Risk factors for opioid overdose and awareness of overdose risk among veterans prescribed chronic opioids for addiction or pain

Polypharmacy Is Associated with Sociodemographic Factors and Socioeconomic Status in United States Adults

A thorough understanding of polypharmacy is required to create public health initiatives that minimize the potential for adverse outcomes. This study aimed to investigate the relationship between sociodemographic factors, socioeconomic status (SES), and polypharmacy risk in United States (US) individuals between 1999-2000 and 2017-2018. The cross-sectional National Health and Nutrition Examination Survey dataset covered ten cycles between 1999-2000 and 2017-2018. All individuals aged ≥18 years were included. The simultaneous use of at least five medications by one person is known as polypharmacy. Multivariable logistic regression showed that there was a statistically significant association between polypharmacy sociodemographic factors (such as age between 45 and 64 (odds ratio [OR] = 3.76; 95% confidence interval [CI] = 3.60-3.92; p < 0.0001) and age of 65 years or above (OR = 3.96; 95% CI = 3.79-4.13; p < 0.0001), especially women (OR = 1.09; 95% CI = 1.06-1.13; p < 0.0001), non-Hispanic blacks (OR = 1.66; 95% CI = 1.51-1.83; p < 0.0001), and veterans (OR = 1.27; 95% CI = 1.22-1.31; p < 0.0001)) and SES (such as being married (OR = 1.14; 95% CI = 1.08-1.19; p = 0.031), widowed, divorced, or separated (OR = 1.21; 95% CI = 1.15-1.26; p < 0.0001), a college graduate or above (OR = 1.21, 95% CI = 1.15-1.27, p < 0.0001), and earning > USD 55,000 per year (OR = 1.86; 95% CI = 1.79-1.93; p < 0.0001)). Individuals aged 45 years and above, women, and non-Hispanic blacks with higher educational levels and yearly incomes were more likely to experience polypharmacy in the US between 1999-2000 and 2017-2018.

Naloxone Knowledge and Attitudes Towards Overdose Response Among Family Members of People who Misuse Opioids

Providing family members of individuals with opioid use disorders (OUD) naloxone is a cost-effective way to prevent overdose deaths. However, misconceptions and negative attitudes towards naloxone hinder family engagement with naloxone programs. This study examines factors associated with knowledge and attitudes toward naloxone among adults with close family members who misused opioids. Adults with family members (parent, step-parent, child, spouse, sibling, or step-sibling) who misused opioids (N = 299) completed a web-based survey. Participants were recruited through treatment providers, community groups, and social media. Surveys assessed naloxone knowledge, attitudes toward overdose response, demographics, completion of naloxone training, attitude toward medications for OUD, and family members' overdose history. Multiple regression was used to identify factors associated with naloxone knowledge (Model 1) and attitudes toward overdose response (Model 2). A graduate degree (B = .35, p < .003) and a history of overdose (B = 0.21, p = .032) were associated with greater naloxone knowledge. Age (B = .11, p < .001), race/ethnicity (B = -1.39, p = .037), naloxone training (B = 2.70, p < .001), and more positive attitude toward medications for OUD (B = 1.50, p = .003) were associated with attitudes toward overdose response. Family members are potential allies in reducing drug overdose deaths, and families may need broader education about naloxone. Awareness of previous overdose was associated with greater naloxone knowledge. Findings related to race/ethnicity suggest the need to reach family members of minoritized racial groups to provide access to naloxone training. Findings point to where education and distribution efforts may focus on increasing knowledge and improving attitudes among those closest to people with OUD.

Naloxone-Prescribing Practices in a Freestanding Rehabilitation Hospital

OBJECTIVE

The study aims to determine whether Physical Medicine & Rehabilitation physicians offer naloxone per the Centers for Disease Control and Prevention Guidelines to patients at the highest risk of complications from opioid treatment and whether there is a difference between inpatient and outpatient naloxone prescribing.

DESIGN

A retrospective chart review on 389 adults (outpatient n = 166; inpatient n = 223) from May 4 to May 31, 2022, at an academic rehabilitation hospital. Prescribed medications and comorbidities were evaluated to determine whether Centers for Disease Control and Prevention criteria for offering naloxone were met and whether naloxone was offered.

RESULTS

One hundred twenty-nine opioid prescriptions were written for 102 outpatients; 61 qualified for naloxone (morphine milliequivalent range = 10-1080, mean = 158.08). On inpatient, 68 patients received 86 opioid prescriptions; 35 qualified for naloxone (morphine milliequivalent range = 3.75-246, mean = 62.36). Overall, there was a significantly lower rate of opioid prescriptions for inpatients (30.49%) than outpatients (61.45%) ( P < 0.0001), a nonsignificant lower rate of inpatient (51.47%) than outpatient (59.80%) "at-risk" prescriptions ( P = 0.351), and a weakly significant lower rate of naloxone prescribing for inpatient (2.86%) than outpatient visits (8.20%) ( P < 0.0519).

CONCLUSIONS

At this rehabilitation hospital, there was a low rate of naloxone prescribing by inpatient and outpatient providers, with a higher rate occurring in the outpatient than inpatient setting. More research is needed to understand this prescribing trend to determine potential interventions.

Fatal drug overdoses in individuals treated pharmacologically for chronic pain: a nationwide register-based study

INTRODUCTION

Chronic pain patients may be at an increased risk for drug overdoses as a result of comorbid psychiatric disorders and treatment with risk-increasing prescription medications, such as opioids. We aimed to characterise fatal drug overdoses and investigate factors associated with the deaths among individuals who had been treated pharmacologically for chronic pain.

METHODS

We included all individuals who received analgesics reimbursed for chronic pain in Norway during 2010-9 (n=569 047). Among this population, we identified all individuals with drug overdoses as cause of death (cases). Extracting data from national registries on diagnoses, filled prescriptions, and socioeconomic variables, we used a nested case-control design to compare the cases with age- and sex-matched controls from the study population.

RESULTS

Overall, 623 (0.11%) individuals in the study population died of an overdose. Most, 66.8%, had overdosed accidentally, and 61.9% as a result of pharmaceutically available opioids. Compared with the controls (n=62 245), overdoses overall were associated strongly with substance use disorders (adjusted odds ratio 7.78 [95% confidence interval 6.20-9.77]), use of combinations of opioids, benzodiazepines and related drugs and gabapentinoids (4.60 [3.62-5.85]), previous poisoning with pharmaceuticals (2.78 [2.20-3.51]), and with living alone the last year of life (2.11 [1.75-2.54]). Intentional overdoses had a stronger association with previous poisonings with pharmaceuticals whereas accidental overdoses were strongly associated with substance use disorders.

CONCLUSIONS

This study shows the need for better identification of overdose and suicide risk in individuals treated for chronic pain. Extra caution is needed when treating complex comorbid disorders, especially with overdose risk-increasing medications.

Exploring the Association Between Opioid Use Disorder and Alzheimer's Disease and Dementia Among a National Sample of the U.S. Population

BACKGROUND

Past research suggests associations between heavy alcohol use and later life dementia. However, little is known about whether opioid use disorder (OUD) and dementia share this association, especially among age groups younger than 65 years old.

OBJECTIVE

Examine the association between OUD and Alzheimer's disease (AD) and dementia.

METHODS

Electronic health records between 2000 and 2021 for patients age 12 or older were identified in the Cerner Real-World database™. Patients with a prior diagnosis of dementia were excluded. Patients were followed for 1-10 years (grouped by one, three, five, and ten-year follow-up periods) in a matched retrospective cohort study. Cox proportional hazards regressions were used to estimate adjusted hazard ratios (aHRs) of incident AD/dementia stratified by age and follow-up group.

RESULTS

A sample of 627,810 individuals with OUD were compared to 646,340 without OUD. Individuals with OUD exhibited 88% higher risk for developing AD/dementia compared to those without OUD (aHR = 1.88, 95% CI 1.74, 2.03) within 1 year follow-up and 211% (aHR = 3.11, 95% CI 2.63, 3.69) within 10 years follow-up. When stratifying by age, younger patients (age 12-44) had a greater disparity in odds of AD/dementia between OUD and non-OUD groups compared with patients older than 65 years.

CONCLUSIONS

Additional research is needed to understand why an association exists between OUD and AD/dementia, especially among younger populations. The results suggest that cognitive functioning screening programs for younger people diagnosed with OUD may be useful for targeting early identification and intervention for AD/dementia in particularly high risk and marginalized populations.

Use of Predictive Analytics to Identify Unhealthy Opioid Use and Guide Intervention

OBJECTIVE

The authors aimed to use the newly developed Opioid Risk Stratification Tool to identify individuals who may be at risk for unhealthy opioid use and to examine the impact of applying a mailing and engagement intervention to this population and their prescribers, with the goal of reducing high-risk prescribing behaviors, opioid medication use, and mortality rates.

METHODS

A nonrandomized controlled study was conducted with members from two Medicaid managed care organizations. In both the intervention (N=131) and control (N=187) groups, an algorithm identified members at moderate to high risk for hazardous opioid use. Members at increased risk in the intervention group and their prescribers received a letter from the managed care organization, and members still at risk 3 months after the mailing were contacted by a care coordinator. Individuals in the control group were not contacted. Medicaid claims data were used to compare opioid use and prescribing practices between groups before and after the intervention.

RESULTS

Individuals in the intervention group were less likely to have any opioid prescription postintervention compared with those in the control group (OR=0.55, p<0.001), and the intervention group had a greater reduction in the number of individuals with concurrent opioid and benzodiazepine prescriptions (OR=0.49, p=0.042). Practices such as multiple opioid prescriptions and multiple prescribers of opioids were not affected by the intervention.

CONCLUSIONS

An intervention targeting individuals at risk for hazardous opioid use was associated with a reduction in some high-risk prescribing practices. Future research should determine the ideal mix of interventions to reduce as many risk factors as possible.

Patient-centered quality measurement for opioid use disorder: Development of a taxonomy to address gaps in research and practice

Background: Evidence-based treatment is provided infrequently and inconsistently to patients with opioid use disorder (OUD). Treatment guidelines call for high-quality, patient-centered care that meets individual preferences and needs, but it is unclear whether current quality measures address individualized aspects of care and whether measures of patient-centered OUD care are supported by evidence. Methods: We conducted an environmental scan of OUD care quality to (1) evaluate patient-centeredness in current OUD quality measures endorsed by national agencies and in national OUD treatment guidelines; and (2) review literature evidence for patient-centered care in OUD diagnosis and management, including gaps in current guidelines, performance data, and quality measures. We then synthesized these findings to develop a new quality measurement taxonomy that incorporates patient-centered aspects of care and identifies priority areas for future research and quality measure development. Results: Across 31 endorsed OUD quality measures, only two measures of patient experience incorporated patient preferences and needs, while national guidelines emphasized providing patient-centered care. Among 689 articles reviewed, evidence varied for practices of patient-centered care. Many practices were supported by guidelines and substantial evidence, while others lacked evidence despite guideline support. Our synthesis of findings resulted in EQuIITable Care, a taxonomy comprised of six classifications: (1) patient Experience and engagement, (2) Quality of life; (3) Identification of patient risks; (4) Interventions to mitigate patient risks; (5) Treatment; and (6) Care coordination and navigation. Conclusions: Current quality measurement for OUD lacks patient-centeredness. EQuIITable Care for OUD provides a roadmap to develop measures of patient-centered care for OUD.

U.S. Military veterans and the opioid overdose crisis: a review of risk factors and prevention efforts

U.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019. Risk for overdose among veterans is complex and influenced by ongoing interaction among physiological/biological, psychological, and socio-structural factors. A thorough understanding of opioid-related overdose among veterans, one that goes beyond simple pharmacological determinism, must examine the interplay of pain, pain treatment, and stress, as well as psychological and social experiences-before, during, and after military service. Comprehensive efforts to tackle the overdose crisis among veterans require interventions that address each of these dimensions. Promising interventions include widespread naloxone distribution and increased provision of low-threshold wrap-around services, including medications for opioid use disorder (MOUD) and holistic/complementary approaches. Interventions that are delivered by peers - individuals who share key experiential or sociodemographic characteristics with the population being served - may be ideally suited to address many of the barriers to opioid-related risk mitigation common among veterans. Community care models could be beneficial for the large proportion of veterans who are not connected to the Veterans Health Administration and for veterans who, for various reasons including mental health problems and the avoidance of stigma, are socially isolated or reluctant to use traditional substance use services. Interventions need to be tailored in such a way that they reach those more socially isolated veterans who may not have access to naloxone or the social support to help them in overdose situations. It is important to incorporate the perspectives and voices of veterans with lived experience of substance use into the design and implementation of new overdose prevention resources and strategies to meet the needs of this population. Key messagesU.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019.The risks for overdose that veterans face need to be understood as resulting from an ongoing interaction among biological/physiological, psychological, and social/structural factors.Addressing drug overdose in the veteran population requires accessible and non-judgemental, low threshold, wraparound, and holistic solutions that recognise the complex aetiology of overdose risk for veterans.

Marketing Opioids to Veterans and Older Adults: A Content Analysis of Internal Industry Documents Released from State of Oklahoma v. Purdue Pharma LP, et al

CONTEXT

From 1999 to 2018 the opioid epidemic claimed more than 500,000 lives in the United States. Military veterans and older adults were particularly affected; veterans' deaths attributed to opioid use increased by 65% from 2010 to 2016, while opioid prescriptions for older adults increased ninefold between 1995 and 2010.

METHODS

We reviewed internal pharmaceutical industry documents released in legal discovery to determine how companies targeted these groups to increase prescribing and sales. This review included an analysis of corporate goals and plans identified through internal emails, sales pitches, and presentations.

FINDINGS

These policy and advertising campaigns focused on (a) lobbying policy makers, (b) undertaking unbranded campaigns promoting opioid use, and (c) promoting opioid use in research and the popular media. Opioid manufacturers claimed that opioids could resolve preexisting concerns identified among military veterans and older adults and that the use of opioids would improve quality of life. These campaigns were positioned as public health initiatives and efforts to increase disease awareness.

CONCLUSIONS

The findings suggest a need for regulatory reform and transparency related to lobbying, advocacy group relationships with industry, and pharmaceutical advertising.

Cessation of group battlefield acupuncture visits due to COVID-19: a pilot study

BACKGROUND

Prior to the COVID-19 pandemic, battlefield acupuncture (BFA) was offered to veterans with chronic pain in multidisciplinary group visits.

OBJECTIVE

We aimed to assess the impact of cessation of BFA due to COVID-19 and to determine the utility of different aspects of the group visits for chronic pain management.

METHODS

Participants who had attended at least three BFA group visits completed questionnaires assessing the impact of treatment interruption on pain, overall function and desire to resume treatment.

RESULTS

Thirty-nine veterans were surveyed; 49% responded to the questionnaire. Ninety percent (17/19) agreed that BFA was an important part of pain management and that their pain had worsened after treatment interruption. Seventy-four percent (14/19) responded that they were taking more pain medications since BFA had ended. Ninety-five percent (18/19) responded that BFA improved daily function; 79% (15/19) agreed that BFA improved their sleep. Ninety-five percent (18/19) were interested in resuming BFA. Camaraderie was mentioned as the most helpful aspect of the group by 8/19 (42%) of participants. Participation of health psychology and nutrition were each mentioned as a most helpful aspect of the group by 5/19 (26%) of participants.

CONCLUSION

Our results suggest that participants may have believed that BFA, camaraderie, and input from nutrition and health psychology services were important contributors to their pain control. The results also suggest that veterans may have suffered worsening pain, used more pain medications, and had worsening quality of sleep and daily function during the COVID-related clinic disruption, and that they were interested in resumption of the program.

Telehealth Utilization Is Associated with Lower Risk of Discontinuation of Buprenorphine: a Retrospective Cohort Study of US Veterans

OBJECTIVE

Treatment for opioid use disorder (OUD) may include a combination of pharmacotherapies (such as buprenorphine) with counseling services if clinically indicated. Medication management or engagement with in-person counseling services may be hindered by logistical and financial barriers. Telehealth may provide an alternative mechanism for continued engagement. This study aimed to evaluate the association between telehealth encounters and time to discontinuation of buprenorphine treatment when compared to traditional in-person visits and to evaluate potential effect modification by rural-urban designation and in-person and telehealth combination treatment.

METHODS

A retrospective cohort study of Veterans diagnosed with OUD and treated with buprenorphine across all facilities within the Veterans Health Administration (VHA) between 2008 and 2017. Exposures were telehealth and in-person encounters for substance use disorder (SUD) and mental health, treated as time-varying covariates. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year.

RESULTS

Compared to in-person encounters, treatment discontinuation was lower for telehealth for SUD (aHR: 0.69; 95%CI: 0.60, 0.78) and mental health (aHR: 0.69; 95%CI: 0.62, 0.76). There was no evidence of effect modification by rural-urban designation. Risk of treatment discontinuation appeared to be lower among those with telehealth only compared to in-person only for both SUD (aHR: 0.48, 95%CI: 0.37, 0.62) and for mental health (aHR: 0.46; 95%CI: 0.33, 0.65).

CONCLUSIONS

As telehealth demonstrated improved treatment retention compared to in-person visits, it may be a suitable option for engagement for patients in OUD management. Efforts to expand services may improve treatment retention and health outcomes for VHA and other health care systems.

Evaluation of Family Characteristics and Multiple Hospitalizations at the End of Life: Evidence from the Utah Population Database

Background: Scant research has examined the relationship between family characteristics and end-of-life (EOL) outcomes despite the importance of family at the EOL. Objectives: This study examined factors associated with the size and composition of family relationships on multiple EOL hospitalizations. Design: Retrospective analysis of the Utah Population Database, a statewide population database using linked administrative records. Setting/subjects: We identified adults who died of natural causes in Utah, United States (n = 216,913) between 1998 and 2016 and identified adult first-degree family members (n = 743,874; spouses = 13.2%; parents = 3.6%; children = 51.7%; siblings = 31.5%). Measurements: We compared demographic, socioeconomic, and death characteristics of decedents with and without first-degree family. Using logistic regression models adjusting for sex, age, race/ethnicity, marital status, comorbidity, and causes of death, we examined the association of first-degree family size and composition, on multiple hospitalizations in the last six months of life. Results: Among decedents without documented first-degree family members in Utah (16.0%), 57.7% were female and 7 in 10 were older than 70 years. Nonmarried (aOR = 0.90, 95% CI = 0.88-0.92) decedents and decedents with children (aOR = 0.97, 95% CI = 0.94-0.99) were less likely to have multiple EOL hospitalizations. Family size was not associated with multiple EOL hospitalizations. Conclusions: First-degree family characteristics vary at the EOL. EOL care utilization may be influenced by family characteristics-in particular, presence of a spouse. Future studies should explore how the quality of family networks, as well as extended family, impacts other EOL characteristics such as hospice and palliative care use to better understand the EOL care experience.

Perceived risk factors for severe Covid-19 symptoms and their association with health behaviours: Findings from the HEBECO study

Risk perceptions are important influences on health behaviours. We used descriptive statistics and multivariable logistic regression models to assess cross-sectionally risk perceptions for severe Covid-19 symptoms and their health behaviour correlates among 2206 UK adults from the HEBECO study. The great majority (89-99%) classified age 70+, having comorbidities, being a key worker, overweight, and from an ethnic minority as increasing the risk. People were less sure about alcohol drinking, vaping, and nicotine replacement therapy use (17.4-29.5% responding 'don't know'). Relative to those who did not, those who engaged in the following behaviours had higher odds of classifying these behaviours as (i) decreasing the risk: smoking cigarettes (adjusted odds ratios, aORs, 95% CI = 2.26, 1.39-3.37), and using e-cigarettes (aORs = 5.80, 3.25-10.34); (ii) having no impact: smoking cigarettes (1.98; 1.42-2.76), using e-cigarettes (aORs = 2.63, 1.96-3.50), drinking alcohol (aORs = 1.75, 1.31-2.33); and lower odds of classifying these as increasing the risk: smoking cigarettes (aORs: 0.43, 0.32-0.56), using e-cigarettes (aORs = 0.25, 0.18-0.35). Similarly, eating more fruit and vegetables was associated with classifying unhealthy diet as 'increasing risk' (aOR = 1.37, 1.12-1.69), and exercising more with classifying regular physical activity as 'decreasing risk' (aOR = 2.42, 1.75-3.34). Risk perceptions for severe Covid-19 among UK adults were lower for their own health behaviours, evidencing optimism bias. These risk perceptions may form barriers to changing people's own unhealthy behaviours, make them less responsive to interventions that refer to the risk of Covid-19 as a motivating factor, and exacerbate inequalities in health behaviours and outcomes.

Clinical pharmacist involvement in expanding naloxone distribution in a veteran population

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To describe the process used in a clinical pharmacist specialist (CPS)-led Opioid Overdose Education and Naloxone Distribution (OEND) program initiative to increase naloxone distribution to veterans at high risk for overdose via provider education and identification of barriers to naloxone distribution.

SUMMARY

Drug overdose is the leading cause of accidental death in the United States. One step toward counteracting the epidemic includes expanding access to and use of naloxone. The Veterans Health Administration has developed initiatives to target veterans at risk for opioid overdose, such as the Veterans Affairs (VA) OEND program. Pharmacists can play a unique role in OEND by both prescribing naloxone and educating patients and providers on risk mitigation strategies. Through provider education, patient education, and facility-wide initiatives, naloxone prescribing was increased by 9-fold from August 2016 to August 2018. In addition, the number of new naloxone prescribers increased by almost 7-fold during the intervention period. Naloxone distribution to high-risk groups drastically increased across all target groups.

CONCLUSION

CPS involvement in promoting OEND at VAPHS drastically increased rates of prescribing of naloxone kits to veterans at risk for opioid overdose. This initiative showed that a CPS can play multiple roles in supporting OEND outreach at a large healthcare setting.

Association Between Buprenorphine for Opioid Use Disorder and Mortality Risk

INTRODUCTION

Veterans with opioid use disorder have an increased risk of suicide and overdose compared with the general population. Buprenorphine, a U.S. Food and Drug Administration-approved medication to treat opioid use disorder, has shown benefits, including decreased risk of illicit drug use and overdose. This study assesses the mortality outcomes with buprenorphine pharmacotherapy among Veterans up to 5 years from treatment initiation.

METHODS

This was a retrospective cohort study of Veterans receiving buprenorphine (2008-2017) across any Veterans Health Administration facility. Buprenorphine pharmacotherapy was evaluated as a time-varying covariate. The primary outcome was death up to 5 years from treatment initiation by suicide and overdose combined; secondary outcomes included suicide, overdose, opioid-specific overdose, and all-cause death. Secondary analyses included evaluating the risk of mortality in recent discontinuation and effect modification by select characteristics. All analyses were conducted in 2020.

RESULTS

Veterans who were not receiving buprenorphine were 4.33 (adjusted hazard ratio; 95% CI=3.60, 5.21) times more likely to die by suicide/overdose than those receiving buprenorphine pharmacotherapy on any given day, with similar protective associations with treatment across secondary outcomes. The risk of suicide/overdose was highest 8-14 days from treatment discontinuation (adjusted hazard ratio=6.54, 95% CI=4.32, 9.91) than in currently receiving buprenorphine pharmacotherapy. There was no evidence of effect modification by the selected covariates.

CONCLUSIONS

Mortality risk was greater among Veterans who were not receiving buprenorphine pharmacotherapy than among those who were. Providers should consider whether buprenorphine pharmacotherapy, either intermittent or continuous, may provide health benefits for their patients and prevent mortality.

Valoración del riego de adicción a tramadol en pacientes con dolor crónico no oncológico

Objetivo El manejo del dolor crónico no oncológico con analgésicos opioides ha sido de importancia para el control de los síntomas y el restablecimiento de la actividad, sin embargo, el riesgo de adicción asociado a estos medicamentos es ampliamente conocido y evaluado. Este estudio evalúa el riesgo de adicción que presentaban los pacientes con manejo de tramadol describiendo los factores mas frecuentes en la muestra estudiada frente a lo reportado en la literatura. Métodos Una muestra de 76 pacientes de una clínica de dolor que están en manejo con tramadol y se les administra un cuestionario con características demográficas y con la escala Opioid Risk Tool para el riesgo de adicción. Resultados El 57,89% de los sujetos fueron mujeres, el 55,20% se encontraba entre los 29 y 59 años. El riesgo de adicción moderado se encontró en el 9,09% de las mujeres y en el 37,05% de los hombres. La inclusión de otras enfermedades como ansiedad y trastorno de estrés postraumático aumenta el riesgo de adicción a severo en 6,06% de los hombres. Conclusiones La valoración del riesgo de adicción a opioides debe tener en cuenta los factores encontrados en la población colombiana.

Naloxone's role in the national opioid crisis-past struggles, current efforts, and future opportunities

Over the past 25 years, naloxone has emerged as a critical lifesaving overdose antidote. Public health advocates and community activists established early methods for naloxone distribution to people who inject drugs, but a legacy of stigmatization and opposition to universal naloxone access continues to limit the drug's full potential to reduce opioid-related mortality. The establishment of naloxone distribution programs under the umbrella of syringe exchange programs faces the same practical, ideological and financial barriers to expansion similar to those faced by syringe exchange programs themselves. The expansion of naloxone from the confines of a few syringe exchange programs to what we see today represents an enormous triumph for the grass-roots activists, service providers, and public health professionals who have fought to guarantee lay access to naloxone. Despite the extensive efforts to expand access to naloxone, naloxone continues to remains a scarce resource in many US localities. Considerable naloxone "deserts" remain and even where there is naloxone access, it does not always reach those at risk. Promising areas for expansion include the development of more robust telehealth methods for naloxone distribution, including subsidized mail delivery programs; lowering barriers to pharmacy access; working with hospitals, ambulances, and law enforcement to expand naloxone "leave behind" programs; providing naloxone co-prescription with medications for opioid use disorder; and working with prisons, shelters, and networks of people who use drugs to increase access to the lifesaving medication. Efforts to ensure over-the-counter and low- or no-cost naloxone are ongoing and stand alongside medication-assisted treatments as efficacious, readily-actionable, and cost-efficient population-level interventions available for combatting opioid-related overdose in the United States.

Impact of policy changes on the provision of naloxone by pharmacies in Ontario, Canada: a population-based time-series analysis

BACKGROUND AND AIMS

In June 2016, the Ontario, Canada government implemented the Ontario Naloxone Program for Pharmacies (ONPP), authorizing pharmacists to provide injectable naloxone kits at no charge to all Ontario residents. In March 2018, the program was amended to include intranasal naloxone and remove the requirement to present a government health card to the dispensing pharmacist. We examined whether these changes increased naloxone dispensing through the ONPP.

DESIGN

Population-based time-series analysis using interventional autoregressive integrated moving average models.

SETTING

Ontario, Canada.

PARTICIPANTS

All Ontario residents between 1 July 2016 and 31 March 2020.

MEASUREMENTS

Monthly rates of pharmacy naloxone dispensing.

FINDINGS

Overall, 199 484 individuals were dispensed a naloxone kit during the study period. In the main analysis, the rate of pharmacy naloxone dispensing increased by 65.1% following program changes (55.6-91.8 kits per 100 000 population between February 2018 and May 2018; P = 0.01). In subgroup analyses, naloxone dispensing increased among individuals receiving opioid agonist therapy (OAT) (3374.9-7264.2 kits per 100 000 OAT recipients; P = 0.04) among individuals receiving other prescription opioids (192.8-381.8 kits per 100 000 population prescribed opioids; P < 0.01), among individuals with past opioid exposure (134.7-205.6 kits per 100 000 population with past opioid exposure; P < 0.01) and in urban centers (56.2-91.4 kits per 100 000 population; P < 0.01). We did not observe a clear impact on pharmacy-dispensed naloxone to individuals with no or unknown opioid exposure (34.4-39.3 kits per 100 000 population with no/unknown opioid exposure; P = 0.42) and in rural regions (50.4-97.2 kits per 100 000 population; P = 0.09).

CONCLUSIONS

Changes to the Ontario Naloxone Program for Pharmacies to add intranasal naloxone and remove the requirement to present a government health card appeared to increase pharmacy-based naloxone dispensing uptake in Ontario, Canada, particularly among individuals at high risk of inadvertent opioid overdose.

Modifying and Evaluating the Opioid Overdose Knowledge Scale for Prescription Opioids: A Pilot Study of the Rx-OOKS

OBJECTIVE

To develop a validated instrument that measures knowledge about prescription opioid overdose.

METHODS

Within an integrated health care system, we adapted, piloted, and tested the reliability and predictive validity of a modified Opioid Overdose Knowledge Scale (OOKS) instrument specific to prescription opioids (Rx-OOKS) with a patient population prescribed long-term opioid therapy and potentially at risk of opioid overdose. We used an interdisciplinary team approach and patient interviews to adapt the instrument. We then piloted the survey on a patient sample and assessed it using Cronbach's alpha and logistic regression.

RESULTS

Rx-OOKS (N = 56) resulted in a three-construct, 25-item instrument. Internal consistency was acceptable for the following constructs: "signs of an overdose" (10 items) at α = 0.851, "action to take with opioid overdose" (seven items) at α = 0.692, and "naloxone use knowledge" (eight items) at α = 0.729. One construct, "risks of an overdose" (three items), had an α of 0.365 and was subsequently eliminated from analysis due to poor performance. We conducted logistic regression to determine if any of the constructs was strongly associated with future naloxone receipt. Higher scores on "actions to take in an overdose" had nine times the odds of receiving naloxone (odds ratio [OR] = 9.00, 95% confidence interval [CI] = 1.42-57.12); higher "naloxone use knowledge" scores were 15.8 times more likely to receive naloxone than those with lower scores (OR = 15.83, 95% CI = 1.68-149.17).

CONCLUSIONS

The Rx-OOKS survey instrument can reliably measure knowledge about prescription opioid overdose recognition and naloxone use. Further, knowledge about actions to take during an opioid overdose and naloxone use were associated with future receipt of naloxone.

Patient perspectives of barriers to naloxone obtainment and use in a primary care, underserved setting: A qualitative study

Background: Gaps in naloxone obtainment and use are not well studied, particularly among minoritized groups. Objective: To describe patient perspectives that serve as barriers to naloxone obtainment and the number of patients who obtained naloxone in a primarily African American population in a primary care, underserved setting. Methods: This qualitative study conducted semi-structured interviews and included 36 adults who were prescribed naloxone at a federally qualified health center using convenience sampling. Participants answered survey questions describing naloxone acceptability, perceived risk for overdose, and barriers to naloxone use. Results: Sixty-nine percent of the patients were Black or African American. The majority of patients attempted to fill their naloxone at a local pharmacy (69%) and reported no difficulties (88%). Five major themes revealed: overall positive views of naloxone because it saves lives; existing knowledge gaps related to indications for naloxone prescription; stigma surrounding receiving a naloxone prescription; inadequacies of the patient education provided; and the role providers play in naloxone receptivity Conclusions: Among a majority African American population, many perceived naloxone to be lifesaving. However, stigmatizing perceptions and inability to recall patient education contribute to a perception of low overdose risk. Further research describing the impact of the opioid epidemic on underrepresented groups is necessary.

Examination of the clinical factors associated with attendance at emergency departments for chronic pain management and the cost of treatment relative to that of other significant medical conditions

ABSTRACT

Little is known about risk factors for emergency department (ED) attendance for chronic pain (CP) management and the relative service burden. We examined ED utilisation in patients with CP, identified risk factors associated with attendance for chronic musculoskeletal pain (CMP), and estimated the comparative cost of treatment. The study cohort comprised a random sample of 3700 adults from the general population in Tayside, Scotland. Linked regional extracts, spanning a 12-month period, were obtained from national registers, providing information on ED attendances, community-dispensed prescribing, and outpatient clinic attendances. The National Health Service Scotland Cost Book was used to ascertain the current average cost of an ED attendance (£130; ∼$167). All-cause ED attendance was higher in those with CP (68.5%; n = 252) than without (29.3%; n = 967). In the entire cohort, more patients attended the ED for the treatment of CMP than for any other medical condition (n = 119; 32.3% of those with CP). Risk factors for ED attendance for CMP were: recent analgesic dose decreases (OR = 4.55); and transitioning from opioid to nonopioid analgesics (OR = 5.08). Characteristics protective of ED attendance for CMP were: being in receipt of strong opioids (OR = 0.21); transitioning from nonopioid to opioid analgesics (OR = 0.25); recent analgesic dose increases (OR = 0.24); and being prescribed tricyclic antidepressants (OR = 0.10), benzodiazepines (OR = 0.46), or hypnotics (OR = 0.45). Chronic musculoskeletal pain was one of the most expensive conditions to treat (£17,680 [∼$22,668] per annum), conferring a substantial burden on ED services. Improved understanding of the risk/protective factors could inform healthcare redesign to reduce avoidable ED attendances for CMP management.

Trends in Urine Drug Monitoring Among Persons Receiving Long-Term Opioids and Persons with Opioid Use Disorder in the United States

BACKGROUND

Practice guidelines recommend urine drug monitoring (UDM) at least annually in the setting of chronic opioid therapy as an objective assessment of substance use. However, empirical evidence on who gets tested and how often testing occurs is lacking.

OBJECTIVES

This study investigates 10-year UDM trends in the United States based on 2 factors: (1) the duration of prescription opioid treatment, and (2) having an opioid use disorder (OUD) diagnosis and medications for opioid use disorder (MOUD) prescriptions.

STUDY DESIGN

Observational cross-sectional study.

SETTING

Research was conducted using administrative claims data from Optum's deidentified Clinformatics Data Mart Database for the period 2007 to 2016. The dataset contained information on the plan enrollment and health care claims from 50 states and the District of Columbia.

METHODS

To examine trends in UDM based on the duration of prescription opioid treatment, persons receiving prescription opioid analgesics were categorized into 4 groups based on the number of days covered: (a) less than 90 days, (b) 90 to 179 days, (c) 180 to 269 days, and (d) at least 270 days. To examine trends based on an OUD diagnosis and MOUD prescriptions, persons diagnosed with OUD were identified and categorized based on the presence of MOUD prescriptions as follows: (a) OUD with buprenorphine (BPN) and naltrexone (NTX) in the same year; (b) OUD with BPN only; (c) OUD with NTX only; (d) OUD with chronic prescription opioid analgesics (>= 90 days); (e) OUD without prescription opioid analgesics, BPN, or NTX; and (f) chronic prescription opioid analgesics (>= 90 days) without an OUD diagnosis. For analysis, the percent receiving UDM was estimated per group per year. Then the data were restricted to those receiving at least one UDM to estimate the average number of UDM per person.

RESULTS

Data included an average of 364,485 persons per year receiving prescription opioid analgesics for chronic use, and 10,277 per year receiving an OUD diagnosis. Among those receiving prescription opioid analgesics, less than 50% received UDM. For those receiving at least one UDM, one additional UDM was performed per person as the duration of opioids increased by 90 days. Among persons with OUD, the percent receiving UDM was the highest for those receiving both BPN and NTX (87%), followed by those receiving BPN only (80%), chronic opioids (79%), NTX only (72%), and those not receiving any MOUD/opioids (54%).

LIMITATIONS

Methadone dispensing for OUD treatments was not captured in administrative claims data.

CONCLUSIONS

Although recommended for patients with chronic pain, UDM is provided less than half of the time for these patients. However, once patients received at least one UDM, they would continue to receive it on a fairly regular basis. Compared with those with chronic pain, persons diagnosed with OUD are more likely to receive UDM at a more frequent interval.

Prescription opioid misuse and its correlates among veterans and military in the United States: A systematic literature review

BACKGROUND

Prescription opioid misuse (POM) has become a critical public health issue in the United States (US), with veteran and military population being especially vulnerable to POM. However, limited behavioral interventions have been developed for veterans and military to reduce POM risk due to the lack of an adequate understanding of POM andrelated factors among veterans and military. The current study aims to review and synthesize empirical findings regarding POM and its correlates among US veterans and military.

METHODS

We conducted a systematic review of 17 empirical studies (16 quantitative studies and one qualitative study) from 1980 to 2019 that reported POM statistics (e.g., prevalence) and examined correlates of POM in veterans and military.

RESULTS

The prevalence of POM in veterans and military ranged from 6.9%-77.9% varying by study samples, individual POM behaviors, and recalled time periods. Several factors were identified to be associated with POM in veterans and military. These factors included socio-demographic factors (age, race/ethnicity, education, relationship status, and military status), pain-related factors (pain symptoms, severity, interference, and cognitions), other physical factors (e.g., common illness), opioid-medication-related factors (receipt of opioid medications and quantity of opioid medications), behavioral factors (substance use disorder, alcohol use, cigarette use, and other prescription drug use), and psychological factors (psychiatric symptoms and cognitive factors).

CONCLUSIONS

POM was prevalent in veterans and military and could be potentially influenced by multiple psycho-behavioral factors. Future research guided by a theoretical framework is warranted to examine psycho-behavioral influences on POM and their mechanisms and to inform effective psychosocial POM interventions in veterans and military.

Oral Opioid Prescribing Trends in the United States, 2002-2018

OBJECTIVE

To conduct a retrospective analysis of sequential cross-sectional data of opioid prescribing practices in patients with no prior history of opioid use.

METHODS

Individuals filling an oral opioid prescription who had 1 year of prior observation were identified from four different administrative claims databases for the period between January 1, 2002, and December 31, 2018: IBM MarketScan® Commercial Database (CCAE), Multi-State Medicaid Database (MDCD), Medicare Supplemental Database (MDCR), and Optum© De-Identified Clinformatics® Data Mart Database. Outcomes included incidence of new opioid use and characteristics of patients' first opioid prescription, including dispensed morphine milligram equivalent (MME) per day, total MME dispensed, total MME ≥300, and days' supply of prescription for ≤3 or ≥30 days.

RESULTS

There were 40,600,696 new opioid users identified. The incidence of new opioid use in the past 17 years ranged from 6% to 11% within the two commercially insured databases. Incidence decreased over time in MDCD and was consistently higher in MDCR. Total MME dispensed decreased in MDCD and increased in CCAE, with no major changes in the other databases. The proportion of patients receiving ≥30-day prescriptions decreased and the proportion of patients receiving ≤3-day prescriptions increased in MDCD, while ≥30-day prescriptions in the Optum database dramatically increased (low of 3.0% in 2003 to peak of 16.9% in 2017).

CONCLUSIONS

Opioid prescribing practices varied across different populations of insured individuals during the past 17 years. The most substantial changes in opioid prescriptions over time have occurred in MDCD, with reductions in use across multiple metrics.

Leveraging immersive technology to expand access to opioid overdose reversal training in community settings: Results from a randomized controlled equivalence trial

BACKGROUND

Immersive video (e.g. virtual reality) poses a promising and engaging alternative to standard in-person trainings and can potentially increase access to evidence-based opioid overdose prevention programs (OOPPs). Therefore, the objective of this equivalence study was to test whether the immersive video OOPP was equivalent to a standard in-person OOPP for changes in opioid overdose knowledge and attitudes.

METHODS

A team of nurses and communication researchers developed a 9-minute immersive video OOPP. To test whether this immersive video OOPP (treatment) demonstrated equivalent gains in opioid overdose response knowledge and attitudes as in-person OOPPs (standard of care control), researchers deployed a two-day field experiment in Philadelphia, Pennsylvania, USA. In this equivalence trial, 9 libraries were randomly assigned to offer treatment or control OOPP to community members attending naloxone giveaway events. In this equivalence design, a difference between treatment and control groups pre- to post-training scores within -1.0 to 1.0 supports equivalence between the trainings.

RESULTS

Results demonstrate participants (N = 94) exposed to the immersive video OOPP had equivalent improvements on posttest knowledge (β=-0.18, p = .61) and more favorable attitudes about responding to an opioid overdose (β=0.26, p = .02) than those exposed to the standard OOPP. However, these minor differences in knowledge and attitudes were within the equivalence interval indicating that the immersive video OOPP remained equivalently effective for community members.

CONCLUSIONS

Community partnerships, like those between public health departments and libraries, can provide opportunities for deploying novel immersive video OOPP that, alongside standard offerings, can strengthen community response to the opioid crisis.

Feasibility and acceptability of take-home naloxone for people released from prison in New South Wales, Australia

INTRODUCTION AND AIMS

To assess the feasibility and acceptability of a take-home naloxone program for people with a history of opioid use released from prison in New South Wales, Australia.

DESIGN AND METHODS

Cross-sectional interviews with people with a history of opioid use who were recently released from prison (n = 105), and semi-structured interviews with key clinical and operational staff of Justice Health and Forensic Mental Health Network and Corrective Services NSW (n = 9).

RESULTS

Among people with a history of opioid use who had recently left prison, there was very high awareness of the elevated risk of overdose following release from prison (95%) and the potential for naloxone to reverse an opioid overdose (97%). Participants considered that their personal risk of overdose was low, despite ongoing opioid use being common. Participants were largely supportive of take-home naloxone, but the majority (83%) stated that proactively obtaining naloxone would be a low priority for them following release. Key informants were supportive of introducing naloxone training and supply and identified barriers to implementation, including adequate resourcing, identifying the population for training, and developing an appropriate model of training and implementation.

DISCUSSION AND CONCLUSION

There was widespread support for naloxone training in custody and distribution at release among people recently released from prison and key stakeholders in health-care provision and prisons administration. As proactively accessing naloxone is a low priority for patients, naloxone supply at release may be more effective than programs that refer releasees to local pharmacies, but developing a sustainable supply model requires consideration of several barriers.

A History of Prescription Drug Monitoring Programs in the United States: Political Appeal and Public Health Efficacy

Prescription drug monitoring programs (PDMPs) have become a widely embraced policy to address the US opioid crisis. Despite mixed scientific evidence on their effectiveness at improving health and reducing overdose deaths, 49 states and Washington, DC have adopted PDMPs, and they have received strong bipartisan legislative support. This article explores the history of PDMPs, tracking their evolution from paper-based administrative databases in the early 1900s to modern-day electronic systems that intervene at the point of care. We focus on two questions: how did PDMPs become so widely adopted in the United States, and how did they gain popularity as an intervention in the contemporary opioid crisis? Through this historical approach, we evaluate what PDMPs reflect about national drug policy and broader cultural understandings of substance use disorder in the United States today. (Am J Public Health. 2020;110:1191-1197. 10.2105/AJPH.2020.305696).

How I treat pain in hematologic malignancies safely with opioid therapy

The field of malignant hematology has experienced extraordinary advancements with survival rates doubling for many disorders. As a result, many life-threatening conditions have since evolved into chronic medical ailments. Paralleling these advancements have been increasing rates of complex hematologic pain syndromes, present in up to 60% of patients with malignancy who are receiving active treatment and up to 33% of patients during survivorship. Opioids remain the practice cornerstone to managing malignancy-associated pain. Prevention and management of opioid-related complications have received significant national attention over the past decade, and emerging data suggest that patients with cancer are at equal if not higher risk of opioid-related complications when compared with patients without malignancy. Numerous tools and procedural practice guides are available to help facilitate safe prescribing. The recent development of cancer-specific resources directing algorithmic use of validated pain screening tools, prescription drug monitoring programs, urine drug screens, opioid use disorder risk screening instruments, and controlled substance agreements have further strengthened the framework for safe prescribing. This article, which integrates federal and organizational guidelines with known risk factors for cancer patients, offers a case-based discussion for reviewing safe opioid prescribing practices in the hematology setting.

Racial/Ethnic Differences in the Medical Treatment of Opioid Use Disorders Within the VA Healthcare System Following Non-Fatal Opioid Overdose

BACKGROUND

After non-fatal opioid overdoses, opioid prescribing patterns are often unchanged and the use of medications for opioid use disorder (MOUDs) remains low. Whether such prescribing differs by race/ethnicity remains unknown.

OBJECTIVE

To assess the association of race/ethnicity with the prescribing of opioids and MOUDs after a non-fatal opioid overdose.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients prescribed ≥ 1 opioid from July 1, 2010, to September 30, 2015, with a non-fatal opioid overdose in the Veterans Health Administration (VA).

MAIN MEASURES

Primary outcomes were the proportion of patients prescribed: (1) any opioid during the 30 days before and after overdose and (2) MOUDs within 30 days after overdose by race and ethnicity. We conducted difference-in-difference analyses using multivariable regression to assess whether the change in opioid prescribing from before to after overdose differed by race/ethnicity. We also used multivariable regression to test whether MOUD prescribing after overdose differed by race/ethnicity.

KEY RESULTS

Among 16,210 patients with a non-fatal opioid overdose (81.2% were white, 14.3% black, and 4.5% Hispanic), 10,745 (66.3%) patients received an opioid prescription (67.1% white, 61.7% black, and 65.9% Hispanic; p < 0.01) before overdose. After overdose, the frequency of receiving opioids was reduced by 18.3, 16.4, and 20.6 percentage points in whites, blacks, and Hispanics, respectively, with no significant difference-in-difference in opioid prescribing by race/ethnicity (p = 0.23). After overdose, 526 (3.2%) patients received MOUDs (2.9% white, 4.6% black, and 5.5% Hispanic; p < 0.01). Blacks (adjusted OR (aOR) 1.6; 95% CI 1.2, 1.9) and Hispanics (aOR 1.8; 95% CI 1.2, 2.6) had significantly larger odds of receiving MOUDs than white patients.

CONCLUSIONS

In a national cohort of patients with non-fatal opioid overdose in VA, there were no racial/ethnic differences in changes in opioid prescribing after overdose. Although blacks and Hispanics were more likely than white patients to receive MOUDs in the 30 days after overdose, less than 4% of all groups received such therapy.

Opioids: Pharmacology, Physiology, and Clinical Implications in Pain Medicine

Opioid receptors and opioid agonists are widespread throughout nature. Endogenous opioids mediate complex functions in animals and in humans. The opioid system in humans plays a central role in pain control and is a key mediator of hedonic homeostasis, mood, and well-being. This system also regulates responses to stress and several peripheral physiologic functions, including respiratory, gastrointestinal, endocrine, and immune systems. This article provides an overview of the basic physiology of opioids, reviews opioid pharmacology, and attempts to address several issues of current importance in the management of patients with established long-term opioid therapy.

Optimism and opioid misuse among justice-involved children

AIM

Adolescents in the criminal justice system, called justice-involved children (JIC), are particularly vulnerable in the modern opioid misuse (OM) epidemic. After release, relapse and overdose occur at higher rates than the general population. The current study assesses optimism and likelihood of P30D consumption of non-prescription or illicit opioids among JIC.

METHODS

The study examines a sample of 79,960 JIC from the Florida Department of Juvenile Justice. Multivariate logistic regression was employed, controlling for gender, race, family income, age, history of mental problems, history of depression, and county of residence.

RESULTS

JIC who reported very low optimism on the final screen had over 8 times the odds of meeting criteria for P30D OM compared to those with high optimism while adjusting for covariates.

CONCLUSIONS

Further research is needed to understand the potential for optimism to serve as a protective factor. Optimism can be developed, and therefore can possibly be incorporated to design novel interventions or integrated into empirically validated treatment programs to precipitate uptake.

The Opioid Epidemic: Challenge to Military Medicine and National Security

Introduction

We examine the current status of the military relevance of opioids, their use and misuse in military and veteran populations, the national security consequences of opioid use in our military age population, public health implications, and military, veteran, and government solutions for opioid addiction.

Materials and Methods

A literature search of recent published research, federal government, and related open source materials was conducted using PubMed, Google, and Google Scholar, and all materials retrieved were manually identified, screened, and evaluated for inclusion. A modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach was used for the selection of relevant articles. Heath policy literature and relevant demographic information published within the last 5 years was also included to provide current information and search for solutions to address the escalating national opioid crisis.

Results

Synthetic opioids are used for pain and trauma management, not readily substituted, and have exceptionally high addiction potential. Combat wounded veterans have greater potential for opioid misuse than civilian populations. Assessment, management, and treatment of opioid use in this population are essential. Veterans receiving synthetic opioids have been noted to have multiple overdose risk factors. Opioids are readily available nationally as “street drugs” and also in the form of fentanyl-contaminated heroin. The opioid crisis affects the military age population and the top states for military enlistments. Younger age males with lower education and income are at significant risk for opioid use disorder. Recently increased drug overdose deaths contribute to an increased U.S. mortality rate with a commensurate decline in life expectancy at birth. Opioid abuse contributes to increased incidence of infectious disease. Behavioral health programs directed at military and veterans to identify risk factors for opioid misuse have been introduced. Prescription drug monitoring initiatives continue for these populations with increased information exchanged between military and civilian healthcare. Lifesaving interventions for opioid addiction include methadone maintenance and fentanyl test strip accessibility. Newly implemented federal funding healthcare initiatives to the states are now directed at opioid use prevention and enhanced surveillance.

Conclusions

Given increasing rates of opioid addiction and death, viable solutions are universally needed. Successful intervention measures should be widely shared between military, veteran, and civilian healthcare and public health communities. Increased collaboration between these groups could inculcate successful programs to prevent and decrease opioid use. Results received from recent military and veterans’ programs for prescription and electronic medical record (EMR) monitoring and data sharing may also prove useful for civilian healthcare providers and hospital systems. Future evaluations from ongoing federally funded programs to the states for addiction surveillance and intervention may help create measures to address the proliferation of opioid addiction with increased death rates. Anticipated results from these federal efforts should help inform opioid programs in military and veterans’ health systems.

Examining Factors Associated with Non-Fatal Overdose among People Who Inject Drugs in Rural Appalachia

Overdose (OD) deaths have continued to rise in the United States posing a critical public health challenge. Various factors have been associated with increased likelihood of OD, including history of injection drug use. Purpose: This study examined multi-level factors associated with non-fatal OD among current people who inject drugs (PWID) in Appalachian Kentucky. Methods: This cross-sectional study utilized data from 324 PWID recruited via Respondent-Driven Sampling techniques in three Appalachian counties. The analysis focused on correlates of overdose history among people who inject drugs (PWID). Findings: Approximately 36.7% of our sample reported having overdosed in their lifetime, with only 21.4% currently having access to a naloxone kit for OD reversal. Respondents who had injected fentanyl alone or in combination with another drug (OR = 4.26, 95% CI= 2.31,7.86) had 4 times higher odds of an OD than those who did not. Our study found those who injected buprenorphine as primary drug (OR = 0.29, 95% CI = 0.10,0.81) had lower odds of OD compared to those who injected heroin. Conclusions/Importance: Given an increase in OD prevalence among PWID in the U.S, and especially among people living in the Appalachian region of Kentucky, assessing factors associated with OD is critical in development of tailored public health interventions to address the disparate rates of non-fatal OD in this vulnerable population.

Between- and within-person associations between opioid overdose risk and depression, suicidal ideation, pain severity, and pain interference

BACKGROUND

To better understand overdose (OD) risk and develop tailored overdose risk interventions, we surveyed 234 opioid-using veterans residing in New York City, 2014-2017. Our aim was to better understand how predictors of OD may be associated with physical and mental health challenges, including pain severity and interference, depression and suicidal ideation over time.

METHODS

Veterans completed monthly assessments of the Overdose Risk Behavior Scale (ORBS), pain severity and interference, suicidal ideation, and depression for up to two years and were assessed an average of 14 times over 611 days. To estimate between-person and within-person associations between time-varying covariates and opioid risk behavior, mixed-effects regression was used on the 145-person subsample of veterans completing the baseline and at least three follow-up assessments.

RESULTS

The level of each time-varying covariate at the average of study time (between-person effect) was positively related to ORBS for pain severity and interference, suicidal ideation, and depression. Deviations from individuals' personal trajectories (within-person effect) were positively related to ORBS for pain severity and interference, suicidal ideation, and depression.

CONCLUSIONS

US military veterans endure physical and mental health challenges elevating risk for opioid-related overdose. When pain severity, pain interference, suicidal ideation and depression were higher than usual, opioid risk behavior was higher. Conversely, when these health issues were less of a problem than usual, opioid risk behavior was lower. Assessing the physical and mental health of opioid-using veterans over time may support the development and implementation of interventions to reduce behaviors that increase the likelihood of overdose.

Suicidal motivations reported by opioid overdose survivors: A cross-sectional study of adults with opioid use disorder

BACKGROUND

Prior studies in heroin use disorder reported low rates (10%) of suicidal intention with non-fatal opioid overdose but did not assess dimensional ratings of suicidal ideation. This study aims to quantify the frequency and intensity of ratings of desire to die and perceived overdose risk proximal to the most recent opioid overdose event among individuals admitted for opioid use disorder detoxification/stabilization.

METHODS

Cross-sectional study (June 2017-July 2018) assessing patterns of opioid use and variables related to overdose history was conducted in a not-for-profit psychiatric hospital. Adults (>18 years) with opioid use disorder were eligible and 120 of 122 participants completed all measures. Forty-one percent were women and 85% self-identified as white. Participants' perceptions of the likelihood of overdose and their suicidal motivations (defined as desire to die) prior to most recent opioid overdose was self-rated on a scale of 0 (no desire to die/no risk of death) to 10 (I definitely wanted to die/I definitely thought I would die).

RESULTS

Most (92%) surviving opioid overdose used heroin/fentanyl; over half reported some desire to die prior to their most recent overdose, with 36% reporting strong (>7/10) desire to die and 21% reporting 10/10 "I definitely wanted to die." Perceptions of overdose risk were also variable, with 30% reporting no (0/10) likelihood of overdose and 13% reporting a high (10/10) likelihood.

CONCLUSIONS

Suicidal motivation prior to opioid overdose is common and falls along a continuum of severity. Longitudinal studies are needed to determine if suicide prevention interventions may reduce opioid overdose in those at risk.

Military veterans' overdose risk behavior: Demographic and biopsychosocial influences

BACKGROUND

U.S. military veterans face many biopsychosocial (BPS) challenges post-service that may elevate risk for opioid-related overdose including physical pain, mental health concerns and social stressors. Some veterans use opioids to manage pain and cope with social readjustment. This study assessed associations between BPS factors and recent engagement in overdose risk behavior in a community sample of post-9/11 veterans who used opioids in New York City.

METHODS

Participants (n = 218) were recruited through convenience sampling and completed a baseline assessment including a validated Opioid Risk Behavior Scale (ORBS) that measured past-30-day engagement in 22 opioid-related overdose risk behaviors. Analyses examined associations between ORBS scores and hypothesized demographic, biological/physical, psychological and social predictors. Incident rate ratios estimated the expected relative difference in ORBS score associated with each predictor.

RESULTS

Participants reported an average of 4.72 overdose risk behaviors in the past 30 days. Significant independent predictors of higher ORBS score, after adjustment for demographics and current prescription medications, were past-30-day: depression symptoms; unsheltered or living in a homeless shelter (vs. private housing); history of mental health treatment; experiencing stressful life events; average pain severity; and pain interference.

CONCLUSION

Veterans face myriad BPS challenges and, while drug-related overdose risks are well understood, findings suggest that other factors-including mental health, pain and stressful life events-may also be associated with overdose risk among opioid-using veterans. The larger challenges veterans face should be considered in the context of BPS forms of pain management when tailoring and delivering overdose prevention interventions.

Rates, knowledge and risk factors of non-fatal opioid overdose among people who inject drugs in India: A community-based study

INTRODUCTION AND AIMS

Non-fatal opioid overdose (NFOO) predicts future fatal opioid overdose and is associated with significant morbidity. There is limited literature on the rates and risk factors for NFOO in people who inject drugs (PWID) from India. We aimed to study the rates of NFOO and documented risk factors for NFOO, as well as knowledge-level of NFOO among PWID from India.

DESIGN AND METHODS

Community-based, cross-sectional and observational study. We interviewed 104 adult male participants receiving HIV prevention services. Drug use patterns, rates of NFOO and opioid overdose risk factors, knowledge about opioid overdose and its management were assessed.

RESULTS

The mean age of the participants was 27.9 years. The most common opioid used for injecting was heroin followed by buprenorphine. About 45% (n = 47) participants had experienced an opioid overdose at least once in their lifetime. Around 25% (n = 26) participants had overdosed in the past year, while 21% (n = 22) participants had overdosed within the past 3 months. The majority had risk factors that could predispose them to NFOO. No participant was aware of the use of naloxone for opioid overdose.

DISCUSSION AND CONCLUSION

The rates of NFOO as well as risk factors for overdose among PWID from India are high, with poor knowledge on overdose management. There is urgent need for a program to prevent and manage opioid overdose among PWID in India.

Risk Factors for Drug Overdose in Young People: A Systematic Review of the Literature

Objectives: Drug overdose (OD) deaths have been increasing over the past 20 years. Although risk factors for drug OD have been identified in adult populations, less is known about risk factors for OD in young people. The aim of this review is to systematically examine the literature to identify risk factors for drug OD specific to young people, including adolescents and young adults. Methods: Our initial PubMed search identified 4001 articles. Included were cross-sectional and longitudinal cohort studies published in English that compared young people who experienced a drug OD to those who did not. Review articles, meta-analyses, case-reports, editorials, epidemiological studies, and qualitative studies were excluded. Two investigators reviewed the full texts of all relevant articles and extracted data on sample demographics, prevalence of OD, and correlates associated with OD. Results: Twelve relevant studies were identified reflective of a sample of 5020 unique individuals with an age range of 14-30 years, and a mean age range of 20.2-26 years. The lifetime prevalence of OD in these young people ranged from 24% to 48%. Substance use characteristics most often associated with OD included injection drug, opioid, and tranquilizer use. Polysubstance use was also found to be strongly associated with OD in three studies. Other replicated risk factors for OD in young people included histories of psychopathology, incarceration, unstable housing, and witnessing an OD. Conclusion: Opioid, tranquilizer, and injection drug use have been identified as risk factors for OD in both younger and older adult populations. Risk factors that emerged as noteworthy predictors of OD in young people specifically include polysubstance use, psychiatric comorbidity, unstable housing, and witnessing an OD. There remains a paucity of literature on drug OD risk factors in young people, with little information regarding medical and treatment history risk factors.

Opioid Prescription Patterns and Risk Factors Associated With Opioid Use in the Netherlands

IMPORTANCE

An increase in opioid prescription has been observed in the Netherlands. It is vital to understand this increase and to identify risk factors for opioid prescription to ensure that health interventions remain appropriately targeted.

OBJECTIVES

To determine the prevalence of opioid prescriptions and adverse events associated with opioids, and to identify risk factors associated with opioid prescription in the Dutch population.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used national statistics from the Netherlands from January 1, 2013, to December 31, 2017, including the full Dutch population of 16 779 575 people in 2013 and 17 081 507 people in 2017. Data from the Dutch Health Monitor surveys of 2012 and 2016 were also included. Databases were anonymized prior to analysis. All analyses were performed between December 2018 and February 2019.

EXPOSURE

Opioid prescription.

MAIN OUTCOMES AND MEASURES

The main outcomes were the dynamics of opioid prescriptions, hospital admissions for opioid overdose, and opioid overdose mortalities. The secondary outcome was risk factors associated with opioid prescription.

RESULTS

In 2013, 814 211 individuals (4.9% of the total population) received an opioid prescription. In 2017, 1 027 019 individuals (6.0% of the total population) received at least 1 opioid prescription (mean [SD] age, 59.3 [18.5] years; 613 203 [59.7%] women). The rate of hospital admissions for opioid overdose was 9.2 per 100 000 inhabitants in 2013 and 13.1 per 100 000 inhabitants in 2017 (relative risk, 1.43 [95% CI, 1.34-1.52]). Similarly, an increased risk of opioid overdose death was observed, from 0.83 per 100 000 inhabitants in 2013 to 1.2 per 100 000 inhabitants in 2017 (relative risk, 1.49 [95% CI, 1.20-1.85]). Based on data from the 2012 Dutch Health Monitor survey, risk factors associated with opioid prescription included being older than 65 years (odds ratio [OR], 4.20 [95% CI, 3.98-4.43]), having only a primary school education (OR, 3.62 [95% CI, 3.46-3.77]), being widowed (OR, 3.30 [95% CI, 3.13-3.49]), reporting always feeling symptoms of depression (OR, 3.77 [95% CI, 3.41-4.18]), and reporting poor or very poor physical health (OR, 10.40 [95% CI, 10.01-10.81]). Self-reported back pain (OR, 4.34 [95% CI, 4.23-4.46]) and rheumatoid arthritis or fibromyalgia (OR, 3.77 [95% CI, 3.65-3.90]) were also associated with opioid prescription. However, unemployment (OR, 1.05 [95% CI, 0.96-1.13]) was not associated with opioid prescription, and alcohol use disorder (OR, 0.76 [95% CI, 0.73-0.80]) was negatively associated with opioid prescription.

CONCLUSIONS AND RELEVANCE

This study found that opioid prescriptions have increased in the Netherlands. Although the risk of adverse events is still relatively low, there is an urgent need to review pain management to prevent a further increase in opioid prescription.

The Needle and the Damage Done: Framing the Heroin Epidemic in the Cincinnati Enquirer

This case study focuses on the Cincinnati Enquirer's coverage of the heroin epidemic. The Enquirer started the first heroin beat in January 2016, and it could serve as a model for other news organizations. Reporters used combinations of episodic, thematic, public health, and crime and law enforcement frames in their coverage. These news frames are discussed in terms of how individualism-collectivism, geographic location, available resources, and social determinants inform journalistic and societal discussions of the heroin epidemic in terms of solutions instead of responsibility or blame.

Prescribing of Opioids and Benzodiazepines Among Patients With History of Overdose

OBJECTIVES

Addiction and overdose related to prescription drugs continues to be a leading cause of morbidity and mortality in the United States. We aimed to characterize the prescribing of opioids and benzodiazepines to patients who had previously presented with an opioid or benzodiazepine overdose.

METHODS

This was a retrospective chart review of patients who were prescribed an opioid or benzodiazepine in a 1-month time-period in 2015 (May) and had a previous presentation for opioid or benzodiazepine overdose at a large healthcare system.

RESULTS

We identified 60,129 prescribing encounters for opioids and/or benzodiazepines, 543 of which involved a patient with a previous opioid or benzodiazepine overdose. There were 404 unique patients in this cohort, with 97 having more than 1 visit including a prescription opioid and/or benzodiazepine. A majority of prescriptions (54.1%) were to patients with an overdose within the 2 years of the documented prescribing encounter. Prescribing in the outpatient clinical setting represented half (49.9%) of encounters, whereas emergency department prescribing was responsible for nearly a third (31.5%).

CONCLUSIONS

In conclusion, prescribing of opioids and benzodiazepines occurs across multiple locations in a large health care system to patients with a previous overdose. Risk factors, such as previous overdose should be highlighted through clinical decision support tools in the medical record to help prescribers identify patients at higher risk and to mobilize resources for this patient population. Prescribers need further education on factors that place their patients at risk for opioid use disorder and on alternative therapies to opioids and benzodiazepines.

Chronic Pain, TBI, and PTSD in Military Veterans: A Link to Suicidal Ideation and Violent Impulses?

The polytrauma clinical triad refers to the co-occurrence of chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD). Despite research implicating dyadic relationships between these conditions and adverse outcomes, scant research has examined the polytrauma clinical triad's relation to suicide or violence. The present cross-sectional study was designed to examine whether this complex clinical presentation increases risk of suicidal ideation and violent impulses after accounting for other established risk factors. Veterans who served in the military since September 11, 2001 (N = 667) who reported chronic pain completed an interview and self-report battery. Bivariate analyses showed that suicidal ideation and violent impulses both correlated with PTSD, TBI+PTSD, pain intensity and interference, drug abuse, and major depressive disorder (MDD). Multiple regression analyses showed that: 1) race, chronic pain with PTSD, alcohol abuse, and MDD significantly predicted suicidal ideation, 2) pain interference, chronic pain with TBI, chronic pain with PTSD, chronic pain with TBI+PTSD, drug abuse, and MDD significantly predicted violent impulses, and 3) pain interference was a more critical predictor of suicidal and violent ideation than pain intensity. Implications for risk assessment and treatment are discussed.

PERSPECTIVE

This article presents results from a study examining predictors of suicide and violence risk among a sample of post-9/11 U.S. Veterans with chronic pain. Health care professionals should assess for pain interference, TBI, PTSD, depression, and alcohol/drug abuse when conducting risk assessments with this population.

A retrospective chart review of opioid represcribing following nonfatal overdose at a Veterans Affairs hospital

INTRODUCTION

Opioid-related overdoses have risen despite extensive media coverage and apparent awareness of this public health crisis. Emergency department visits related to opioid use nearly tripled from 2004 to 2011. Patients with mental illness are more likely to be prescribed opioids and have higher rates of overdose. This retrospective chart review sought to determine if opioid represcribing occurred after patients were treated for a nonfatal opioid overdose (NFO) at a Veterans Affairs hospital.

METHODS

Patients who experienced an NFO between 2009 and 2013 were included and charts reviewed until January 1, 2016. Review of the electronic medical record (EMR) was performed to determine if and when opioids were again prescribed after NFO.

RESULTS

Fifty-six veterans met the inclusion criteria. A new opioid prescription was issued to 82% of patients within 3 months following the index NFO date. The average daily morphine equivalent dose prescribed before (122 mg) and after (120 mg) NFO did not differ. A subsequent opioid overdose event occurred in 25% of patients, and there was 1 fatal event. Only 1 patient had medication overdose on the problem list of their EMR.

DISCUSSION

Despite experiencing NFO, veterans continued to be prescribed opioids without significant changes in the drug or dose; some experienced repeated overdose events, possibly due to poor communication and documentation of NFO. Pharmacists can play a key role in clinical interventions and education of patients and prescribers.

Opioid overdose education and naloxone distribution: Development of the Veterans Health Administration's national program

OBJECTIVES

To prevent opioid-related mortality, the Veterans Health Administration (VHA) developed a national Opioid Overdose Education and Naloxone Distribution (OEND) program.

SETTING

VHA's OEND program sought national implementation of OEND across all medical facilities (n = 142).

PRACTICE DESCRIPTION

This paper describes VHA's efforts to facilitate nationwide health care system-based OEND implementation, including the critical roles of VHA's national pharmacy services and academic detailing services.

PRACTICE INNOVATION

VHA is the first large health care system in the United States to implement OEND nationwide. Launching the national program required VHA to translate a primarily community-based public health approach to OEND into a health care system-based approach that distributed naloxone to patients with opioid use disorders as well as to patients prescribed opioid analgesics. Key innovations included developing steps to implement OEND, pharmacy developing standard naloxone rescue kits, adding those kits to the VHA National Formulary, centralizing kit distribution, developing clinical guidance for issuing naloxone kits, and supporting OEND as a focal campaign of academic detailing. Other innovations included the development of patient and provider education resources (e.g., brochures, videos, accredited training) and implementation and evaluation resources (e.g., technical assistance, clinical decision support tools).

EVALUATION

Clinical decision support tools that leverage VHA national data are available to clinical staff with appropriate permissions. These tools allow staff and leaders to evaluate OEND implementation and provide actionable next steps to help them identify patients who could benefit from OEND.

RESULTS

Through fiscal year 2016, VHA dispensed 45,178 naloxone prescriptions written by 5693 prescribers to 39,328 patients who were primarily prescribed opioids or had opioid use disorder. As of February 2, 2016, there were 172 spontaneously reported opioid overdose reversals with the use of VHA naloxone prescriptions.

CONCLUSION

VHA has successfully translated community-based OEND into health care system-based OEND targeting 2 patient populations. There is a tremendous amount that can be learned from VHA's experience implementing this novel health care innovation nationwide.

Literature Review of Research on Chronic Pain and Yoga in Military Populations

Background: Although yoga is increasingly being provided to active duty soldiers and veterans, studies with military populations are limited and effects on chronic pain are largely unknown. We reviewed the existing body of literature and provide recommendations for future research. Methods: We conducted a literature review of electronic databases (PubMed, PsychINFO, Web of Science, Science Citation Index Expanded, Social Sciences Citation Index, Conference Proceedings Citation Index-Science, and Conference Proceedings Citation Index-Social Science & Humanities). The studies were reviewed for characteristics such as mean age of participants, sample size, yoga type, and study design. Only peer-reviewed studies were included in the review. Results: The search yielded only six studies that examined pain as an outcome of yoga for military populations. With one exception, studies were with veteran populations. Only one study was conducted with Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) veterans. One study was a randomized controlled trial (RCT). Four of the five studies remaining used pre/post design, while the last study used a post-only design. Conclusions: Studies on the use of yoga to treat chronic pain in military populations are in their infancy. Methodological weaknesses include small sample sizes, a lack of studies with key groups (active duty, OEF/IEF veterans), and use of single group uncontrolled designs (pre/post; post only) for all but one study. Future research is needed to address these methodological limitations and build on this small body of literature.

Recent Overdose Experiences in a Community Sample of Military Veterans Who Use Opioids

Rising rates of overdose mortality underscore the importance of understanding and preventing overdose. We developed a seven-item scale for the assessment of nonfatal opioid-related overdose experiences, adding items on others' perceptions of whether the participant had overdosed and whether an intervention was attempted to frequently used criteria. We administered the scale to 240 primarily male and minority veterans, recruited using venue-based and chain-referral sampling, who separated from the military post-9/11 and reported current opioid use. The items were internally consistent, and correlated well with overdose risk behaviors (r = .13-.45). The new scale detected overdose events in a significantly higher proportion of participants (36.5%) than that using either self-report criterion (18.2%) or difficulty breathing and losing consciousness criteria (23.8%). These experiences or perceptions should be investigated to inform and better tailor the development of more effective overdose prevention and response programs.

Does trauma exposure predict prescription drug problems beyond the contribution of post-traumatic stress disorder and depression? An analysis of the Mind Your Heart cohort study

It is not clear from prior studies whether trauma exposure predicts substance use problems independent of psychiatric comorbidities. Most prior studies were cross-sectional in nature, and none focused on prescription drug problems. To address this gap in the literature, the current article is a secondary analysis of veterans from the Mind Your Heart prospective cohort study. The primary research question is whether trauma exposure predicts prescription drug problems even after controlling for major psychiatric symptoms, such as post-traumatic stress disorder and depression. Multinomial logistic regression was used to assess whether the 10-item lifetime Brief Trauma Questionnaire (e.g., serious car accidents, war traumas, life-threatening illness, natural disasters, physical, or sexual abuse) predicts prescription drug problems as determined by a self-report categorical question (three answer choices) over a 4-year follow-up time period (n = 661 [100%] at year 1; 83.4% at year 2; 85.9% at year 3; and 78.2% at year 4). Trauma exposure was positively associated with prescription drug problems in unadjusted and age-, sex-, and race-adjusted analyses at follow-up. After accounting for post-traumatic stress disorder (PTSD Checklist-17 Civilian Version) and depression (Patient Health Questionnaire-9) symptoms, trauma exposure was no longer associated with prescription drug problems at all time points (relative risk ratios range 0.91-1.47). These results were robust to different missing data strategies. Trauma exposure was not associated with prescription drug problems over a 4-year follow-up in a prospective cohort study of veterans. Future directions include detailed measures of prescription drug problems and recruitment from community sites.