Correlations between population-levels of prescription opioid dispensing and related deaths in Ontario (Canada), 2005-2016

Trends and correlated outcomes in population-level prescription opioid and transdermal fentanyl use in Israel

BACKGROUND

In the last twenty years, there was a documented increase in prescription opioid procurement in Israel. However, there is still little evidence of the association between opioid procurement rates, health service utilisation in secondary care, and enrollment rates to substance use disorder treatment programmes. In this study, we show trends in the reports of opioid-related hospitalisations, emergency department visits, enrollment to community-based outpatient treatment for Prescription Opioid Use Disorder and opioid-related mortality rates. Additionally, we examine potential correlations between these health service utilisation rates and prescription opioid procurement rates at the population level, with a focus on transdermal fentanyl.

METHODS

A longitudinal study at the population level. We used seven-year data on indicators of opioid-related morbidity, prescription opioid procurement data for 2015-2021, and six-year opioid-related mortality data for 2015-2020. We measure the correlation between procurement rates of prescription opioids in Oral Morphine Equivalent per capita, and aggregated rates obtained from hospital administrative data for hospitalisations, emergency department visits, and patient enrolment in specialised prescription opioid use disorder outpatient treatment in the community setting.

RESULTS

Between 2015 and 2021, procurement rates in primary care per capita for all prescription opioids increased by 85%, while rates of transdermal fentanyl procurement increased by 162%. We found a significant positive correlation at the population level, between annual opioid procurement rates, and rates per population of opioid-related visits to emergency departments (r = 0.96, p value < 0.01, [CI 0.74-0.99]), as well as a positive correlation with the rates per population of patient enrolment in specialised prescription opioid use disorder outpatient treatment (r = 0.93, p value = 0.02, [CI 0.58-0.99]). Opioid-related mortality peaked in 2019 at 0.31 deaths per 100,000 but decreased to 0.20 deaths per 100,000 in 2020.

CONCLUSION

Data shows that all-opioid and transdermal fentanyl procurement has increased yearly between 2015 and 2021. This increase is positively correlated with a growing demand for community-based Prescription Opioid Use Disorder outpatient treatment. Efforts to reduce opioid-related morbidity may require effective approaches toward appropriate prescribing, monitoring, and further increasing access to prescription opioid outpatient treatment.

Population-Based Opioid Prescribing and Overdose Deaths in the USA: an Observational Study

BACKGROUND

Rising opioid-related death rates have prompted reductions of opioid prescribing, yet limited data exist on population-level associations between opioid prescribing and opioid-related deaths.

OBJECTIVE

To evaluate population-level associations between five opioid prescribing measures and opioid-related deaths.

DESIGN

An ecological panel analysis was performed using linear regression models with year and commuting zone fixed effects.

PARTICIPANTS

People ≥10 years aggregated into 886 commuting zones, which are geographic regions collectively comprising the entire USA.

MAIN MEASURES

Annual opioid prescriptions were measured with IQVIA Real World Longitudinal Prescription Data including 76.5% (2009) to 90.0% (2017) of US prescriptions. Prescription measures included opioid prescriptions per capita, percent of population with ≥1 opioid prescription, percent with high-dose prescription, percent with long-term prescription, and percent with opioid prescriptions from ≥3 prescribers. Outcomes were age- and sex-standardized associations of change in opioid prescriptions with change in deaths involving any opioids, synthetics other than methadone, heroin but not synthetics or methadone, and prescription opioids, but not other opioids.

KEY RESULTS

Change in total regional opioid-related deaths was positively correlated with change in regional opioid prescriptions per capita (β=.110, p<.001), percent with ≥1 opioid prescription (β=.100, p=.001), and percent with high-dose prescription (β=.081, p<.001). Change in total regional deaths involving prescription opioids was positively correlated with change in all five opioid prescribing measures. Conversely, change in total regional deaths involving synthetic opioids was negatively correlated with change in percent with long-term opioid prescriptions and percent with ≥3 prescribers, but not for persons ≥45 years. Change in total regional deaths in heroin was not associated with change in any prescription measure.

CONCLUSIONS

Regional decreases in opioid prescriptions were associated with declines in overdose deaths involving prescription opioids, but were also associated with increases in deaths involving synthetic opioids (primarily fentanyl). Individual-level inferences are limited by the ecological nature of the analysis.

Individualized Prospective Prediction of Opioid Use Disorder

OBJECTIVE

Opioid use disorder (OUD) is a chronic relapsing disorder with a problematic pattern of opioid use, affecting nearly 27 million people worldwide. Machine learning (ML)-based prediction of OUD may lead to early detection and intervention. However, most ML prediction studies were not based on representative data sources and prospective validations, limiting their potential to predict future new cases. In the current study, we aimed to develop and prospectively validate an ML model that could predict individual OUD cases based on representative large-scale health data.

METHOD

We present an ensemble machine-learning model trained on a cross-linked Canadian administrative health data set from 2014 to 2018 (n  =  699,164), with validation of model-predicted OUD cases on a hold-out sample from 2014 to 2018 (n  =  174,791) and prospective prediction of OUD cases on a non-overlapping sample from 2019 (n  =  316,039). We used administrative records of OUD diagnosis for each subject based on International Classification of Diseases (ICD) codes.

RESULTS

With 6409 OUD cases in 2019 (mean [SD], 45.34 [14.28], 3400 males), our model prospectively predicted OUD cases at a high accuracy (balanced accuracy, 86%, sensitivity, 93%; specificity 79%). In accord with prior findings, the top risk factors for OUD in this model were opioid use indicators and a history of other substance use disorders.

CONCLUSION

Our study presents an individualized prospective prediction of OUD cases by applying ML to large administrative health datasets. Such prospective predictions based on ML would be essential for potential future clinical applications in the early detection of OUD.

Evaluating the population-level effects of oxycodone restrictions on prescription opioid utilization in Ontario

PURPOSE

To investigate the impact of restrictions on access to long acting oxycodone on prescription opioid use and opioid-related harms.

METHODS

Administrative health data from Ontario, Canada was used to measure differences in opioids dispensed and ED visits for opioid-related overdose, poisoning or substance use following provincial restrictions on access to publicly insured OxyContin (February 29, 2012) and OxyNeo (February 28, 2013). This study focused on the cohort of provincial drug insurance eligible people (people 65+ and select low-income populations) who were dispensed oxycodone prior to the restrictions. Difference-in-differences models with a propensity score matched comparison group of people who were dispensed non-oxycodone opioids were used to estimate the main effects.

RESULTS

In the six months following the delisting of OxyContin, MMEs per person per week for all opioids fell by an average of 7.5% in people dispensed oxycodone relative to the comparison group, and an average of 13.8% in chronic recipients of oxycodone. In the six months following the restrictions on OxyNeo, MMEs per person per week fell by an average of 3.1% in all people dispensed oxycodone, and 25.2% in chronic oxycodone recipients. The decline in oxycodone dispensing amongst chronic oxycodone recipients corresponded with an increase in dispensing of other opioid formulations, particularly hydromorphone and fentanyl. No important differences were observed for ED visits related to opioid poisoning, overdose, or substance use disorder.

CONCLUSIONS

Province-wide restrictions on access to long acting oxycodone had an impact on quantities of all opioids dispensed to chronic recipients of oxycodone, but small impacts on the full population of people dispensed oxycodone; the decline in use was partially offset by increases in use of other publicly-funded opioid formulations. This study suggests that policies limiting access to specific prescription opioids led to overall reductions in publicly-funded prescription opioid use, particularly in chronic oxycodone recipients, without immediate evidence of changes in opioid-related ED visits. This article is protected by copyright. All rights reserved.

The association between the availability of over the counter codeine and the prevalence of non-medical use

PURPOSE

To investigate the prevalence of non-medical use (NMU) of codeine in Germany, Italy, Spain and the UK and whether availability of OTC codeine has any association with NMU of the drug.

METHODS

Data collected in the online Survey of Non-Medical Use of Prescription Drugs, in surveys launched in the second half of 2018 from (Germany (n = 14,969), Italy, (n = 9974), Spain (n = 9912) and the UK (n = 9819) were analysed. For each survey, the estimated prevalence and 95% confidence interval (CI) of respondents reporting NMU of prescription and/or OTC codeine within the last 12 months were calculated and compared.

RESULTS

The prevalence of last 12-month NMU in Spain was 12.6% (95% CI 11.7-13.6) for prescription codeine, 6.3% (5.6-7.0) for OTC codeine and 16.1% (15.1-17.3) for any codeine (prescription and/or OTC). The prevalence of last 12-month NMU in the UK was 5.4% (4.9-5.8) for prescription codeine, 4.5% (4.1-5.0) for OTC codeine and 8.3% (7.8-8.9) for any codeine (prescription and/or OTC). The prevalence of last 12-month NMU for prescription codeine was 2.1% (1.9-2.4) in Germany and 1.9% (1.7-2.2) in Italy.

CONCLUSION

The prevalence of last 12-month NMU of any codeine product is approximately eight times greater in Spain and four times greater in the UK compared to Germany and Italy where the drug is only available by prescription. While other factors may contribute, these findings suggest that availability of codeine OTC is associated with greater NMU.

Nonmedical Prescription Opioid Use among a Sample of College Students: Prevalence and Predictors

Nonmedical use of prescription opioid medication (NMPO) in the United States is a public health crisis, resulting in high rates of emergency room visits, morbidity, and mortality. The purpose of this study was to explore prevalence estimates and correlates of NMPO among a convenience sample of college students in the northeast and southeast regions of the US to help generate directions for future research. Motivations for misuse, age of onset, access, concomitant substance use, and individual factors were investigated among a sample of undergraduate students from two universities. Participants (N = 847) completed a battery of various self-report measures. Findings revealed that 7.7% (Southeastern University) and 12.8% of students (Northeastern University) reported lifetime NMPO, whereas past-month NMPO was reported by 0.8% and 0.9% of participants, respectively. Lifetime history of regularly using alcohol, nonmedical use of benzodiazepine medication, nonmedical use of prescription stimulants, symptoms of depression and anxiety, and executive functioning (i.e., metacognition and behavioral regulation) were significantly related to lifetime history of NMPO in this college sample. These findings offer several potential subsequent lines of investigation regarding the associations between various demographic and psychological factors and NMPO. Future research is needed to help identify college students who are at risk of NMPO.

Why comparative epidemiological indicators suggest that New Zealand is unlikely to experience a severe opioid epidemic

North America (i.e., the United States and Canada) and select other wealthy Commonwealth countries (e.g., Australia, the UK) have been experiencing marked 'opioid epidemics', consisting of elevated opioid use and related (e.g., mortality and morbidity) harms involving both prescription and, increasingly, illicit opioid substances. Multiple commentators have alerted to the possibility of New Zealand becoming home to a similar opioid crisis. In this article, we briefly examine and compare key system-level epidemiological indicators for New Zealand in regards to this situation and prospect. These data suggest that, comparatively, population-level (medical) opioid use, exposure and supply in New Zealand have been low and moderate, mostly involving restrained and lower-risk (e.g., short-duration, few long-acting/high-potency formulations, restricted settings) medical opioid availability, with limited over-time increases and absent the major oscillations in opioid dispensing observed elsewhere. Similarly, illicit opioids have been rather low in availability and use, and do not form primary substances in illicit drug scenes or markets. Correspondingly, opioid-related mortality in New Zealand has been somewhat increasing over-time albeit at comparably low levels, and principally involves methadone, morphine and codeine, i.e. the main opioids medically prescribed. Synthesizing the evidence, New Zealand has not featured the distinct characteristics or system-level drivers that have facilitated the opioid epidemics as have unfolded in other jurisdictions. It appears that New Zealand may have all along engaged in the more measured opioid use practices that other jurisdictions have attempted to revert to post-hoc (but largely when too late) while experiencing extensive adverse consequences related to opioids. On this basis, New Zealand provides for a worthwhile comparative case study towards more moderate opioid utilization and control entailing relatively limited collateral harms (e.g., opioid mortality) on public health compared to elsewhere. Details and characteristics of New Zealand's approach to and experience with opioids should be further examined for future and other jurisdictions' benefit.

Opioid use, regulation, and harms in Brazil: a comprehensive narrative overview of available data and indicators

BACKGROUND

Global opioid consumption increased multifold post-2000, disproportionately in high-income countries, with severe mortality/morbidity consequences. Latin America features comparatively low opioid availability; Brazil, the region's most populous country, makes an interesting case study concerning opioid use/harms. In this comprehensive overview, we aimed to identify and summarize medical and non-medical data and indicators of opioid availability and use, regulation/control, and harm outcomes in Brazil since 2000.

METHODS

We searched multiple scientific databases to identify relevant publications and conducted additional 'grey' literature searches to identify other pertinent information.

RESULTS

Despite some essential indicators, opioid-related data are limited for Brazil. Data indicate that population-level availability of prescription opioids represents only a small fraction of use in comparison to high-income countries. However, within Latin America, Brazil ranks mid-level for opioid consumption, indicating relatively moderate consumption compared to neighboring jurisdictions. Brazil has implemented restrictive regulations to opioid prescribing and is considered 'highly restricted' for opioid access. Codeine remains the major opioid analgesic utilized, but stronger opioids such as oxycodone are becoming more common. Professional knowledge regarding medical opioid use and effects appears limited. National surveys indicate increases in non-medical use of prescription opioids, albeit lower than observed in North America, while illicit opioids (e.g., heroin) are highly uncommon.

CONCLUSIONS

Overall population-level opioid availability and corresponding levels of opioid-related harms in Brazil remain substantially lower than rates reported for North America. However, the available surveillance and analytical data on opioid use, policy/practice, and harms in Brazil are limited and insufficient. Since existing and acute (e.g., pain-related) needs for improved opioid utilization and practice appear to be substantiated, improved indicators for and understanding of opioid use, practice, and harms in Brazil are required.

Comparison of Crude Population-Level Indicators of Opioid Use and Related Harm in New Zealand and Ontario (Canada)

North America and select other Commonwealth jurisdictions have been experiencing unprecedented opioid epidemics characterized by excessive and persistently high levels of opioid misuse, morbidity and mortality, and related disease burden. Recent discussions have considered whether New Zealand might undergo or needs to expect a similar ‘opioid crisis’. Towards further informing these considerations, we examine and compare essential, publicly available indicators of opioid utilization and harms (mortality) from New Zealand and the Canadian province of Ontario, due to the fact that both operate public health care systems in similar socio-cultural settings. We find that the two jurisdictions have featured vastly different population levels of opioid exposure, opioid consumption patterns (e.g., high-dose/long-term/high-risk prescribing) known as key predictors of adverse outcomes, and levels of opioid mortality as evidenced by concrete epidemiological indicators and data. Specifically for opioid-related death rates, these were already approximately threefold higher in Ontario compared to New Zealand based on most recent comparison data (e.g., 2012); these differentials have likely further grown more recently given major and distinct changes in population-level opioid exposure and risks, and subsequent opioid-related deaths since then in Ontario. Based on the present data and related evidence, New Zealand does not seem to need to anticipate an opioid mortality epidemic similar to that experienced in North America; however, it would be of interest to establish more comprehensive and timely surveillance of key system-level indicators of opioid use and harms as are standard in North America. As such, this inter-jurisdictional comparison makes for a case study in starkly contrasting scenarios of opioid use and harms, the drivers behind which deserve further systematic examination.

Endogenous Opiates and Behavior: 2018

This paper is the forty-first consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2018 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (2), the roles of these opioid peptides and receptors in pain and analgesia in animals (3) and humans (4), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (5), opioid peptide and receptor involvement in tolerance and dependence (6), stress and social status (7), learning and memory (8), eating and drinking (9), drug abuse and alcohol (10), sexual activity and hormones, pregnancy, development and endocrinology (11), mental illness and mood (12), seizures and neurologic disorders (13), electrical-related activity and neurophysiology (14), general activity and locomotion (15), gastrointestinal, renal and hepatic functions (16), cardiovascular responses (17), respiration and thermoregulation (18), and immunological responses (19).