioid use in the Health and Retirement Study.

Research Design and Methods

Using 5 waves of data, respondents (N = 10,713) aged 51 and older were identified as reporting no opioid use (n = 8,621), a single wave of use (n = 1,410), or multiple waves of use (n = 682). We conducted a multinomial logistic regression to predict both single- and multiwave opioid use relative to no use. Demographic, socioeconomic, geographic, health, and health care-related factors were included in our model.

Results

Multivariable findings show that, relative to nonusers, both single- and multiwave users were significantly more likely to be younger (relative risk ratio [RRR] = 1.33; RRR = 2.88); report lower household wealth (RRR = 1.47; RRR = 2.88); live in the U.S. Midwest (RRR = 1.29; RRR = 1.56), South (RRR = 1.34; RRR = 1.58), or West (RRR = 1.46; RRR = 2.34); experience interfering pain (RRR = 1.59; RRR = 3.39), back pain (RRR = 1.35; RRR = 1.53), or arthritic pain (RRR = 1.46; RRR = 2.32); and see the doctor frequently (RRR = 1.50; RRR = 2.02). Multiwave users were less likely to be Black (RRR = 0.69) or Hispanic (RRR = 0.45), and less likely to be never married (RRR = 0.52).

Discussion and Implications

We identified demographic, socioeconomic, geographic, and health care-related predictors of chronic multiyear opioid use. Our focus on individuals taking opioids for this extended duration is novel. Differences in opioid use by geographic region and frequency of doctor visits particularly warrant attention from policy-makers and researchers. We make additional recommendations based on a sensitivity analysis limited to 2016-2020 data.

Screening the "Invisible Population" of Older Adult Patients for Prescription Pain Reliever Non-Medical Use and Use Disorders

Background: In the United States, the number of older adults reporting non-medical use of prescription pain relievers (NMUPPR) between 2015 and 2019 has remained constant, while those meeting criteria for opioid use disorders (OUDs) between 2013 and 2018 increased three-fold. These rates are expected to increase due to increased life expectancy among this population coupled with higher rates of substance use. However, they have consistently lower screening rates for problematic prescription pain reliever use, compared to younger cohorts. Objectives: This commentary reviewed trends in older adult NMUPPR and OUDs and reviewed several available screening tools. We then considered reasons why providers may not be screening their patients, with a focus on older adults, for NMUPPR and OUDs. Finally, we provided recommendations to increase screenings in healthcare settings. Results: Low screening rates in older adult patients may be due to several contributing factors, such as providers' implicit biases and lack of training, time constraints, and comorbid conditions that mask NMUPPR and OUD-related symptoms. Recommendations include incorporating more addiction-related curricula in medical schools, encouraging participation in CME training focused on substance use, attending implicit bias training, and breaking down the silos between pharmacy and geriatric, addiction, and family medicine. Conclusions: There is a growing need for older adult drug screenings, and we have provided several recommendations for improvement. By increasing screenings among older populations, providers will assist in the identification and referral of patients to appropriate and timely substance use treatment and resources to ultimately ameliorate the health of older adult patients.

The Emergency Department Longitudinal Integrated Care (ED-LINC) intervention targeting opioid use disorder: A pilot randomized clinical trial

INTRODUCTION

Opioid use disorder (OUD) and related comorbid conditions are highly prevalent among patients presenting to emergency department (ED) settings. Research has developed few comprehensive disease management strategies for at-risk patients presenting to the ED that both decrease illicit opioid use and improve initiation and retention in medication treatment for OUD (MOUD).

METHODS

The research team conducted a pilot pragmatic clinical trial that randomized 40 patients presenting to a single ED to a collaborative care intervention (n = 20) versus usual care control (n = 20) conditions. Interviewers blinded to patient intervention and control group status followed-up with participants at 1, 3, and 6 months after presentation to the ED. The 3-month Emergency Department Longitudinal Integrated Care (ED-LINC) collaborative care intervention for patients at risk for OUD included: 1) a Brief Negotiated Interview at bedside, 2) overdose education and facilitation of MOUD, 3) longitudinal proactive care management, 4) utilization of the statewide health information exchange platform for 24/7 tracking of recurrent ED utilization, and 5) weekly caseload supervision that incorporated measurement-based care treatment assessment with stepped-up care for patients with recalcitrant symptoms.

RESULTS

Overall, the ED-LINC intervention was feasibly delivered and acceptable to patients. The pilot study achieved >80% follow-up rates at 1, 3, and 6 months. In adjusted longitudinal mixed model regression analyses, no statistically significant differences existed in days of opioid use over the past 30 days for ED-LINC intervention patients when compared to patients receiving usual care (incidence-rate ratio (IRR) 1.50, 95% CI 0.54-4.16). The unadjusted mean number of days of illicit opioid use decreased at the 1-month and 3-month follow-up time points for both groups. ED-LINC intervention patients had increased rates of MOUD initiation compared to control patients (50% versus 30%); intervention versus control comparisons did not achieve statistical significance, although power to detect significant differences in the pilot was limited.

CONCLUSIONS

The ED-LINC intervention for patients with OUD can be feasibly implemented and warrants testing in larger scale, adequately powered randomized pragmatic clinical trial investigations.

CLINICALTRIALS

gov NCT03699085.

Chronic Pain, Opioid Use Disorder, and Clinical Management Among Older Adults

Because of unique factors related to physiological changes and altered metabolism in advanced age, special attention is needed concerning chronic pain, opioid use, and opioid use disorder among older adults. Clinicians need to follow the most updated clinical guidelines regarding opioid prescribing. Routine screening and awareness are the keys to identifying opioid use disorder. Comprehensive assessments often require both pain assessment (including functional status) and substance use assessment, including the use of urine toxicological testing and structured, validated screening tools and instruments. Comprehensive, interdisciplinary efforts are critical in managing the care of older adults with chronic pain and opioid use disorder. A collaborative approach that includes substance abuse treatment and pain management (including pain subspecialty care) is often recommended. Medications for opioid use disorder have been extensively studied and have the most convincing evidence to date, and psychosocial treatments may be beneficial in some circumstances.

Evaluating substance use treatment efficacy for younger and older adults

The purpose of this study was to examine the differential efficacy of aftercare substance use treatments for younger (below 40, n = 107) versus older (40+, n = 114) adults (N = 221), using data from a randomized controlled trial in a community-based substance abuse treatment center. The younger adult sample had a mean age of 28.9 while the older adult sample had a mean age of 48.1. Primary outcomes were rates of abstinence and percent use days at 1-year follow-up. Outcomes were compared between standard cognitive behavioral relapse prevention (RP), Mindfulness-Based Relapse Prevention (MBRP), and 12-step-based treatment as usual (TAU). Results showed significant differences by treatment in the older, but not in younger, subsample of participants. Specifically, the older participants in MBRP had significantly higher abstinence rates compared with those in TAU. Further, the older individuals in MBRP had a significantly lower percent of days on which they used compared with those in TAU and RP. Overall, findings suggest that age group may impact aftercare treatment substance use outcomes.

Chronic non-cancer pain among adults with substance use disorders: Prevalence, characteristics, and association with opioid overdose and healthcare utilization

BACKGROUND

Chronic non-cancer pain (CNCP) among patients with substance use disorder (SUD) poses a risk for worse treatment outcomes. Understanding the association of CNCP with SUD is important for informing the need and potential benefits of pain assessment/management among those with SUDs.

METHODS

We analyzed electronic health record data from 2013 to 2018 among adults aged ≥18 years (N = 951,533; mean age: 48.4 years; 57.4 % female) in a large academic healthcare system. Adjusted logistic regression models were conducted to estimate the association of CNCP conditions with opioid overdose, emergency department utilization, and inpatient hospitalization stratified by different SUD diagnoses and by gender.

RESULTS

Among the total sample, the prevalence of CNCP was 46.6 % and any SUD was 11.2 %. The majority of patients with a SUD had CNCP (opioid: 74.7 %; sedative: 72.3 %; cannabis: 64.3 %; alcohol: 58.7 %; tobacco: 59.5 %). The prevalence of CNCP was greater in females vs. males for most SUD diagnoses. The presence of CNCP was associated with more mental health disorders and chronic medical conditions among each SUD group. CNCP was associated with significantly decreased odds of overdose among those with opioid use disorder but increased odds of overdose and healthcare utilization among other SUDs. CNCP was positively associated with overdose in females, but not males, with alcohol or non-opioid drug use disorders.

CONCLUSIONS

The direction and magnitude of the association between CNCP and negative health indicators differed as a function of SUD type and gender, respectively. Greater awareness of potential unmet pain treatment need may have implications for improving SUD outcomes.

Canadian Guidelines on Opioid Use Disorder Among Older Adults

BACKGROUND

In Canada, rates of hospital admission from opioid overdose are higher for older adults (≥ 65) than younger adults, and opioid use disorder (OUD) is a growing concern. In response, Health Canada commissioned the Canadian Coalition of Seniors' Mental Health to create guidelines for the prevention, screening, assessment, and treatment of OUD in older adults.

METHODS

A systematic review of English language literature from 2008-2018 regarding OUD in adults was conducted. Previously published guidelines were evaluated using AGREE II, and key guidelines updated using ADAPTE method, by drawing on current literature. Recommendations were created and assessed using the GRADE method.

RESULTS

Thirty-two recommendations were created. Prevention recommendations: it is key to prioritize non-pharmacological and non-opioid strategies to treat acute and chronic noncancer pain. Assessment recommendations: a comprehensive assessment is important to help discern contributions of other medical conditions. Treatment recommendations: buprenorphine is first line for both withdrawal management and maintenance therapy, while methadone, slow-release oral morphine, or naltrexone can be used as alternatives under certain circumstances; non-pharmacological treatments should be offered as an integrated part of care.

CONCLUSION

These guidelines provide practical and timely clinical recommendations on the prevention, assessment, and treatment of OUD in older adults within the Canadian context.

Substance Use Disorders in Later Life: A Review and Synthesis of the Literature of an Emerging Public Health Concern

Substance use disorders (SUDs) among older persons are among the fastest growing health problems in the United States. The number of older persons is projected to exceed 72.1 million persons by 2030, following a trend of general population growth in the mid-1940s to 1960s. The generation, known as "baby boomers," who refashioned drug use during their 20-30s, are increasingly continuing drug habits into later life. This review aims to assess the epidemiology, impact, and treatment of geriatric SUDs. Academic databases including PubMed, PsychInfo, Ovid, and Medline, were queried up to December 2018 for terms of "geriatric," "older," "elderly," "substance abuse," "drug," "drug use," "drug abuse," "drug dependency," "illicit drugs," and "geriatric psychiatry." Articles identified included 17 government documents, 29 studies based upon government documents, 43 studies not related to US government surveys, 19 review articles, 9 commentary pieces, 4 newspaper articles, 2 textbooks, and 1 published abstract. Evaluated studies and documents together suggest that older individuals are using illicit drugs and meeting criteria for SUDs at higher rates than previous geriatric cohorts resulting in substantial negative impacts on medical and psychiatric conditions. These findings represent a novel trend since previous cohorts of older individuals were thought to rarely use illicit substances. Current treatment models are inadequate to address the new wave of older individuals with SUDs. The fields of geriatrics, addiction, and geriatric psychiatry must work together to establish comprehensive care models and treatment modalities for addressing this emerging public health concern.

Outreach to people who survive opioid overdose: Linkage and retention in treatment

Cognitive motivation theories contend that individuals have greater readiness for behavioral change during critical periods or life events, and a non-fatal overdose could represent such an event. The objective of this study was to examine if the use of a specialized mobile response team (assertive outreach) could help identify, engage, and retain people who have survived an overdose into a comprehensive treatment program. We developed an intervention, consisting of mobile outreach followed by medication and behavioral treatment, in Houston Texas between April and December 2018. Our primary outcome variables were the level of willingness to engage in treatment, and percent who retained in treatment after 30 and 90 day endpoints. We screened 103 individuals for eligibility, and 34 (33%) elected to engage in the treatment program, while two-thirds chose not to engage in treatment, primarily due to low readiness levels. The average age was 38.2 ± 12 years, 56% were male, 79% had no health insurance, and the majority (77%) reported being homeless or in temporary housing. There were 30 (88%) participants still active in the treatment program after 30 days, and 19 (56%) after 90 days. Given the high rates of relapse using conventional models, which wait for patients to present to treatment, our preliminary results suggest that assertive outreach could be a promising strategy to motivate people to enter and remain in long-term treatment.

Patterns of opioid use (codeine, morphine or meperidine) in the Canadian population over time: analysis of the Longitudinal National Population Health Survey 1994-2011

OBJECTIVE

This study aimed to investigate cohort effects in selected opioids use and determine whether cohort differences were associated with changes in risk factors for use over time.

DESIGN

This study presents secondary analyses of a longitudinal survey panel of the general population that collected data biannually.

SETTING

Data from the Canadian Longitudinal National Population Health Survey 1994-2011.

POPULATION

This study included 12 542 participants from the following birth cohorts: post-World War I (born 1915-1924), pre-World War II (born 1925-1934), World War II (born 1935-1944), Older Baby Boom (born 1945-1954), Younger Baby Boom (born 1955-1964), Older Generation X (born 1965-1974) and Younger Generation X (born 1975-1984).

MAIN OUTCOME

Responses to a single question asking about the use of codeine, morphine or meperidine in the past month (yes/no) were examined.

RESULTS

Over and above age and period effects, there were significant cohort differences in selected opioids use: each succeeding recent cohort had greater use than their predecessors (eg, Gen Xers had greater use than younger baby boomers). Selected opioids use increased significantly from 1994 to 2002, plateauing between 2002 and 2006 and then declining until 2011. After accounting for cohort and period effects, there was a decline in use of these opioids with increasing age. Although pain was significantly associated with greater selected opioids use (OR=3.63, 95% CI 3.39 to 3.94), pain did not explain cohort differences. Cohort and period effects were no longer significant after adjusting for the number of chronic conditions. Cohort differences in selected opioids use mirrored cohort differences in multimorbidity. Use of these opioids was significantly associated with taking antidepressants or tranquillisers (OR=2.52, 95% CI 2.27 to 2.81 and OR=1.60, 95% CI 1.46 to 1.75, respectively).

CONCLUSIONS

The findings underscore the need to consider multimorbidity including possible psychological disorders and associated medications when prescribing opioids (codeine, morphine, meperidine), particularly for recent birth cohorts. Continued efforts to monitor prescription patterns and develop specific opioid use guidelines for multimorbidity appear warranted.

Factors Influencing Judgments to Consult Prescription Monitoring Programs: A Factorial Survey Experiment

BACKGROUND

Prescription monitoring programs (PMPs) can provide health care professionals with valuable information. However, few studies have explored providers' decision making for accessing PMPs.

AIMS

This study aimed to identify provider characteristics and situational factors most influencing perceived importance of consulting the PMP for patients in a simulated context.

DESIGN

The study used a cross-sectional factorial survey.

SETTINGS

The survey was administered electronically.

PARTICIPANTS/SUBJECTS

Community pharmacists, advanced practice registered nurses (APRNs), and physicians in Iowa.

METHODS

Participants were recruited by mail which included a link to the online survey. The survey consisted of demographic questions, eight randomly generated vignettes, and one ranked item. The vignettes described a hypothetical prescription using eight experimental variables whose levels were randomly varied. Respondents evaluated each vignette for importance to access the PMP. Analyses used linear mixed-effects models in R (Version 3.5.0).

RESULTS

A total of 138 responses were available for multilevel analysis. Women, physicians, and APRNs rated it more important to consult the PMP for a given prescription compared with men and pharmacists. Accessing a PMP was perceived as more important with cash payments, quantity dispensed, suspicion for misuse, hydromorphone and oxycodone prescriptions, and headache. Advancing age, postoperative pain, and anxiety or sleep indications were associated with less importance.

CONCLUSIONS

Age, indication for prescribing, misuse, and payment mode each independently had greater importance to providers in accessing the PMP. This was the first study to isolate the influence of different controlled substances on how important it was to consult the PMP.

Emergency Department Visits and Overnight Hospital Stays among Persons Aged 50 and Older Who Use and Misuse Opioids

Opioid misuse and adverse health outcomes are serious problems among the 50+ age group. Using data from the 2015-2016 National Survey of Drug Use and Health (N = 17,608 respondents aged 50+), we examined emergency department (ED) visits and hospitalizations among those who reported (1) no opioid use in the past year (61.4%); (2) opioid use but no misuse (36.0%); and (3) opioid misuse (2.6%). Compared to nonusers, those who reported use but no misuse or misuse had greater odds of any ED visit (AOR = 2.24, 95% CI = 2.05-2.47 and AOR = 1.99, 95% CI = 1.55-2.56, respectively) and hospitalization (AOR = 2.87, 95% CI = 2.48-3.32 and AOR = 2.57, 95% CI = 1.88-3.51, respectively); however, only those who used but did not misuse had more ED visits and longer hospital stays than nonusers. Those who misused opioids were younger, but they did not differ from those who used but did not misuse on ED visits and hospitalizations. Since those who misused had significantly higher rates of other substance use disorders and mental health problems than those who used but did not misuse, treatment of opioid misuse should also include help for these problems. Economically disadvantaged older adults suffering from chronic pain and opioid misuse also need assistance accessing effective pain treatment.

A hidden aspect of the U.S. opioid crisis: Rise in first-time treatment admissions for older adults with opioid use disorder

BACKGROUND

Older adults with opioid use disorder (OUD) are a medically complex population. The current study evaluated trends in older adults seeking treatment for OUD, with a focus on primary heroin versus prescription opioid use. This study also compared older adults with OUD to the younger OUD population on demographics and drug use behaviors.

METHODS

Publicly available data from state-certified addiction treatment centers were collected via the Treatment Episode Data Set - Admissions (TEDS-A) between 2004-2015. This study utilized Joinpoint Regression to conduct a cross-sectional, longitudinal analysis of trends in first-time treatment admissions for OUD in adults 55 and older (older adults; n = 400,421) versus adults under the age of 55 (n = 7,795,839). Given the rapid increase in older adults seeking treatment for OUD between 2013-2015, secondary outcomes include changes in demographics and drug use between 2012 (as a baseline year) and 2015.

RESULTS

The proportion of older adults seeking treatment for OUD rose steadily between 2004-2013 (41.2% increase; p-trend = 0.046), then rapidly between 2013-2015 (53.5% increase; p-trend = 0.009). The proportion of older adults with primary heroin use more than doubled between 2012-2015 (p < 0.001); these individuals were increasingly male (p < 0.001), African American (p < 0.001), and using via the intranasal route of administration (p < 0.001).

CONCLUSIONS

There has been a recent surge in older adults seeking treatment for OUD, particularly those with primary heroin use. Specialized treatment options for this population are critically needed, and capacity for tailored elder care OUD treatments will need to increase if these trends continue.

Rising incidence of ageing opioid users within the EU wide treatment demand indicator; The Irish opioid epidemic from 1996 to 2014

BACKGROUND

Literature identifies older people who use opioids as a neglected population. Little is known about temporal changes, or about treatment demand among this population.

METHODS

The EU Treatment Demand Indicator (TDI) for Ireland (1996-2014) was analyzed for trends in new opioid treatment admissions, ageing and drug using behaviors. A Joinpoint analysis was conducted.

RESULTS

Data from 18,692 individuals entering treatment for the first time showed that while the trend of age-adjusted incidence declined between 1996 and 2014, incidence among older age groups increased, with a rising incidence not previously observed among those aged 50 years and older. Subgroups of early and late treatment entries, and early and late opioid onset were observed. The median age commencing opioid use increased by three years from 18 to 21 years (U = 326141.5, p < 0.001). The median age entering treatment increased by 11 years (from age 20 to age 31) (U = 145465.5, p < 0.001). The median opioid-using duration prior to treatment increased by 5 years (from 2 to 7 years) (U = 170807.5, p < 0.001). Half of the individuals started injecting within one year of first using opioids. The median time between first injecting and commencing treatment increased by 6 years for men and 2 years for women.

CONCLUSIONS

The study utilizes European TDI data and finds that those entering treatment in Ireland is older, are injecting longer and are taking longer to enter treatment. These findings highlight how TDI data can be used to identify hidden groups at risk of chronic harm which may require prioritizing in policy and practice.

Pain and Addiction: An Integrative Therapeutic Approach

The current opioid crisis highlights an urgent need for better paradigms for prevention and treatment of chronic pain and addiction. Although many approach this complex clinical condition with the question, "Is this pain or is this addiction?," it is more than the sum of its parts. Chronic pain among those with dependence and addiction often evolves into a complex disabling condition with pain at multiple sites, psychosocial dysfunctions, medical and psychiatric disorders, polypharmacy, and polysubstance use, all interacting with each other in complex ways (multimorbidity). The authors offer an integrative therapeutic approach to manage this complex clinical scenario.

Development of the Older Adult Prescription Drug Assessment Questionnaire for Case Workers

Instruments assessing geriatric case managers’ perceptions of prescription abuse are limited. Based on a review of current literature and pilot testing feedback, 22 items were initially assembled to form an older adult Prescription Drug Assessment Questionnaire (PDAQ). Case managers ( N = 161) at an older adult agency located in a Midwestern state were surveyed using the instrument. Data were subjected to exploratory factor analysis using principal axis factoring (PAF) and Promax rotation, and Horn’s parallel analysis determined the number of extracted factors. PAF generated a final 11-item three-factor model accounting for 51% of total variance explained: Standard Assessment (Factor 1; four items; ∞ = .83), Assessment Belief (Factor 2; three items; ∞ = .74), and Problem Scope (Factor 3; four items; ∞ = .62). The older adult PDAQ is a brief, data-driven instrument with acceptable psychometric properties for assessing perceptions of prescription drug abuse and misuse assessment and counseling.

Heroin use onset among nonmedical prescription opioid users in the club scene

BACKGROUND

Nonmedical prescription opioid use (NMPOU) is well documented among participants in the club scene, yet prior studies have not examined transition to heroin use. We prospectively examined heroin initiation among a sample of young adults with drug involvement associated with participation in the club scene, to understand factors that influence transition from NMPOU to heroin and to identify opportunities for intervention.

METHODS

Data were drawn from a randomized trial that enrolled 750 Miami-based club and prescription drug users through respondent driven sampling, and tested the efficacy of assessment interventions in reducing risk. Participants reported current substance use at baseline, 3, 6, and 12 month follow-ups. We examined predictors of heroin initiation among participants reporting NMPOU at baseline, with no lifetime history of heroin use (N=323).

RESULTS

The mean age was 25.0 years; 67.5% met DSM-IV criteria for substance dependence. About 1 in 13 participants (7.7%) initiated heroin use at follow-up. In univariable comparisons, frequent LSD use, history of drug overdose, high frequency NMPOU, using oral tampering methods, and endorsing a primary medical source for prescription opioids were associated with greater likelihood of heroin initiation. LSD use, oral tampering, and primary medical source were significant predictors in a Cox regression model.

CONCLUSIONS

Heroin initiation of 7.7% suggests a high level of vulnerability for transition among young adult NMPO users in the club scene. The importance of oral tampering methods in the trajectory of NMPOU may indicate a need to further examine the role of abuse deterrent formulations in prevention efforts.

The association between age of onset of opioid use and comorbidity among opioid dependent patients receiving methadone maintenance therapy

Background

Opioid use disorder (OUD) affects approximately 21.9 million people worldwide. This study aims to determine the association between age of onset of opioid use and comorbid disorders, both physical and psychiatric, in patients receiving methadone maintenance treatment (MMT) for OUD. Understanding this association may inform clinical practice about important prognostic factors of patients on MMT, enabling clinicians to identify high-risk patients.

Methods

This study includes data collected between June 2011 and August 2016 for the Genetics of Opioid Addiction research collaborative between McMaster University and the Canadian Addiction Treatment Centers. All patients were interviewed by trained health professionals using the Mini-International Neuropsychiatric Interview and case report forms. Physical comorbidities were verified using patients’ electronic medical records. A multi-variable logistic regression model was constructed to determine the strength of the association between age of onset of opioid use and the presence of physical or psychiatric comorbidity while adjusting for current age, sex, body mass index, methadone dose and smoking status.

Results

Data from 627 MMT patients with a mean age of 38.8 years (SD = 11.07) were analyzed. Individuals with an age of onset of opioid use younger than 18 years were found to be at higher odds for having a physical or psychiatric comorbid disorder compared to individuals with an age of onset of opioid use of 31 years or older (odds ratio 2.94, 95% confidence interval 1.20, 7.19, p = 0.02). A significant association was not found between the risk of having a comorbidity and an age of onset of opioid use between 18 and 25 years or 26 and 30 years, compared to an age of onset of opioid use of 31 years or older.

Conclusion

Our study demonstrates that the younger one begins to use opioids, the greater their chance of having a physical or psychiatric co-morbidity. Understanding the risk posed by an earlier onset of opioid use for the later development of comorbid disorders informs clinical practice about important prognostic predictors and aids in the identification of high-risk patients.

An Assessment of the Impact of a Multipronged Approach to Reducing Problematic Pain Clinics in Florida

The present research evaluates recent changes to Florida law and policy to reduce problematic pain clinics (pill mills) and criminal diversion of prescription opioids. These changes entailed a multipronged effort linking regulatory and criminal-law approaches. Quantitative data from the Florida Department of Health and qualitative data from in-depth interviews with law-enforcement officers assigned to pill-mill taskforces reveal steep declines in pain clinics and pill mills. Respondents credit some regulatory enhancements for the reduction, although they describe some interagency cooperation problems and emphasize that despite success, many troublesome establishments continue to operate. The results suggest that Florida’s effort to reduce opioid diversion by tightening regulatory restrictions and law-enforcement scrutiny illustrates a multiagency approach to a problem spanning public health and criminal justice. This could be an example for other states seeking to combat problems that cannot be effectively addressed using regulatory or criminal law alone.

Routes Into Opioid Analgesic Misuse

Non-medical use of opioid analgesics (OAs) has increased in the United States over the past decade, yet there has been little in-depth exploration into the circumstances of initiation of OA misuse. This study is based on qualitative data from five focus groups conducted with individuals who misused OAs in New York City. Participants ( n = 19) were aged between 20 and 47 years. The majority were male ( n = 14) and non-Hispanic White ( n = 12). Three initiate groups were identified: recreational initiates, who typically began misusing OAs in their teens through non-medical sources; medical initiates, who initiated OA use through medical treatment; and experienced opioid users, who initiated OA use through both recreational and medical channels but whose entry into misuse followed a history of heroin use. Findings show heterogeneous patterns of initiation, indicating the need for prevention and intervention strategies to be tailored to particular groups.

Prescription Drug Misuse in Late Adulthood

Prescription drug misuse is a public health problem, and older adults are at high risk. The underlying factors associated with this problem in late adulthood are not well understood. Using cross-sectional data from telephone interviews with individuals aged 60 years and older in Arizona and Florida ( N = 2,000), this study tests whether hypotheses derived from general strain and low self-control theories are supported while investigating misusing prescription medication. Results from the regression analyses reveal that the association between poor health (conceptualized as a strain) and misusing prescription drugs (conceptualized as criminal coping) is partially explained by depressive symptoms (conceptualized as negative emotionality). The link between problem drinking and prescription drug misuse is fully attenuated when low self-control is included in the model. The results confirm that both theories provide insight into this public health problem and that treatment strategies should target the underlying mechanisms that lead to misuse.

Pain treatment and antiretroviral medication adherence among vulnerable HIV-positive patients

Pain represents a significant source of morbidity, function loss, and decreased quality of life among people living with HIV. The present study examined the associations among pain, pain treatment, and ARV adherence among indigent, HIV-positive substance abusers. Participants were recruited via targeted sampling strategies, and completed a one-time computer-assisted personal interview. ANOVA and chi-square tests were used to analyze differences in demographics, health and psychological status, health behaviors, by pain and pain treatment status; a multivariate logistic regression model was constructed to examine the contribution of pain/treatment status to recent ARV adherence. Results indicated that those with untreated pain had lower odds of achieving gold-standard 95% ARV adherence as compared to the pain-free and treated pain groups; higher substance dependence symptoms were also associated with significantly lower odds of 95% ARV adherence. Findings suggest that pain management is critical to the health of people living with HIV, specifically those with high levels of co-morbid health and psychological problems. The prevalence of untreated pain was elevated among this group, and contributed to reduced ARV adherence. Providers of clinical care to disadvantaged HIV-positive patients should emphasize routine assessment and appropriate treatment of pain in order to provide comprehensive HIV care.

Health-related quality of life among prescription opioid-dependent patients: Results from a multi-site study

BACKGROUND

Although prescription opioid use disorder has recently increased sharply in the United States, relatively little is known about the general well-being of this population. Assessment of quality of life in patients with substance use disorders has been recommended to improve clinical care.

OBJECTIVES

Health-related quality of life was examined in prescription opioid-dependent patients at entry to a national multi-site clinical trial, to compare quality of life scores in the study sample to other populations; further, background variables associated with quality of life in the literature were examined.

METHODS

Prescription opioid-dependent patients (N = 653) were compared to general populations on the Medical Outcome Study Short Form-36 (SF-36) quality of life measure; and the association between patient background variables and quality of life was examined.

RESULTS

Compared to a general population, the current sample of prescription opioid-dependent patients had worse physical (-1.7 points, p < .001) and mental quality of life (-12.3 points, p < .001) as measured by the SF-36, similar to other opioid-use disorder populations. Within our sample, women showed more impairment than men in mental quality of life (-4.3 points, p < .001); older patients scored worse on physical (-5.2 points, p < .001), but not mental, quality of life. Chronic pain was associated with poorer physical quality of life (-9.0 points, p < .001).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The growing focus on wellness underscores the importance of measuring quality of life in addition to substance use outcomes. Routine assessment of health-related quality of life can add an important dimension to overall evaluation of patients' treatment response.

Sex differences in chronic pain management practices for patients receiving opioids from the Veterans Health Administration

BACKGROUND

Women experience chronic pain and use pain-related health care at higher rates than men. It is not known whether the pain-related health care female veterans receive is consistent with clinical practice guideline recommendations or whether receipt of this care differs between men and women.

OBJECTIVE

The aim of this study was to identify whether sex differences in chronic pain management care exist for patients served by the Veterans Health Administration (VHA).

DESIGN

Data on patient demographics, diagnostic criteria, and health care utilization were extracted from VHA administrative databases for fiscal year 2010 (FY10).

PATIENTS

Patients in this study included all VHA patients (excluding metastatic cancer patients) who received more than 90 days of a short-acting opioid medication or a long-acting opioid medication prescription in FY10 study.

MEASURES

Multilevel logistic regressions were conducted to identify sex differences in receipt of guideline-recommended chronic pain management.

RESULTS

A total of 480,809 patients met inclusion criteria. Female patients were more likely to receive most measures of guideline-recommended care for chronic pain including mental health assessments, psychotherapy, rehabilitation therapy, and pharmacy reconciliation. However, women were more likely to receive concurrent sedative prescriptions, which is inconsistent with guideline recommendations. Most of the observed sex differences persisted after controlling for key demographic and diagnostic differences.

CONCLUSIONS

Findings suggest that female VHA patients are more likely to receive an array of pain management practices than male patients, including both contraindicated and recommended polypharmacy. Quality improvement efforts to address underutilization of mental health and rehabilitative services for pain by male patients and polypharmacy in female patients should be considered.

Prevalence of Axis-1 psychiatric (with focus on depression and anxiety) disorder and symptomatology among non-medical prescription opioid users in substance use treatment: systematic review and meta-analyses

Non-medical prescription opioid use (NMPOU) constitutes a substantial clinical and public health concern in North America. Although there is evidence of elevated rates of mental health problems among people with NMPOU, the extent of these correlations specifically in treatment samples has not been systematically assessed. A systematic review and meta-analysis were conducted for Axis-1 psychiatric diagnoses and symptoms with a principal focus on depression and anxiety disorders in substance use treatment samples reporting NMPOU at admission to treatment (both criteria within past 30days). 11 unique studies (all from either the United States or Canada) met inclusion criteria and were included in the meta-analysis. The pooled prevalence of 'any' mental health problems (both diagnosis and symptoms) among substance abuse treatment patients reporting NMPOU was 43% (95% CI: 32%-54%; I(2) for inter-study heterogeneity: 99.5%). The pooled prevalence of depression diagnosis among substance abuse treatment patients reporting NMPOU was 27% (95% CI: 9%-45%; I(2): 99.2%); the pooled prevalence of anxiety diagnosis in the sample was 29% (95% CI: 14%-44%; I(2): 98.7%). The prevalence rates of psychiatric problems (both diagnosis and symptoms), depression diagnosis and anxiety diagnosis are disproportionately high in substance use treatment samples reporting NMPOU relative to general population rates. Adequate and effective clinical strategies are needed to address co-occurring NMPOU and mental health in substance use treatment systems, especially given rising treatment demand for NMPOU. Efforts are needed to better understand the temporal and causal relationships among NMPOU, mental health problems, and treatment seeking in order to improve interventions.

Health and social problems associated with prescription opioid misuse among a diverse sample of substance-using MSM

This study examines associations between prescription opioid misuse and demographics, substance use, sexual behavior, and related health and social problems. Baseline data were collected between 2008 and 2010 from 515 high risk men who have sex with men, ages 18-55, in the Miami-Ft. Lauderdale metropolitan area who reported heavy substance use and HIV risk in the past 90 days. Prescription opioid misuse was associated with other substance use, drug injection, substance dependence, and history of arrest. Implications, limitations, and directions for future study are discussed.

Under treatment of pain: a prescription for opioid misuse among the elderly?

OBJECTIVE

To examine the demographic, physical, and mental health characteristics; current drug use patterns; motivations for use; and diversion sources among elderly prescription opioid misusers.

DESIGN

Mixed methods design.

SETTING

Research field offices, or senior or community center offices in South Florida.

SUBJECTS

Individuals aged 60 and over reporting past 90-day prescription medication misuse; only prescription opioid misusers (N = 88) were included in the final analysis.

METHODS

The Global Appraisal of Individual Needs was the main survey instrument. A subsample of elderly reporting substantial prescription drug misuse were chosen for the in-depth interview (N = 30).

RESULTS

The mean age was 63.3. Fifty percent reported ever being admitted to a drug treatment program; several endorsed recent illicit drug use: powder cocaine and/or crack (35.2%), marijuana (30.7%), heroin (14.8%). The majority reported past year severe physical pain and discomfort (86.4%), and misuse of their primary opioid for pain (80.7%); over half (52.3%) obtained their primary opioid from their regular doctor. Qualitative data highlight the misuse of prescription opioids due to untreated or undertreated pain. Participants with primary opioid misuse for pain had over 12 times higher odds of obtaining the medication from their regular doctor (odds ratio [OR] = 12.22, P = 0.002) and had lower odds of using a dealer (OR = 0.20, P = 0.005).

CONCLUSIONS

Findings suggest that this group of elderly participants often misuse their own prescriptions for pain management. This study highlights the need to educate prescribing professionals on appropriate pain management for older adults while still being sensitive to issues of substance abuse and dependence.

Substance use disorders and psychiatric comorbidity in mid and later life: a review

BACKGROUND

Globally, adults aged 65 years or older will increase from 516 million in 2009 to an estimated 1.53 billion in 2050. Due to substance use at earlier ages that may continue into later life, and ageing-related changes in medical conditions, older substance users are at risk for substance-related consequences.

METHODS

MEDLINE and PsychInfo databases were searched using keywords: alcohol use disorder, drug use disorder, drug misuse, substance use disorder, prescription drug abuse, and substance abuse. Using the related-articles link, additional articles were screened for inclusion. This review focused on original studies published between 2005 and 2013 to reflect recent trends in substance use disorders. Studies on psychiatric comorbidity were also reviewed to inform treatment needs for older adults with a substance use disorder.

RESULTS

Among community non-institutionalized adults aged 50+ years, about 60% used alcohol, 3% used illicit drugs and 1-2% used nonmedical prescription drugs in the past year. Among adults aged 50+, about 5% of men and 1.4% of women had a past-year alcohol use disorder. Among alcohol users, about one in 14 users aged 50-64 had a past-year alcohol use disorder vs one in 30 elder users aged 65+. Among drug users aged 50+, approximately 10-12% had a drug use disorder. Similar to depressive and anxiety disorders, substance use disorders were among the common psychiatric disorders among older adults. Older drug users in methadone maintenance treatment exhibited multiple psychiatric or medical conditions. There have been increases in treatment admissions for illicit and prescription drug problems in the United States.

CONCLUSIONS

Substance use in late life requires surveillance and research, including tracking substance use in the racial/ethnic populations and developing effective care models to address comorbid medical and mental health problems.

Toward primary prevention of extra-medical OxyContin® use among young people

OBJECTIVE

The prevention research context includes current epidemic levels of hazards associated with extra-medical use of OxyContin® (to get high or otherwise outside prescribed boundaries) among teenagers and young adults, and a recent OxyContin® re-formulation with an intent to reduce these hazards, plus hope for possibly beneficial primary prevention impact. The aim is to create a benchmark of risk estimates for the years just prior to OxyContin® re-formulation in anticipation of potential public health benefit in future years, with a focus on teens and the youngest adults in the United States, and to compare two methods for estimating peak risk.

METHOD

The data are from nationally representative probability sample surveys of 12-21 year olds, yielding estimates for incidence of extra-medical OxyContin® use. Samples are of the non-institutionalized United States population, recruited and assessed in National Surveys on Drug Use and Health (NSDUH), each year from 2004 through 2008. In aggregate, the sample includes 135,552 young people who had not used OxyContin® extra-medically prior to their year of survey assessment.

RESULTS

The main outcome was the estimated population-level age-specific incidence of extra-medical OxyContin® use, 2004-2008. We found that during the 2004-2008 interval the estimated risk accelerated from age 12 years, reached a peak value in mid-adolescence at roughly five newly incident users per 1000 persons per year (95% confidence intervals, 0.3%, 0.7%), and then declined. A meta-analysis approach to year-by-year data differentiated age patterns more clearly than a pooled estimation approach.

CONCLUSION

Studying young people in the United States, we have discovered that the risk of starting to use OxyContin® extra-medically rises to a peak by mid-adolescence and then declines. From a methods standpoint, the meta-analysis serves well in this context; there is no advantage to pooling survey data across years. We also discovered that during any given year a pediatrician might rarely see even one patient who has just started to use OxyContin® to get high or for other extra-medical purposes. Implications for screening are discussed.

Update on prescription extended-release opioids and appropriate patient selection

Chronic pain is largely underdiagnosed, often undertreated, and expected to increase as the American population ages. Many patients with chronic pain require long-term treatment with analgesic medications, and pain management may involve use of prescription opioids for patients whose pain is inadequately controlled through other therapies. Yet because of the potential for abuse and addiction, many clinicians hesitate to treat their patients with pain with potentially beneficial agents. Finding the right opioid for the right patient is the first - often complicated - step. Ensuring that patients continue to properly use the medication while achieving therapeutic analgesic effects is the long-term goal. Combined with careful patient selection and ongoing monitoring, new formulations using extended-release technologies incorporating tamper-resistant features may help combat the growing risk of abuse or misuse, which will hopefully reduce individual suffering and the societal burden of chronic pain. The objective of this manuscript is to provide an update on extended-release opioids and to provide clinicians with a greater understanding of which patients might benefit from these new opioid formulations and how to integrate the recommended monitoring for abuse potential into clinical practice.

Demographic and clinical characteristics of middle-aged versus younger adults enrolled in a clinical trial of a web-delivered psychosocial treatment for substance use disorders

OBJECTIVE

Evidence suggests that substance abuse is becoming more prevalent in middle-aged adults. The objective of this secondary analysis was to add to the growing empirical literature on the unique features of middle-aged substance abuse populations.

METHODS

We descriptively compared baseline demographic and clinical characteristics of middle-aged (age 45-62 years, n = 111) and younger (age 18-44 years, n = 395) substance abusers entering a Web-based psychosocial treatment study as part of the National Institute on Drug Abuse Clinical Trials Network.

RESULTS

A significantly greater percentage of middle-aged adults were nonwhite and had a marital status other than single/never married. There was a significant association between frequency of Internet use and the age group. Forty-six percent of middle-aged adults versus 21% of younger adults reported no Internet use in the prior 90 days. A significantly greater percentage of middle-aged adults used cocaine, and a significantly greater percentage of younger adults used marijuana and opioids. Clinically significant cognitive impairment (z < -1.0) was found for the average participant in both groups on logical association of familiar concepts.

CONCLUSIONS

This secondary analysis of a National Institute on Drug Abuse Clinical Trials Network study provides additional information on the unique features of middle-aged substance abusers. Increasing knowledge of similarities and differences between younger and middle-aged substance abusers can help with potential age-specific substance abuse treatment planning.

Management of pain with comorbid substance abuse

Substance use disorders are a large public health problem in the United States. Over the past decade, there has been a trend of increased prescription drug misuse, morbidity, and mortality related to prescription opioids. For providers who treat pain, this has led to clinical dilemmas as the newly appreciated risks must be balanced with the benefits of treatment, particularly in patients with known substance use disorders. Acute, chronic, and palliative each present distinct issues in pain treatment. A best practices model of pain treatment, including risk stratification and integrative treatment, may provide the best prospect for safe and effective treatment.