Prescription drug abuse: from epidemiology to public policy

International external validation of the SORG machine learning algorithm for predicting sustained postoperative opioid prescription after anterior cervical discectomy and fusion using a Taiwanese cohort of 1,037 patients

BACKGROUND CONTEXT

Anterior cervical discectomy and fusion (ACDF) is widely performed for cervical spine disorders, with opioids commonly prescribed postoperatively for pain management. However, prolonged opioid use carries significant risks such as dependency and adverse health effects. Predictive models like the SORG machine learning algorithm (SORG-MLA) have been developed to forecast prolonged opioid use post-ACDF. External validation is essential to ensure their effectiveness across different healthcare settings and populations.

PURPOSE

The study aimed to assess the generalizability of the SORG-MLA to a Taiwanese patient cohort for predicting prolonged opioid use after ACDF.

STUDY DESIGN

Retrospective cohort study utilizing data from a tertiary care center in Taiwan.

PATIENT SAMPLE

1,037 patients who underwent ACDF between 2010 and 2018 were included.

OUTCOME MEASURES

The primary outcome was sustained postoperative opioid prescription defined as continuous opioid use for at least 90 days following ACDF.

METHODS

The performance of the SORG-MLA in the validation cohort was assessed using discrimination measures (area under the receiver operating characteristic curve [AUROC] and the area under the precision-recall curve [AUPRC]), calibration, overall performance (Brier Score), and decision curve analysis. Comparing the validation cohort to the developmental revealed significant differences in demographic profiles, medicolegal frameworks, ethnic cultural contexts and key predictors of postoperative opioid use identified by the SORG-MLA. The Taiwanese cohort was characterized by an older age demographic, a lower proportion of female participants, higher smoking prevalence, higher incidence of preoperative myelopathy and radiculopathy, and more frequent use of antidepressants prior to surgery. Conversely, these patients were less likely to have extended preoperative opioid prescriptions beyond 180 days, undergo multilevel ACDF procedures, or be treated with concurrent medications such as Beta-2 agonists, Gabapentin, and ACE inhibitors. This study had no funding source or conflict of interests.

RESULTS

The model demonstrated good discriminative ability, with an AUROC of 0.78 and an AUPRC of 0.35. Calibration curves indicated that the model overestimated the risk of prolonged opioid use. This discrepancy may be attributed to the significantly higher incidence of sustained opioid consumption in the American development cohort, spanning from 2000 to 2018, which was threefold higher than that in the Taiwanese validation cohort between 2010 and 2018 (9.9% [270/2737] vs. 3.3% [34/1037]; p < .01). The Brier score was 0.033, which improved upon the null model's score of 0.040, indicating robust overall performance. Decision curve analysis confirmed the model's clinical utility, demonstrating net benefits across various decision thresholds.

CONCLUSIONS

The SORG-MLA has demonstrated robust discriminative abilities and overall performance when applied to a unique Taiwanese cohort. However, the model exhibited an overestimation of the risk of prolonged opioid use, suggesting the need for recalibration with more contemporary data to reflect current opioid prescription practices, ethnic and cultural differences, and opioid regulations. Following recalibration, integration and prospective validation within the electronic healthcare system should be pursued. This will enable clinicians to proactively identify patients at heightened risk of prolonged opioid use following ACDF.

A case report of pregabalin misuse leading to drug dependence

Pregabalin misuse and dependence have become emerging concerns in recent years, particularly in regions where traditional drug-related crimes have been curbed, prompting users to seek alternative substances. Although pregabalin is primarily used for treating conditions such as epilepsy, neuropathic pain, and generalized anxiety disorder, its sedative and euphoric effects make it prone to misuse. This case report presents a 20-year-old male who developed pregabalin dependence after using the drug intermittently at escalating doses over a year. He experienced withdrawal symptoms including palpitations, tremors, irritability, insomnia, and auditory hallucinations upon cessation of the drug, which were alleviated by resuming pregabalin use. Upon admission, he was diagnosed with pregabalin dependence, hyperuricemia, and thyroid nodules. The patient underwent a comprehensive treatment plan involving benzodiazepines, antidepressants, and antipsychotics, leading to substantial improvement in mood, anxiety, psychotic symptoms, and withdrawal symptoms. This case highlights the growing issue of pregabalin misuse, the associated withdrawal symptoms, and the importance of early intervention and systematic treatment strategies. It emphasizes the need for stricter prescription controls, patient education on the risks of misuse, and multidisciplinary approaches to the treatment of pregabalin dependence. Further research is necessary to better understand the mechanisms behind pregabalin misuse and to develop improved prevention and treatment protocols.

Simultaneous multi-targeted forensic toxicological screening in biological matrices by MRM-IDA-EPI mode

The toxicologist ascertains drug assumptions in case of paediatric intoxications and death for overdose. The analytical approach consists of initially screening and consequently confirming drug positivity. We developed a toxicological screening method and validated its use comparing the results with a LC-MS/MS analysis. The method identifies 751 drugs and metabolites (704 in positive and 47 in negative mode). Chromatographic separation was achieved eluting mobile phase A (10 mM ammonium formate) and B (0.05% formic acid in methanol) in gradient on Kinetex Phenyl-Hexyl (50 × 4.6 mm, 2.6 μm) with 0.7 mL/min flow rate for 11 min. Multiple Reaction Monitoring (MRM) was adopted as survey scan and, after an Information-Dependent Analysis (IDA) (threshold of 30,000 for positive and 1000 cps for negative mode), the Enhanced Product Ion (scan range: 50-700 amu) was triggered. The MS/MS spectrum generated was compared with one of the libraries for identification. Data processing was optimised through creation of rules. Sample preparation, mainly consisting of deproteinization and enzymatic hydrolysis, was set up for different matrices (blood, urine, vitreous humor, synovial fluid, cadaveric tissues and larvae). Cut-off for most analytes resulted in the lowest concentration tested. When the results from the screening and LC-MS/MS analysis were compared, an optimal percentage of agreement (100%) was assessed for all matrices. Method applicability was evaluated on real paediatric intoxications and forensic cases. In conclusion, we proposed a multi-targeted, fast, sensitive and specific MRM-IDA-EPI screening having an extensive use in different toxicological fields.

Psychological Distress Mediates the Relationship Between HIV-Related Stigma and Prescription Opioid Misuse Among Chinese People Living with HIV

Prescription opioid misuse (POM) among people living with HIV (PLWH) is a serious concern due to risks related to dependence and overdose, and PLWH may be at higher risk for POM due to psychosocial stressors including psychological distress. However, scant POM research has examined the role of HIV-related stigma (e.g., internalized stigma, enacted stigma) in POM among PLWH. Guided by minority stress theory, this study examined a hypothesized serial mediation among enacted stigma, internalized stigma, psychological distress, and POM within a sample of Chinese PLWH with pain symptoms enrolled in a wave (between November 2017 and February 2018) of a longitudinal cohort study in Guangxi (n = 116). Models were tested individually for six enacted stigma experiences, controlling for key demographic and health-related variables (e.g., CD4 + count). Results showed HIV-related workplace discrimination was the most common stigma experience (12%,) and 10.3% of PLWH reported POM. Indirect effect analyses showed that internalized stigma was indirectly associated with POM through psychological distress. Internalized stigma and psychological distress mediated the association between workplace discrimination and POM. Family discrimination, gossip, and healthcare discrimination were directly associated with POM. This study suggests that Chinese PLWH may engage in POM to cope with psychological distress that is rooted in HIV-related stigma and highlights the important context of workplace discrimination for PLWH. Implications for interventions to reduce POM among PLWH are discussed.

Multinational appraisal of the epidemiological distribution of opioid fatalities: a systematic review and meta-analysis

Background

The global or multinational scientific evidence on the distribution of opioid fatality is unknown. Hence, the current study collects epidemiological characteristics to shed light on the ongoing global or multinational opioid crisis and to promote the development of public health prevention/management strategies.

Method

All documents on PRISMA standards were retrieved via electronic databases.

Results

Among the 47 articles relevant to our studies, which depict a total population size of 10,191 individuals, the prevalence of opioid fatal overdose was 15,022 (14.74%). Among the 47 articles, 14 of them reported the gender of the participants, with 22,125 (15.79%) male individuals and 7,235 (5.17%) female individuals, and the age distribution of the participants that was most affected by the overdose was as follows: 29,272 (31.13%) belonged to the 18-34-year-old age group and 25,316 (26.92%) belonged to the less than 18-year-old age group. Eighteen studies qualified for the meta-analysis of the multinational prevalence of fatal opioid overdose, depicting an overall pooled prevalence estimate of 19.66%, with 95% CIs (0.13-0.29), I2 = 99.76% determined using the random-effects model, and Q statistic of 7198.77 (p < 0.0001). The Egger test models of publication bias revealed an insubstantial level of bias (p = 0.015). The subgroup analysis of the study design (cohort or other) revealed that others have the highest prevalence estimate of 34.37, 95% CIs (0.1600-0.5901), I2 = 97.04%, and a sample size of less than 1,000 shows the highest prevalence of 34.66, 95% CIs (0.2039-0.5234), I2 = 97.82%, compared to that of more than 1,000 with a prevalence of 12.28, 95% CIs (0.0675-0.2131), I2 = 99.85%. The meta-regression analysis revealed that sample size (less-than or greater-than 1,000), (p = 0.0098; R2 = 3.83%) is significantly associated with the observed heterogeneity.

Conclusion

Research-based findings of fatal opioid overdose are grossly lacking in middle- and low-income nations. We established that there is a need for opioid fatality surveillance systems in developing nations.

Prescription Opioid Misuse, Pain Interference, Resilience, and Anxiety Among Chinese People Living with HIV: A Moderated Mediation Model

Prescription opioid misuse (POM) is a concern in people living with HIV (PLWH). Pain interference is a robust factor, and its influences would occur through anxiety and resilience. Limited POM studies attend to Chinese PLWH. This study examined POM and its underlying psychological mechanism using data of PLWH with pain (n = 116) from a cohort study in Guangxi. The PROCESS macro was employed to examine a hypothesized moderated mediation model among pain interference, resilience, anxiety, and POM. Results showed 10.3% PLWH engaged in past-three-month POM. After controlling for demographics, HIV-related clinical outcomes, and pain severity, anxiety mediated the association between pain interference and POM (β = 0.46, 95% CI = 0.01 to 10.49), and the mediation was moderated by resilience (moderated mediation index = - 0.02, 95% CI = - 0.784 to - 0.001). Chinese PLWH seem to misuse opioids to cope with pain-related anxiety. Resilience appears to offer protection.

Effects of sex and estrous cycle on intravenous oxycodone self-administration and the reinstatement of oxycodone-seeking behavior in rats

Introduction

The increasing misuse of both prescription and illicit opioids has culminated in a national healthcare crisis in the United States. Oxycodone is among the most widely prescribed and misused opioid pain relievers and has been associated with a high risk for transition to compulsive opioid use. Here, we sought to examine potential sex differences and estrous cycle-dependent effects on the reinforcing efficacy of oxycodone, as well as on stress-induced or cue-induced oxycodone-seeking behavior, using intravenous (IV) oxycodone self-administration and reinstatement procedures.

Methods

In experiment 1, adult male and female Long-Evans rats were trained to self-administer 0.03 mg/kg/inf oxycodone according to a fixed-ratio 1 schedule of reinforcement in daily 2-h sessions, and a dose-response function was subsequently determined (0.003-0.03 mg/kg/inf). In experiment 2, a separate group of adult male and female Long-Evans rats were trained to self-administer 0.03 mg/kg/inf oxycodone for 8 sessions, followed by 0.01 mg/kg/inf oxycodone for 10 sessions. Responding was then extinguished, followed by sequential footshock-induced and cue-induced reinstatement tests.

Results

In the dose-response experiment, oxycodone produced a typical inverted U-shape function with 0.01 mg/kg/inf representing the maximally effective dose in both sexes. No sex differences were detected in the reinforcing efficacy of oxycodone. In the second experiment, the reinforcing effects of 0.01-0.03 mg//kg/inf oxycodone were significantly attenuated in females during proestrus/estrus as compared to metestrus/diestrus phases of the estrous cycle. Neither males nor females displayed significant footshock-induced reinstatement of oxycodone seeking, but both sexes exhibited significant cue-induced reinstatement of oxycodone seeking at magnitudes that did not differ either by sex or by estrous cycle phase.

Discussion

These results confirm and extend previous work suggesting that sex does not robustly influence the primary reinforcing effects of oxycodone nor the reinstatement of oxycodone-seeking behavior. However, our findings reveal for the first time that the reinforcing efficacy of IV oxycodone varies across the estrous cycle in female rats.

Effects of sex and estrous cycle on intravenous oxycodone self-administration and the reinstatement of oxycodone-seeking behavior in rats

The increasing misuse of both prescription and illicit opioids has culminated in a national healthcare crisis in the United States. Oxycodone is among the most widely prescribed and misused opioid pain relievers and has been associated with a high risk for transition to compulsive opioid use. Here, we sought to examine potential sex differences and estrous cycle-dependent effects on the reinforcing efficacy of oxycodone, as well as on stress-induced or cue-induced oxycodone-seeking behavior, using intravenous (IV) oxycodone self-administration and reinstatement procedures. In experiment 1, adult male and female Long-Evans rats were trained to self-administer 0.03 mg/kg/inf oxycodone according to a fixed-ratio 1 schedule of reinforcement in daily 2-hr sessions, and a dose-response function was subsequently determined (0.003-0.03 mg/kg/inf). In experiment 2, a separate group of adult male and female Long-Evans rats were trained to self-administer 0.03 mg/kg/inf oxycodone for 8 sessions, followed by 0.01 mg/kg/inf oxycodone for 10 sessions. Responding was then extinguished, followed by sequential footshock-induced and cue-induced reinstatement tests. In the dose-response experiment, oxycodone produced a typical inverted U-shape function with 0.01 mg/kg/inf representing the maximally effective dose in both sexes. No sex differences were detected in the reinforcing efficacy of oxycodone. In the second experiment, the reinforcing effects of 0.01-0.03 mg//kg/inf oxycodone were significantly attenuated in females during proestrus/estrus as compared to metestrus/diestrus phases of the estrous cycle. Neither males nor females displayed significant footshock-induced reinstatement of oxycodone seeking, but both sexes exhibited significant cue-induced reinstatement of oxycodone seeking at magnitudes that did not differ either by sex or by estrous cycle phase. These results confirm and extend previous work suggesting that sex does not robustly influence the primary reinforcing effects of oxycodone nor the reinstatement of oxycodone-seeking behavior. However, our findings reveal for the first time that the reinforcing efficacy of IV oxycodone varies across the estrous cycle in female rats.

Ethanol and Medical Psychotropics Co-Consumption in European Countries: Results from a Three-Year Retrospective Study of Forensic Samples in Spain

Ethanol and medical psychotropics (MPs) are legal psychoactive substances widely consumed in Western countries that are routinely detected in standard toxicological analyses at compulsory autopsies, and toxicokinetic interactions between these drugs have been described. However, studies assessing the consequences of this co-consumption are scarce in Europe. We performed a retrospective study on toxicological results from compulsory autopsies in Spain. Thirty-five legal psychotropics, including ethanol, were measured in blood samples from 380 decedents to assess the determinants of such co-consumption. MPs were detected in 42.4% of the subjects. Polypharmacy was frequent in our series (25%), being more frequent in men than in women. More than one-third of the decedents had detectable levels of ethanol, and a significant positive association between ethanol levels and age was evident. About one-third of MPs consumers were also co-consumers of ethanol. The simultaneous consumption of ethanol and MPs was higher in men than in women. Blood alcohol concentrations (BAC) were lower in men who consumed MPs. In polypharmacy deaths, there was a significant negative association between the number of MPs consumed and BAC in men (r = -0.097; p = 0.029). Our results showed a high prevalence of co-consumption of MPs and ethanol in the European population involved in medico-legal issues and suggest that toxicokinetic interactions may be lowering BAC in men. This is a very worrying result, as it could indicate that the legal blood ethanol limits set by legislation would not be appropriate for men on MPs treatment.

Are prescription misuse and illicit drug use etiologically distinct? A genetically-informed analysis of opioids and stimulants

BACKGROUND

Drug classes are grouped based on their chemical and pharmacological properties, but prescription and illicit drugs differ in other important ways. Potential differences in genetic and environmental influences on the (mis)use of prescription and illicit drugs that are subsumed under the same class should be examined. Opioid and stimulant classes contain prescription and illicit forms differentially associated with salient risk factors (common route of administration, legality), making them useful comparators for addressing this etiological issue.

METHODS

A total of 2410 individual Australian twins [Mage = 31.77 (s.d. = 2.48); 67% women] were interviewed about prescription misuse and illicit use of opioids and stimulants. Univariate and bivariate biometric models partitioned variances and covariances into additive genetic, shared environmental, and unique environmental influences across drug types.

RESULTS

Variation in the propensity to misuse prescription opioids was attributable to genes (41%) and unique environment (59%). Illicit opioid use was attributable to shared (71%) and unique (29%) environment. Prescription stimulant misuse was attributable to genes (79%) and unique environment (21%). Illicit stimulant use was attributable to genes (48%), shared environment (29%), and unique environment (23%). There was evidence for genetic influence common to both stimulant types, but limited evidence for genetic influence common to both opioid types. Bivariate correlations suggested that prescription opioid use may be more genetically similar to prescription stimulant use than to illicit opioid use.

CONCLUSIONS

Prescription opioid misuse may share little genetic influence with illicit opioid use. Future research may consider avoiding unitary drug classifications, particularly when examining genetic influences.

Patterns and Correlates of Polysubstance Use Among Individuals With Severe Alcohol Use Disorder

AIM

The present study examined patterns and correlates of polysubstance use among individuals with severe alcohol use disorder (AUD).

METHODS

Participants were 2785 individuals (63% female; mean age = 43 years, range = 18-78 years) from the Genes, Addiction and Personality Study. All participants met lifetime criteria for severe AUD (6+ symptoms). We used latent class analysis to identify patterns of frequency of lifetime use for cigarettes, marijuana, cocaine, stimulants, sedatives, opioids and hallucinogens. A variety of demographic and behavioral correlates of latent class membership were tested in univariable and multivariable models.

RESULTS

A five-class solution was selected: extended range polysubstance use (24.5%); cigarette and marijuana use (18.8%); 'testers,' characterized by high probabilities of smoking 100 or more cigarettes, using marijuana 6+ times, and trying the remaining substances 1-5 times (12.3%); moderate range polysubstance use (17.1%) and minimal use (reference class; 27.3%). In univariable analyses, all potential correlates were related to latent class membership. In the multivariable model, associations with gender, race/ethnicity, age of onset for alcohol problems, dimensions of impulsivity, depressive symptoms, antisocial behavior and family history density of alcohol problems remained significant, though the pattern and strength of associations differed across classes. For instance, sensation-seeking, lack of premeditation and family history were uniquely associated with membership in the extended range polysubstance use class.

CONCLUSION

Patterns of polysubstance use are differentially related to demographic and behavioral factors among individuals with severe AUD. Assessing use across multiple substances may inform the selection of targets for treatment and prevention.

'I Was Present but I Was Absent': Perceptions and Experiences of the Non-Medical Use of Prescription or over the Counter Medication among Employed South African Women

BACKGROUND

The need for workplace substance use prevention programmes globally and in South Africa is driven by the growing problem of substance use and the associated burden on the health and welfare of employees, their families and organizations. Substance use, which include the non-medical use of medications (both prescription and over-the counter), remains widespread and is a major cause of mortality and a risk factor for non-communicable diseases (NCDs).

METHOD

Twenty in-depth semi-structured qualitative interviews were conducted with employed women in treatment or shortly out of treatment for the non-medically indicated use of over the counter or/and prescription medications (NMIU). These interviews were conducted face-to face with women residing in the Western and Eastern Cape provinces of South Africa. Thematic analysis using NVIVO was used to analyse data collected.

RESULTS

The findings from this study suggest that previous use of legal or illegal substances and challenging life experiences underpin pathways to the non-medical use of over-the-counter and prescription medications among employed women. Factors found to contribute to misuse relate to a lack of understanding on risks, and health professional prescribing practices, while mitigators to harmful use were related to increased awareness and understanding harmful practices, the need for improved access and referral to specialist treatment as well as prevention programmes for women.

CONCLUSION

With the improved understanding of the issues surrounding the NMIU of over-the-counter and prescription medications among employed women, the need for interventions to prevent misuse and inadvertently dependency is highlighted.

Recovery from opioid use disorder: A 4-year post-clinical trial outcomes study

BACKGROUND

Opioid use disorder (OUD) seriously impacts public health in the United States. However, few investigations of long-term outcomes following treatment with medication for OUD exist. Additionally, these studies have prioritized opioid use and treatment utilization outcomes, and a gap in knowledge regarding long-term, multidimensional trajectories of OUD recovery exists. This study investigated a diverse array of outcomes for individuals with OUD at an average of 4.2 years post clinical trial participation.

METHODS

Individuals who previously participated in long-acting buprenorphine subcutaneous injection clinical trials (NCT023579011; NCT025100142; NCT02896296) and enrolled in The Remission from Chronic Opioid Use-Studying Environmental and SocioEconomic Factors on Recovery (RECOVER; NCT03604861) Study participated in a follow up assessment (n = 216). Substance use, psychosocial, opioid dependence, and delay discounting outcomes were assessed. Regression analyses were conducted to determine significant associations between psychosocial/opioid dependence variables and both recent opioid use and delay discounting.

RESULTS

The majority of participants reported abstinence from opioids since the last RECOVER study assessment (mean 2.26 years; 55%) and in the past 30 days (69%). Participants reported low levels of depression and psychological distress. Positive associations between depression and opioid craving with past 30-day opioid misuse and delay discounting, and negative associations between quality of life and treatment effectiveness with these outcomes were observed.

CONCLUSIONS

This study examined longer term OUD recovery outcomes. Participants reported high levels of abstinence from opioids and psychosocial functioning. These encouraging results highlight the multidimensional nature of recovery from OUD, and further support the effectiveness of buprenorphine as an OUD treatment.

Prevention of Drug Use in Early Adolescents in Palu City, Indonesia

BACKGROUND: In the last three decades, there has been a significant increase in risky behavior among adolescents in various countries, including Indonesia. They tend to get involved in potentially harmful activities and are at a greater risk of this behavior than other age groups. AIM: This study aims to provide information about preventing drug use in early adolescents in Palu City. METHODS: This qualitative study was carried out in Palu City between July and October 2021 using a phenomenological approach, with 7 informants that were selected using a purposive method. The data were collected through in-depth interviews and the comments recorded were analyzed. Furthermore, ethical considerations were taken into account which includes seeking the consent of the study participants to record the interviews, respecting the confidentiality of information, and giving the right to withdraw. RESULTS: The result showed that risky behavior related to drug abuse among young adolescents is prevented by prioritizing education through related institutions such as the National Narcotics Agency (BNN) and schools. CONCLUSIONS: Based on the result, prevention of risky behavior related to drug abuse is through the supervision of the school and people. Furthermore, the availability of information needs to be addressed by the extension system implemented by the Palu City BNN as a source of information for students in breaking the chain of drug abuse. Social control and supervision from parents are also needed to prevent this behavior among adolescents, especially students.

Optimization of Prescription Drug Monitoring Program to Overcome Opioid Epidemic in West Virginia

The development of the Prescription Drug Monitoring Program (PDMP) led to an innovation in the healthcare organization system (HCOs). The PDMP system has been utilized in different states at various organizational levels in an effort to achieve improved health outcomes, reduce the number of prescription drug overdoses, and lighten the economic burden that follows. However, during the implementation of PDMP, there were several barriers and limitations that were discovered. Those barriers impeded the process of utilization of PDMP, such as the complex user interface and lack of training for healthcare providers. The purpose of this paper was to examine the advances and limitations in the utilization and implementation of PDMP in the US healthcare industry and develop strategies for effective use of PDMP in West Virginia.

The qualitative part of this paper was a literature review. The paper referred to several peer-reviewed studies and research articles from several reliable resources, which were reached by databases or Google Scholar. A total of 44 articles were reviewed for this study.

The implementation of the PDMP was influenced by benefits and barriers. This article reviewed several studies in general that demonstrated positive outcomes from the implementation of PDMP, including a reduced number of prescription drug overdoses, coordinated care for patients, and improved health outcomes. However, the barriers and limitations were not neglected, which mainly include integration of PDMP into the electronic health record (EHR) system, lack of training for the providers, and lack of basic standards for the use of PDMP.

Although the new health reforms encouraged the adaption of PDMP among providers, data reporting and data interpretation still remain major concerns for assessing the health outcomes of PDMP implementation.

Using wearable technology to detect prescription opioid self-administration

ABSTRACT

Appropriate monitoring of opioid use in patients with pain conditions is paramount, yet it remains a very challenging task. The current work examined the use of a wearable sensor to detect self-administration of opioids after dental surgery using machine learning. Participants were recruited from an oral and maxillofacial surgery clinic. Participants were 46 adult patients (26 female) receiving opioids after dental surgery. Participants wore Empatica E4 sensors during the period they self-administered opioids. The E4 collected physiological parameters including accelerometer x-, y-, and z-axes, heart rate, and electrodermal activity. Four machine learning models provided validation accuracies greater than 80%, but the bagged-tree model provided the highest combination of validation accuracy (83.7%) and area under the receiver operating characteristic curve (0.92). The trained model had a validation sensitivity of 82%, a specificity of 85%, a positive predictive value of 85%, and a negative predictive value of 83%. A subsequent test of the trained model on withheld data had a sensitivity of 81%, a specificity of 88%, a positive predictive value of 87%, and a negative predictive value of 82%. Results from training and testing model of machine learning indicated that opioid self-administration could be identified with reasonable accuracy, leading to considerable possibilities of the use of wearable technology to advance prevention and treatment.

Medical Psychotropics in Forensic Autopsies in European Countries: Results from a Three-Year Retrospective Study in Spain

Medical psychotropics are widely used and prescribed in developed countries. These medications may have an impairing effect on mood or perception and may induce harmful behaviors. Nevertheless, in Europe, studies on their importance from a medico-legal perspective are scarce. To fill this gap, we evaluate the determinants of these drugs in a retrospective study based on data obtained from forensic autopsies. Toxicological analyses were performed on 394 blood samples from compulsory autopsies at the Institute of Legal Medicine of Las Palmas. Of the samples, 41% (159) were positive for at least one psychotropic, with benzodiazepines being the most frequently detected (24.1%), followed by opiates and antidepressants. Benzodiazepines, opiates, and antidepressants were detected more frequently in men who suffered a violent death. More than 30% of the positive samples showed two or more drugs, suggesting a prevalence of polypharmacy among forensic autopsy subjects, with the most frequently combination found being benzodiazepines plus opiates (28.3% of positive samples). A combination of opiates plus antidepressants was also found in subjects involved in violent deaths. Our results suggest that more than 40% of the adult European population involved in medico-legal issues may be under the influence of legal psychotropics. The link between violent deaths and the use of medical psychotropics is particularly worrisome and indicates that these drugs should be carefully monitored in developed countries, in all forensic autopsies, in a similar way to illegal psychotropics.

Compliance of Private Pharmacy Retail Outlets to Narcotic Drug Regulations in Ethiopia: A Cross-Sectional and Simulated Client Study Method

BACKGROUND

Inappropriate use of narcotic drugs is a growing worldwide health challenge. The problem is even worse in Sub-Saharan Africa where organized supply chain regulations on dispensing and stock management are poor for controlling these global challenges.

METHODS

A mixed method, descriptive cross-sectional and simulated client study design was used from September 10, 2020 to November 26, 2020 to assess the extent of utilization and compliance of narcotic drug dispensing in private pharmacy retail outlets of Gondar and Bahir Dar town of Amhara region, Ethiopia. A total of 107 private pharmacy outlets were on duty. But in simulated study, purposive sampling is a method that prioritizes study units having the data of interest.

RESULTS

A total of 107 private pharmacy retails outlets were included in the survey. The average compliance to the controlled prescription regulation of Ethiopia in all pharmacy outlets (107) of the five drugs were calculated and found to be poor, 23.9% (SD = 18.3%). Compliance to strong narcotics is extremely low, 3.3 % for pethidine and 8% for morphine. Religion of the professionals has significant association with compliance to the prescription of narcotic drugs (p < .001).

DISCUSSION

In the era of narcotic epidemics, as a result of growing global inappropriate use of controlled drugs, the finding of this study gives an insight for a serious and strict regulation in managing and controlling the overall distribution of the narcotic drugs.

CONCLUSIONS

The compliance of the private retail pharmacies of Ethiopia to the regulation of controlled drugs is low.

Rates and Predictors of Using Opioids in the Emergency Department to Treat Migraine in Adolescents and Young Adults

OBJECTIVES

This study aimed to determine the rate and context in which opioids are used to treat migraine in adolescents and young adults seen in emergency care settings.

METHODS

Data from 2010 to 2016 in the Cerner Health Facts electronic health record data warehouse were analyzed using multilevel logistic regression to estimate the population likelihood of an opioid being used in the emergency department (ED) to treat a primary diagnosis of migraine in adolescents and young adults and to evaluate the extent to which this likelihood varies as a function of characteristics of the patient (age, sex, race, and insurance), encounter (referral source, provider specialty, and encounter duration and year), and ED (region, setting, size, payer mix, and academic status).

RESULTS

The study identified 14,494 eligible ED encounters with unique patients, of which 23% involved an opioid. Likelihood of being treated with opioids was significantly higher for patients who were older, female, white, and seen by a surgeon and who had longer encounters and encounters earlier in the time period sampled. Sites varied widely in percentage of encounters involving opioids (mean, 26.4% ± 20.1%; range, 0-100%), with higher rates associated with smaller sites with relatively higher proportions of commercially insured patients.

CONCLUSIONS

Use of opioids in the ED to treat migraine in youth is fairly common, with rate variation reflecting broader trends in for whom opioids tend to be more likely to be prescribed. These findings may be helpful for benchmarking and informing quality improvement efforts aimed at reducing unwarranted opioid exposure in youth.

Addictive profiles of Lebanese university students in terms of smoking, alcohol, and illegal drug use

The Lebanese economic crisis, financial crisis, and USD shortage were conducive to an increased drug addiction especially for students who feel that their future in Lebanon is not safe, as well as the psychological fragility of the Lebanese people, and the more permissive sociocultural context. Our study aimed to assess the addiction levels and profiles of university students in Lebanon, and thus to evaluate the rapid rising in dependence regarding smoking, alcohol, and illegal drug use during this crisis. This cross-sectional study was carried out between February and September 2020. A total of 467 participants (315 females, 152 males; Mage = 23.48 ± 6.03) were recruited through convenience sampling through several universities in Lebanon's governorates. Participants received the online link to the survey. Students were divided into three clusters as follows: cluster 1, which corresponds to students with moderate addictions; cluster 2, which corresponds to students with high addictions; and cluster 3, which corresponds to students with low addictions. When comparing cluster 1 to cluster 3, the results of the multinomial regression showed that older age (aOR=1.08) and having a high monthly income compared to no income (aOR=2.78) were significantly associated with higher odds of being in cluster 1 compared to cluster 3. When comparing cluster 2 to cluster 3, the results of the multinomial regression showed that female gender (aOR=0.19) was significantly associated with lower odds of being in cluster 2 compared to cluster 3, whereas having a dead (aOR=16.38) or divorced parent (aOR=6.54) and having a low (aOR=3.93) or intermediate income compared to zero income (aOR=4.71) were significantly associated with higher odds of being in cluster 2 compared to cluster 3. The results of our study revealed a considerable prevalence of addiction to alcohol, illicit drugs, and specially to smoking, among Lebanese university students. These findings emphasize the need to implement firm policies and rules in an attempt to minimize the tendency of the young population to engage in such addictions.

College-based social and situational predictors of real-time prescription drug misuse in daily life

BACKGROUND

This study examined social and situational context predictors of prescription drug misuse among college-students at a large public university in the Midwest. Social and situational context predictors considered were hour of the day, weekend vs weekday, whether participants were at home or another place, and who they were with during instances of misuse. Salient social events, including home football games, city-regulated parties, and the 2019 Midwest polar vortex were also recorded.

METHOD

Using ecological momentary assessment methodology, 297 students completed momentary reports for 28 days. Participants indicated whether they had misused prescription medication (sedatives or sleeping pills, tranquilizers or anxiety medications, stimulants, and pain relievers) and reported on their social and situational context in the moment of misuse.

RESULTS

Multilevel modeling indicated that participants were more likely to misuse prescription medication earlier in the day vs. the evening, on weekdays vs. weekends, when at home vs. not at home, and while alone vs. with others.

CONCLUSIONS

This study provides descriptive information on the social context in which prescription drug misuse is most likely to occur among college students. Our findings suggest that social and situational contexts of prescription drug misuse likely differ as compared to other substances (e.g., alcohol) among college students. Further research aimed at identifying momentary predictors of prescription drug misuse in this population is warranted.

Drugs of Abuse-Opioids, Sedatives, Hypnotics

Over the last 2 decades, prescription and nonprescription substance use has significantly increased. In this article, 3 particular drug classes-opioids, sedatives, and hypnotics-are discussed. For each class, a brief history of the agent, a description of relevant pharmacology, the clinical presentation of overdose, the management of specific drug overdoses, and a summary of salient points are presented. The intent is to provide a clinically relevant and comprehensive approach to understanding these potential substance exposures in order to provide a framework for management of opioid, sedative, and hypnotic overdoses.

Typologies of illicit drug use in mid-adulthood: a quasi-longitudinal latent class analysis in a community-based sample of twins

AIMS

To identify drug use typologies based on substances used and persistence of use over two time points, use a genetically informed design to explore twin concordance of and genetic influence on the use typologies and compare patterns of declined/discontinued ("desistant") and persistent drug use on drug use correlates.

DESIGN

Latent class analysis was applied to data from a cross-sectional self-report survey on current and past drug use. Use characteristics, use disorder, and psychiatric problems were compared across classes.

SETTING

Computer-assisted telephone interview in respondents' homes.

PARTICIPANTS

A total of 3785 individual twins and siblings (1365 men, 2420 women; M_age  = 32) from the Australian Twin Registry Cohort III.

MEASUREMENTS

A comprehensive interview assessed prior to past year and past year use of cannabis, stimulants, cocaine/crack, hallucinogens, opioids, sedatives, inhalants, dissociatives, and solvents; age of first use; opportunity to use; peer drug use; attention deficit/hyperactivity, conduct, antisocial personality, depressive, and substance use disorders; and suicidality.

FINDINGS

A five-class solution emerged: no/low use (50%), desistant cannabis use (23%), desistant party drug use (18%), persistent prescription drug misuse (4%), and persistent polydrug use (5%). Twin concordances were higher among monozygotic (k = 0.30-0.35) than dizygotic pairs (same-sex k = 0.19-0.20; opposite sex k = 0.07), and biometric modeling suggested that the persistent polydrug use class, in particular, was highly heritable (a²  = 0.94). Conduct disorder (OR = 2.40), antisocial personality disorder (OR = 3.27), and suicidal ideation (OR = 1.98) increased persistent polydrug use risk; depression (OR = 2.38) and lifetime suicide attempt (OR = 2.31) increased persistent prescription misuse risk. Relative to persistent prescription drug misuse, persistent polydrug use was associated with higher rates of cannabis and stimulant use disorder (OR = 6.14-28.01), younger first substance use (OR = 0.82-0.83), more drug use opportunity (OR = 10.66-66.06), and more drug-using peers (OR = 4.66-9.20).

CONCLUSIONS

Unique patterns of declined/discontinued ("desistant") and persistent drug use are differentially heritable and differentially associated with risk factors, psychiatric symptoms, and substance use disorder outcomes.

Chronic opioid exposure differentially modulates oxycodone self-administration in male and female rats

Withdrawal from opioid painkillers can produce short‐lived physical symptoms and protracted psychological symptoms including anxiety and depressive‐like states that often lead to opioid misuse and opioid use disorder (OUD). Studies testing the hypothesis that opioid withdrawal potentiates the reinforcing effects of opioid self‐administration (SA) are largely inconclusive and have focused on males. Although some clinical evidence indicates that women are more likely than men to misuse opioids to self‐medicate, preclinical studies in both sexes are lacking. Based on clinical reports, we hypothesized that withdrawal from escalating‐dose morphine injections that approximates a prescription painkiller regimen would lead to increased oxycodone SA to a greater extent in female compared to male rats. After escalating‐dose morphine (5–30 mg/kg or vehicle, twice/day for 12 days), rats underwent a 2‐week abstinence period during which withdrawal signs were measured. The impact of this treatment was assessed on oxycodone SA acquisition, maintenance, dose response, and progressive ratio responding, with additional analyses to compare sexes. We found that both sexes expressed somatic withdrawal, whereas only males demonstrated hyperalgesia in the warm water tail flick assay. During SA acquisition, males with prior morphine exposure took significantly more oxycodone than females. Finally, females with prior morphine exposure demonstrated the lowest motivation to SA oxycodone in the progressive ratio test. Contrary to our initial hypothesis, our findings suggest that prior opioid exposure increases vulnerability to initiate misuse more in males and decreases the reinforcing efficacy of oxycodone in females.

Predictors of controlled prescription drug non-medical and lifetime use among patients accessing public mental health services in Uganda: a cross-sectional study

OBJECTIVES

We determined the prevalence of controlled prescription drug (CPD) non-medical and lifetime use and their predictors among patients at three public psychiatric clinics in Uganda to identify missed care opportunities, enhanced screening priorities, and drug control needs.

METHODS

A cross-sectional survey of 1275 patients was performed from November to December 2018. Interviewer-administered semi-structured questionnaires, desk review guide and urine drug assays were employed. Questionnaire recorded CPD non-medical and illicit drug use history from patients' files, CPD lifetime use and risk factors. Desk review guide recorded recently prescribed drugs in patients' files to corroborate with urine assays. Predictors were analysed by multivariate logistic regression.

RESULTS

From desk review, 145 (11.4%) patients had history of CPD non-medical use and 36 (2.8%) had used illicit drugs. Of 988 patients who provided urine, 166 (16.8%) self-medicated CPDs, particularly benzodiazepines while 12 (1.2%) used illicit drugs. Of those with drug-positive urine, 123 (69.1%) had no documented history of CPD non-medical and illicit drug use. Being an inpatient (OR=10.90, p<0.001) was independently associated with CPD non-medical use. Additionally, being an inpatient (OR=8.29, p<0.001) and tobacco consumption (OR=1.85, p=0.041) were associated with CPD non-medical and illicit drug use combined. Among participants, 119 (9.3%) reported CPD lifetime use, and this was independently associated with education level (OR=2.71, p<0.001) and history of treatment for substance abuse (OR=2.08, p=0.018).

CONCLUSIONS

CPD non-medical use is common among Uganda's psychiatric patients, and more prevalent than illicit drug use. Rapid diagnostic assays may be needed in psychiatric care in resource limited settings. It is necessary to assess how CPD non-medical use impacts mental care outcomes and patient safety. High risk groups like inpatients and tobacco consumers should be prioritised in psychiatric screening.

Hazardous alcohol use is associated with greater pain interference and prescription opioid misuse among persons living with HIV and chronic pain

BACKGROUND

Alcohol use is common among persons living with HIV (PLWH), who often experience chronic pain, yet its impact on pain and opioid misuse is not fully characterized.

METHODS

We assessed associations between hazardous alcohol use and pain interference, defined as the self-reported impact of pain on daily living, pain severity, and risk for opioid misuse among PLWH who were on long-term opioid therapy (LTOT). A cohort was recruited as part of the "Targeting Effective Analgesia in Clinics for HIV" (TEACH) study, a randomized controlled trial to improve LTOT in HIV clinics. The Alcohol Use Disorders Test (AUDIT), Brief Pain Inventory (BPI) and the Current Opioid Misuse Measure (COMM) were administered at both baseline and 12-months. Linear mixed and generalized estimating equation models, incorporating data from both time points, evaluated associations between hazardous alcohol use (AUDIT ≥8) and: pain interference (0-10), pain severity (0-10), and opioid misuse risk (COMM ≥13), adjusting for age, gender, depressive symptoms, use of non-alcohol substances, time-point, and study-arm.

RESULTS

The sample was comprised of 166 participants, of which 31 (19%) reported hazardous alcohol use. The majority were male (65%), black (72%), and the mean age was 54 (range: 29-77). Hazardous alcohol use was significantly associated with higher pain interference (adjusted mean difference [AMD]: 1.02; 95% CI: 0.08, 1.96) and higher odds of opioid misuse risk (AOR: 3.73, 95% CI: 1.88-7.39), but not pain severity (AMD: 0.47, 95% CI: - 0.35, 1.29).

CONCLUSIONS

Hazardous alcohol use was associated with greater functional impairment in daily living from their pain and higher odds for prescription opioid misuse in this study of PLWH on LTOT. Providers should be attentive to alcohol use among PLWH who are prescribed opioids given associations with pain and opioid misuse.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02564341 (Intervention, September 30, 2015) and NCT02525731 (Patient Cohort, August 17, 2015). Both prospectively registered.

Poly-prescription drug misuse across the life course: Prevalence and correlates across different adult age cohorts in the U.S

BACKGROUND

Most research on prescription drug misuse (PDM) focuses on the misuse of specific classes of psychoactive prescription drugs among adolescents or young adults. The current research addressed important gaps in the literature by assessing poly-prescription drug misuse (poly-PDM), the misuse of more than one class of psychoactive prescription drug, across different adult age cohorts.

METHODS

We used the 2015-2018 National Survey on Drug Use and Health to examine the prevalence of past-year poly-PDM and specific combinations of PDM. Multinomial logistic regression was used to identify demographic, health-related factors, and substance use behaviors that were significantly associated with poly-PDM.

RESULTS

The prevalence of poly-PDM decreases with age and is common among individuals who engage in PDM. Slightly more than one in four respondents in age cohorts 18-25 (31.66%, 95% CI = 30.35, 33.00) and 26-34 (29.92%, 95% CI = 25.82, 30.12) who engage in PDM, misused more than one class of prescription drug. Additionally, poly-PDM was identified as a high-risk type of PDM as roughly 60% of adults younger than 65 who endorse poly-PDM reported having a substance use disorder (SUD). While certain characteristics (i.e., race/ethnicity, marital status, depression, suicidal ideation, illegal drug use, and SUD) were consistently associated with poly-PDM across age cohorts, other characteristics (i.e., sexual identity, income, and justice involvement) varied across age cohorts. Finally, a comparison of poly-PDM to single PDM showed, in all age cohorts, that having an SUD was associated with an increased likelihood of poly-PDM, while Black adults were less likely than whites to report poly-PDM.

CONCLUSIONS

By identifying prevalence and correlates of poly-PDM across adult age cohorts, the current research has significant implications. Understanding stability and heterogeneity in the characteristics associated with poly-PDM should inform interventions, identify at-risk groups, and shape public health approaches to dealing with high-risk substance use behavior.

Early Detection of Prescription Drug Abuse Using Doctor Shopping Monitoring From Claims Databases: Illustration From the Experience of the French Addictovigilance Network

Opioid analgesics and maintenance treatments, benzodiazepines and z-drugs, and other sedatives and stimulants are increasingly being abused to induce psychoactive effects or alter the effects of other drugs, eventually leading to dependence. Awareness of prescription drug abuse has been increasing in the last two decades, and organizations such as the International Narcotics Control Board has predicted that, worldwide, prescription drug abuse may exceed the use of illicit drugs. Assessment of prescription drug abuse tackles an issue that is hidden by nature, which therefore requires a specific monitoring. The current best practice is to use multiple detection systems to assess prescription drug abuse by various populations in a timely, sensitive, and specific manner. In the early 2000's, we designed a method to detect and quantify doctor shopping for prescription drugs from the French National Health Data System, which is one of the world's largest claims database, and a first-class data source for pharmacoepidemiological studies. Doctor shopping is a well-known behavior that involves overlapping prescriptions from multiple prescribers for the same drug, to obtain higher doses than those prescribed by each prescriber on an individual basis. In addition, doctor shopping may play an important role in supplying the black market. The paper aims to review how doctor shopping monitoring can improve the early detection of prescription drug abuse within a multidimensional monitoring. The paper provides an in-depth overview of two decades of development and validation of the method as a complementary component of the multidimensional monitoring conducted by the French Addictovigilance Network. The process accounted for the relevant determinants of prescription drug abuse, such as pharmacological data (e.g., formulations and doses), chronological and geographical data (e.g., impact of measures and comparison between regions), and epidemiological and outcome data (e.g., profiles of patients and trajectories of care) for several pharmacological classes (e.g., opioids, benzodiazepines, antidepressants, and methylphenidate).

Attitudes and Knowledge Regarding Pain Management and Addiction in Massachusetts: A Mixed Methods Study on Podiatric Residents

BACKGROUND

The opioid epidemic has hit disastrous levels across the United States. Many attempts have been made to counteract this, including policy changes and modification of provider and patient behavior. The purpose of this study was to understand the current state of podiatric residents' knowledge regarding pain management and addiction.

METHODS

This study used mixed quantitative-qualitative methods. Two focus groups were conducted with two podiatric residency programs to understand current issues and inform the creation of a survey. A 30-question survey was created and peer reviewed to assess general pain management knowledge, levels of confidence in pain management and addiction, and areas for improvement.

RESULTS

Pain management education in podiatry is mainly focused on opioids. These concepts are often taught in a nonstandardized method, which does not often include nonopioid alternatives. Knowledge of risk factors for addiction was lacking, whereas knowledge of behaviors concerning for addiction was more bountiful. Thirty-three surveys were completed of a possible 39. A knowledge score was created from eight survey questions for a total of 10 points, with an average score of 4.61. There was no statistical difference between those with and without a pain management rotation. Nearly all residents felt comfortable managing surgical pain. The residents are "never" or "only occasionally" inquiring about risk factors for addiction. Questions asked also suggest that the residents are not thinking about their role within the opioid epidemic.

CONCLUSIONS

As the opioid epidemic grows, it is imperative to examine the causes and solutions to the problem. Focusing efforts on educating resident physicians is one method to address the issue. The results of this study show that pain management basics need to be reinforced and more time must be spent emphasizing the importance of thorough patient histories and educating patients when prescribing pain medication.

Recreational Cannabis Use and Risk of Prescription Opioid Overdose: Insights from Pediatric Inpatients

Objectives

Our first goal is to evaluate the prevalence of hospital admissions for prescription opioid overdose (POD) in pediatric inpatients, and next goal is to measure the independent association between cannabis use disorders (CUD) and POD.

Methods

We used the nationwide inpatient sample (NIS) and included 27,444,239 pediatric inpatients (age ≤ 18 years), and 10,562 (0.04%) were managed primarily for POD. The odds ratio (OR) of the association of variables in POD inpatients was measured using the binomial logistic regression model that was adjusted for demographic confounders and psychiatric comorbidities.

Results

Adolescents have higher odds (OR 10.75, 95% CI 10.16-11.36) of POD-related hospitalization compared to children ≤ 12 years. Whites formed the significant proportion (67%), and those from low-income families (<50th percentile) had higher likelihood for POD-related hospitalization. The most prevalent psychiatric comorbidities were mood disorders (44.3%) and anxiety disorders (14.6%). Prevalent comorbid substance use disorders (SUDs) included cannabis (14.2%), tobacco (13.1%), and opioid (9.4%). A higher odds of association with POD-related hospitalizations were seen in pediatric inpatients with comorbid opioid (OR 8.79, 95% CI 8.08-9.56), tobacco (OR 1.58, 95% CI 1.47-1.70), and cannabis (OR 1.68, 95% CI 1.57-1.81) use disorders.

Conclusion

The prescription opioid is a bridge to opioid abuse/dependence, thereby increasing the risk of other SUDs like tobacco (by 58%) and cannabis (by 68%). Regulating the easy availability of prescription opioids and also improving the existing prescription trends are an essential way to reduce this problem. Finally, awareness and counseling are recommended strategies for harm reduction/rehabilitation among the pediatric population.

Development and Acceptability of a Method to Investigate Prescription Drug Misuse in Daily Life: Ecological Momentary Assessment Study

Background

Prescription drug misuse and abuse is an established public health challenge, and young adults are particularly affected. There is a striking lack of real-time, naturalistic data collection assessing intentions to misuse and other precipitating factors at the time of actual misuse, leaving the conditions under which individuals are most likely to misuse prescription medications unknown. Ecological momentary assessment (EMA) apps and protocols designed to capture this information would accelerate and expand the knowledge base and could directly contribute to prevention and treatment efforts.

Objective

The objectives of this study are to describe the development and administration of a mobile app and the EMA protocol designed to collect real-time factors associated with college students’ prescription drug misuse intentions and behaviors in daily life; present completion rates, compliance, acceptability, and reactivity associated with the EMA protocol for participants who endorsed recent prescription drug misuse at screening (ie, risk group; n=300) and those who did not (ie, nonrisk group; n=55); and establish initial construct validity by linking the reports of misuse behaviors in daily life collected via the EMA app to prescription drug misuse reported on a standard survey.

Methods

An EMA data collection app and protocol were designed specifically to capture hypothesized contextual factors along with prescription drug misuse intentions and behaviors in daily life. Using this protocol, young adult college students (N=352) completed signal- and event-contingent reports over a 28-day period. When the intention to misuse a prescription drug was endorsed, a brief follow-up prompt was sent 15 min later to collect participants’ indications of whether or not misuse had occurred.

Results

Risk-group participants were significantly more likely than nonrisk counterparts to endorse any prescription drug misuse intentions in daily life (P<.001), to complete one or more follow-up reports (P<.001), and to endorse any prescription drug misuse behavior in daily life on the follow-ups (P<.001). Overall, participants demonstrated consistent engagement with the EMA procedures and returned an average of 74.5 (SD 23.82; range 10-122) reports. Participants in the risk and nonrisk groups did not differ in the number of reports they completed (P=.12), the number of their reporting days (P=.32), or their average completion rates (P=.14). The results indicated some evidence of reactivity to the momentary reporting procedure. Participants reported uniformly positive experiences and remained highly engaged throughout the reporting protocol and broader study.

Conclusions

The novel EMA app and protocol provide an effective way to assess real-time factors associated with prescription drug misuse intentions and behaviors in daily life. The resulting investigations offer the potential to provide highly translatable information for research and prevention efforts.

Assessment of Probable Opioid Use Disorder Using Electronic Health Record Documentation

IMPORTANCE

Electronic health records are a potentially valuable source of information for identifying patients with opioid use disorder (OUD).

OBJECTIVE

To evaluate whether proxy measures from electronic health record data can be used reliably to identify patients with probable OUD based on Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study analyzed individuals within the Geisinger health system who were prescribed opioids between December 31, 2000, and May 31, 2017, using a mixed-methods approach. The cohort was identified from 16 253 patients enrolled in a contract-based, Geisinger-specific medication monitoring program (GMMP) for opioid use, including patients who maintained or violated contract terms, as well as a demographically matched control group of 16 253 patients who were prescribed opioids but not enrolled in the GMMP. Substance use diagnoses and psychiatric comorbidities were assessed using automated electronic health record summaries. A manual medical record review procedure using DSM-5 criteria for OUD was completed for a subset of patients. The analysis was conducted beginning from June 5, 2017, until May 29, 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome was the prevalence of OUD as defined by proxy measures for DSM-5 criteria for OUD as well as the prevalence of comorbidities among patients prescribed opioids within an integrated health system.

RESULTS

Among the 16 253 patients enrolled in the GMMP (9309 women [57%]; mean [SD] age, 52 [14] years), OUD diagnoses as defined by diagnostic codes were present at a much lower rate than expected (291 [2%]), indicating the necessity for alternative diagnostic strategies. The DSM-5 criteria for OUD can be assessed using manual medical record review; a manual review of 200 patients in the GMMP and 200 control patients identifed a larger percentage of patients with probable moderate to severe OUD (GMMP, 145 of 200 [73%]; and control, 27 of 200 [14%]) compared with the prevalence of OUD assessed using diagnostic codes.

CONCLUSIONS AND RELEVANCE

These results suggest that patients with OUD may be identified using information available in the electronic health record, even when diagnostic codes do not reflect this diagnosis. Furthermore, the study demonstrates the utility of coding for DSM-5 criteria from medical records to generate a quantitative DSM-5 score that is associated with OUD severity.

Medical cannabis laws and medical and non-medical prescription stimulant use among a nationally representative sample of US Adults: Examining the role of sexual identity and gender

BACKGROUND

Medical marijuana laws (MMLs) can impact marijuana and opioid use, but the relationship between MMLs and other drugs, such as prescription stimulants, remains unexamined. Because lesbian, gay and bisexual (LGB) individuals report higher levels of prescription stimulant use than heterosexuals, we explored the relationship between MMLs and past-year medical and non-medical stimulant use by sexual identity and gender.

METHODS

We pooled 2015-2017 National Survey on Drug Use and Health data for adults (n = 126 463), and used survey-weighted multinomial logistic regression to estimate odds of past-year (a) medical prescription stimulant use, (b) non-medical prescription stimulant use and (c) non-medical versus medical stimulant use. We stratified by gender, adjusted for sociodemographic characteristics, and tested the interaction between MML state residence and sexual identity.

RESULTS

Bisexual men had higher medical (6.4% versus 4.1%; aROR=1.93[1.29-2.88]) and non-medical stimulant use 6.6% versus 2.4%; aROR=2.23[1.44-3.44]) than heterosexual men. Bisexual women had higher non-medical stimulant use (6.8% versus 1.6%; aROR=1.54[1.23-2.93] than heterosexual women. Female (aROR=0.70[0.62-0.78]) and male (aROR=0.74[0.66-0.82]) heterosexuals in MML states had lower odds of medical stimulant use than in non-MML states. Bisexual men in MML states had lower odds of medical (aROR=0.36[0.21-0.61]) and non-medical stimulant use (aROR=0.48[0.29-0.81]) than bisexual men in non-MML states. Similar patterns emerged for bisexual women's non-medical use (aROR=0.57[0.40-0.81]).

CONCLUSION

Prescription stimulant use was higher in non-MML states for most LGB subgroups. MMLs may differentially impact stimulant use, primarily for bisexual men and women. States enacting MMLs should consider potential impacts on drugs other than marijuana, especially among LGB populations.

Compliance of private pharmacies in Uganda with controlled prescription drugs regulations: a mixed-methods study

Background

Controlled prescription drug use disorders are a growing global health challenge in Sub-Saharan Africa. Effective supply chain regulations on dispensing and stock control are important for controlling this epidemic. Since compliance with these regulations in resource-limited countries is poor, there is need to understand its predictors in order to reduce the risk of prescription drug use disorders.

Methods

A mixed-methods study utilizing a structured questionnaire and a simulated client guide was undertaken in Kampala and Mbale towns in Uganda. The questionnaire recorded self-reported dispensing and verified stock control practices and their covariates from 101 private pharmacies. The guide recorded actual dispensing practices from 27 pharmacies. Snowball sampling was done to enrich the sample with pharmacies that stock opioids. The mean compliance with good dispensing and stock control practices was calculated. Multivariate logistic regression analyses were applied to identify predictors of compliance.

Results

The mean compliance with dispensing and stock control requirements was 82.9% and 23%, respectively. Twenty percent and 40% of the pharmacies dispensed pethidine without a prescription and with invalid prescriptions, respectively. Having a pharmacist on duty (OR = 5.17; p = 0.02), prior in-service training on narcotics regulations (OR = 3.51; p = 0.04), and previous narcotics audits by the regulator (OR = 5.11; p = 0.01) were independent predictors of compliance with stock control requirements. Pharmacies with a previous history of poor compliance with dispensing requirements were less likely to demonstrate good compliance (OR = 0.21; p = 0.01).

Conclusions

There is suboptimal compliance to controlled prescription drug regulations among Uganda’s pharmacies. A previous history of poor compliance to dispensing requirements predicted low compliance in subsequent assessments. Training and regulatory audits increased compliance in stock control but not dispensing. Expansion of training and audits to more pharmacies and/or incentives for compliance are necessary.

"It's Took Over This Region": Patient Perspectives of Prescription Drug Abuse in Appalachia

Background: Prescription drug abuse is a public health problem in the United States and the region of Appalachia, specifically. Primary care and addiction medicine-as possible points of access for prescription drugs with abuse potential and points of intervention for prescription drug abuse-are among the medical fields at its forefront. Little is known, however, about perceptions of prescription drug abuse across the two patient populations. Objectives: The objective of this qualitative analysis was to explore perceptions of the scale and context of prescription drug abuse among primary care and addiction medicine patients in Appalachia. Methods: As part of a mixed methods study, semi-structured interviews were conducted with 20 patients from primary care and addiction medicine in Central and South Central Appalachia from 2014 to 2015. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was used to identify themes. Results: Three themes were identified: (1) pervasiveness of prescription drug abuse, describing perceptions of its high prevalence and negative consequences; (2) routes and routine practices for prescription drug acquisition and distribution, describing perceptions of routes of access to prescription drugs and behaviors exhibited to acquire and distribute prescription drugs; and (3) rationales for prescription drug acquisition and distribution, describing perceptions of the two underlying reasons for these processes-tolerance/addiction and revenue source. Conclusions/Importance: Perceptions of prescription drug abuse among primary care and addiction medicine patients in Appalachia are multifaceted, especially regarding prescription drug acquisition and distribution. Clinical practice implications for mitigating prescription drug abuse are discussed.

Examining the association between bullying victimization and prescription drug misuse among adolescents in the United States

BACKGROUND

Although studies have examined the association between bullying victimization and adolescent substance behaviors, there is a dearth of research investigating the association between bullying victimization and prescription drug misuse. The objective of this study was to examine the cross-sectional association between bullying victimization and prescription drug misuse among adolescents.

METHODS

Data for this study came from the 2017 Youth Risk Behavior Survey. A sample of 9974 adolescents aged 14-18 years (50.1% female) were analyzed using binary logistic regression with prescription drug misuse as the outcome variable and bullying victimization as the main explanatory variable.

RESULTS

Of the 9,974 adolescents, 13.1% misused prescription drugs. One in ten adolescents were victims of both school bullying and cyberbullying, 5.1% were victims of only cyberbullying, 9% were victims of only school bullying, and 75.8% experienced neither school bullying nor cyberbullying victimization. In the binary logistic regression model, adolescents who experienced both school bullying and cyberbullying victimization had 1.66 times higher odds of misusing prescription drugs (AOR = 1.66, p < .001, 95% CI = 1.34-2.06) and adolescents who experienced only school bullying victimization had 1.30 times higher odds of misusing prescription drugs (AOR = 1.30, p < .05, 95% CI = 1.02-1.64). Being lesbian, gay, or bisexual; feeling sad or hopeless; cigarette smoking; binge drinking; cannabis use; and illicit drug use were statistically significantly associated with prescription drug misuse.

CONCLUSIONS

Understanding the association between bullying victimization and prescription drug misuse could contribute to early identification of adolescents who may misuse prescription drugs.

Multispecialty Opioid Risk Reduction Program Targeting Chronic Pain and Addiction Management in Veterans

A primary care pain clinic and telehealth program manages veterans at high-risk for noncancer chronic pain and addiction, offering education and support to multidisciplinary health care providers to reduce dependence on high-level opioids.

Methamphetamine Use and Cardiovascular Disease

While the opioid epidemic has garnered significant attention, the use of methamphetamines is growing worldwide independent of wealth or region. Following overdose and accidents, the leading cause of death in methamphetamine users is cardiovascular disease, because of significant effects of methamphetamine on vasoconstriction, pulmonary hypertension, atherosclerotic plaque formation, cardiac arrhythmias, and cardiomyopathy. In this review, we examine the current literature on methamphetamine-induced changes in cardiovascular health, discuss the potential mechanisms regulating these varied effects, and highlight our deficiencies in understanding how to treat methamphetamine-associated cardiovascular dysfunction.

Provider-patient communication about prescription drug abuse: A qualitative analysis of the perspective of prescribers

Background: Provider-patient communication underpins many initiatives aimed at reducing the public health burden associated with prescription drug abuse in the United States. The purpose of this qualitative analysis was to examine the characteristics of provider-patient communication about prescription drug abuse from the perspective of prescribers. Methods: From 2014 to 2015, 10 semi-structured interviews were conducted with a purposive sample of prescribers from multiple professions and medical fields in Central and South Central Appalachia. The interviews were conducted using a guide informed by Social Cognitive Theory and community theory research, audio-recorded, and transcribed verbatim. Thematic analysis, facilitated by NVivo 10 software, was used to generate themes. Results: Prescribers described 3 primary communication patterns with patients related to prescription drug abuse-informative, counteractive, and supportive. Prescribers also reported multiple factors-personal (e.g., education, experiences, and feelings of tension) and environmental (e.g., relationship with a patient, clinical resources, and policies on controlled prescription drugs)-that affect provider-patient communication and, by association, delivery of patient care related to prescription drug abuse. Conclusions: The findings suggest that provider-patient communication about prescription drug abuse is multidimensional and dynamic, characterized by multiple communication patterns and contributory factors. They have implications for (1) research aimed at advancing theoretical understanding of prescriber prescription drug abuse communication behaviors with patients and (2) interventions aimed at strengthening prescriber prescription drug abuse communication behaviors with patients.

Prescription drug suicide in non-abusers: A 6-year forensic survey

BACKGROUND

Prescription drug suicide merits study to guide the development of strategies to reduce suicide risk. We examined prescription drug suicide specifically in non-abusers of prescription drugs; this is a relatively unexplored subject.

METHODS

Six-year data on prescription drug suicide in non-abusers were extracted from the records of the Department of Forensic Medicine at the All India Institute of Medical Sciences, New Delhi. These records contained information obtained from the scene of the suicide, from interviews with relatives of the deceased, and from forensic toxicological analyses at two laboratories.

RESULTS

There were 27 (8%) cases of prescription drug suicide in non-abusers out of 338 cases of suicidal poisoning. The mean age of this sample was 26 years. The sample was 74% male. Nearly half of the cases (44%) were students. A combination of dextropropoxyphene with dicyclomine, with or without paracetamol, was used by 41% of cases. Overdose was achieved through the ingestion of 10-40 (median, 30) tablets or by the injection of 2-3 (median, 2) vials of medication. In 52% of cases, it appeared that the drugs had been procured over the counter.

CONCLUSIONS

It is reassuring that the absolute number of prescription drug suicides in non-abusers was small; the findings, however, are important because they could serve as a baseline for assessing time trends in future studies. For the present, we suggest that prescription drugs of potential abuse, especially those containing opioids and antispasmodics, should be prescribed and dispensed judiciously, especially to youth.

Factors associated with prescription pain reliever misuse: An analysis of statewide data

OBJECTIVES

Characterize the individual-level risk factors associated with recent prescription pain reliever misuse (PPRM).

DESIGN

A multivariable logistic regression was developed with 21 covariates.

SETTING AND PARTICIPANTS

The 2015 Ohio Medicaid Assessment Survey (OMAS) was analyzed. The 2015 OMAS was a complex-designed representative survey of all adult Ohioans, regardless of Medicaid status (n = 42,876).

OUTCOME MEASURES

The main outcome was PPRM within the past year ("yes" vs. "no").

RESULTS

An estimated 2.75% of adults in Ohio reported PPRM in the past year (approximately 242,232 individuals). The regression model identified 11 covariates with significantly higher odds of PPRM within the past year. The 5 covariates with the largest, significant effect sizes were binge drinking habits (adjusted odds ratio [AOR] for binge drinking in the past month: 2.35, 95% CI 1.97-2.81; AOR for drinking in the past month but no bingeing: 1.43, 95% CI 1.22-1.67), did not get medical examination, medical supplies, mental health care, or eyeglasses in the past year because of cost (AOR 1.74, 95% CI 1.44-2.11), no insurance (AOR 1.67, 95% CI 1.15-2.45), emergency room visits in the past year (AOR 1.66, 95% CI 1.42-1.93), and had problems paying medical bills in the past year (AOR 1.52, 95% CI 1.29-1.80).

CONCLUSION

In this cross-sectional study of 42,847 adult Ohioans, the covariates associated with PPRM in the past year were identified and quantified. The significant covariates can be broadly grouped into substance use history, poor health care access, demographic characteristics, and chronic health conditions. The single covariate with the largest effect size was binge drinking in the past month; those individuals were more than twice as likely to have endorsed PPRM in the past year compared with those who did not drink at all in the past month.

The epidemiology of benzodiazepine misuse: A systematic review

BACKGROUND

Benzodiazepine misuse is a growing public health problem, with increases in benzodiazepine-related overdose deaths and emergency room visits in recent years. However, relatively little attention has been paid to this emergent problem. We systematically reviewed epidemiological studies on benzodiazepine misuse to identify key findings, limitations, and future directions for research.

METHODS

PubMed and PsychINFO databases were searched through February 2019 for peer-reviewed publications on benzodiazepine misuse (e.g., use without a prescription; at a higher frequency or dose than prescribed). Eligibility criteria included human studies that focused on the prevalence, trends, correlates, motives, patterns, sources, and consequences of benzodiazepine misuse.

RESULTS

The search identified 1970 publications, and 351 articles were eligible for data extraction and inclusion. In 2017, benzodiazepines and other tranquilizers were the third most commonly misused illicit or prescription drug in the U.S. (approximately 2.2% of the population). Worldwide rates of misuse appear to be similar to those reported in the U.S. Factors associated with misuse include other substance use, receipt of a benzodiazepine prescription, and psychiatric symptoms and disorders. Benzodiazepine misuse encompasses heterogeneous presentations of motives, patterns, and sources. Moreover, misuse is associated with myriad poor outcomes, including mortality, HIV/HCV risk behaviors, poor self-reported quality of life, criminality, and continued substance use during treatment.

CONCLUSIONS

Benzodiazepine misuse is a worldwide public health concern that is associated with a number of concerning consequences. Findings from the present review have implications for identifying subgroups who could benefit from prevention and treatment efforts, critical points for intervention, and treatment targets.

Age-specific risk of substance use disorders associated with controlled medication use and misuse subtypes in the United States

OBJECTIVE

To examine the age-specific risk of past-year substance use disorders (SUDs) associated with use and misuse of prescription opioids, stimulants, sedatives and tranquilizers.

METHODS

The authors analyzed nationally representative data from 114,043 U.S. individuals aged 12 and older in the 2015-2016 National Survey on Drug Use and Health. For each controlled medication class, logistic regression was used to model any past-year SUD as a function of use pattern: no use or misuse, use without misuse, prescription drug misuse (PDM). Among individuals reporting PDM, logistic regression was used to model any past-year SUD as a function of PDM subtype (misuse of someone else's medication only, misuse of one's own medication only, and misuse of one's own and someone else's medication). Analyses were stratified by age group.

RESULTS

Controlled medication use was associated with higher odds of any past-year SUD compared to no use in many age groups and medication classes. Compared to non-use, PDM was associated with higher odds of any past-year SUD across virtually all age groups and medication classes. Compared to misuse of one's own medication only, misuse of both someone else's and one's own medication was associated with higher odds of any past-year SUD for many age groups and medication classes among individuals reporting PDM.

CONCLUSIONS

Clinicians should screen all controlled medication users for PDM and SUDs. Age-specific screening may be required due to heterogeneity in the prevalence and risks of use and misuse of different medications. Determination of PDM subtype can guide interventions to prevent SUDs.

Prescribing in 2019: what are the safety concerns?

INTRODUCTION

Unintended harm from prescribing errors remains a prevalent concern in healthcare leading to significant morbidity and mortality around the world. Prescribers face new challenges to their practice in modern times such as increasingly complex health-care systems, an aging population with increasing multimorbidity, and rapid growth in the number of novel medicines. Areas covered: Prescribing concerns in modern practice are outlined based on seminal literature in this area and the author's continual academic oversight of this topic. Major UK and international reports have been used to highlight the important emerging issues in prescribing, and focused literature searches performed to highlight key papers supporting this review. Expert opinion: Whilst there are many ways to consider mitigating the risk of harm from prescribing, it is suggested that a tripartite approach is required. Patients and carers are essential partners in the process and shared decision-making has replaced paternalistic practice in achieving joint prescribing decisions. Comprehensive and coordinated care is critical to avoid fragmented care and poor transfer of prescribing information. Lastly, a whole systems approach is crucial to ensure that all prescribers are supported (and not overwhelmed) when making safe, effective and timely prescribing decisions.