Prescription opioid dispensing and prescription opioid poisoning: Population data from Victoria, Australia 2006 to 2013

Opioid poisoning in Newcastle over the last three decades: From heroin to prescription opioids

OBJECTIVE

Opioid-related harm has risen in recent decades, but limited research describes the clinical burden of opioid poisoning to Australian EDs. We aimed to investigate hospital presentations with opioid poisoning over three decades.

METHODS

This is an observational series of prospectively collected data investigating presentations of opioid poisoning to an ED in Newcastle (1990-2021). Type of opioid, naloxone administration, intubation, intensive care unit (ICU) admission, length of stay and death were extracted from the unit's database.

RESULTS

There were 4492 presentations in 3574 patients (median age 36, 57.7% female), increasing from an average of 93 presentations annually in the first decade to 199 in the third decade. Deliberate self-poisonings accounted for 3694 presentations (82.2%). Heroin dominated the 1990s, peaking in 1999 before decreasing. Prescription opioids then rose, with codeine (usually in paracetamol combination) predominating until 2018, after which oxycodone presentations exceeded them. Methadone consistently increased from six presentations annually in the first decade to 16 in the last decade. Naloxone was administered in 990 (22.0%) presentations and 266 (5.9%) were intubated, most frequently following methadone and heroin exposures. ICU admissions increased from 5% in 1990 to 16% in 2021. Codeine exposures resulted in less severe effects, whereas methadone had more severe effects overall. The median length of stay was 17 h (interquartile range 9-27 h). There were 28 deaths (0.6%).

CONCLUSION

Opioid presentations increased in number and severity over three decades as the type of opioid changed. Oxycodone is currently the main opioid of concern. Methadone poisoning was the most severe.

Peri-OPerative Pain Management, Education & De-escalation (POPPMED), a novel anaesthesiologist-led program, significantly reduces acute and long-term postoperative opioid requirements: a retrospective cohort study

Supplemental Digital Content is Available in the Text.

Perioperative pain management, education, and de-escalation, a single anaesthesiologist-led perioperative service, managed older, high-risk opioid-tolerant patients to achieve sustained oral morphine equivalent daily dosage reductions safely after major orthopaedic, abdominal, and neurosurgery.

Introduction:

The opioid tolerant patient requiring surgery is highly likely to be discharged on high Oral Morphine Equivalent Daily Dosages (OMEDDs), with concomitant risk of increased morbidity and mortality.

Objectives:

We proposed that a single anaesthesiologist-led POPPMED (Peri-Operative Pain Management, Education & De-escalation) service could reduce both short and long-term postoperative patient OMEDDs.

Methods:

From April 2017, our anaesthesiologist-led POPPMED service, engaged 102 perioperative patients treated with >50mg preoperative OMEDDs. We utilized behavioural interventions; acute opioid reduction and/ or rotation; and regional, multimodal and ketamine analgesia to achieve lowest possible hospital discharge and long term OMEDDs.

Results:

Patients' preoperative OMEDDs were [median (IQR): 115mg (114mg)], and were representative of an older [age 62 (15) years], high-risk [89% ASA status 3 or 4] patient population. 46% of patients received an acute opioid rotation; 70% received ketamine infusions; and 44% regional analgesia. OMEDDs on discharge [-25mg (82mg), p=0.003] and at 6-12 months [-55mg (105mg ), p<0.0001] were significantly reduced; 84% and 87% of patients achieved OMEDD reduction on discharge and at 6-12 months. Patients with >90mg preoperative OMEDDs achieved greater reductions [discharge: 71% of patients, -52 mg (118 mg) p<0.0001; 6-12 months: 90% of patients, -90mg (115mg), p<0.0001]. On comparison with a pre-POPPMED surgical cohort, Postoperative Day 1-3 11-point Numerical Rating Scale (NRS-11) area under the curve (AUC) measurements at rest and on movement were not significantly different (largest NRS-11:hours AUC difference [median(IQR)] 22 [13], p= 0.24). Hospital length of stay was variably increased.

Conclusions:

POPPMED achieved sustained OMEDD reductions safely in an older, high-risk opioid tolerant population, with analgesia comparable to a non-POPPMED cohort, and surgery specific effects on length of stay.

An overview of the use and misuse/abuse of opioid analgesics in different world regions and future perspectives

Opioids are an important therapeutic option for severe resistant chronic pain but, in the absence of proper oversight, their use has risks. The level of prescription opioid misuse/abuse differs among countries, due to differences in healthcare systems and pain management approaches. However, evaluating the true dimension of prescription opioid misuse/abuse is complicated by statistical reporting which often does not differentiate between prescription and illicit opioid use, or between prescription opioid use by patients and nonpatients, highlighting a need for greater uniformity. Parallel efforts to educate patients and the general public about opioid risks, facilitate appropriate analgesic prescribing and identify alternative formulations or options to use instead of or with opioids, may contribute to optimizing prescription opioid use for pain management.

Longitudinal Study on Deterrent Effect of Drug-Induced Homicide Law on Opioid-Related Mortality Across 92 Counties and the District of Columbia in the U.S

In response to the opioid epidemic in the United States, the federal and state governments have initiated various public health responses to mitigate the problem. Among others, Drug-Induced Homicide Laws (DIHL) have been introduced to disrupt opioid supply by imposing unconventionally punitive sanctions against sales and distribution. The purpose of this study was to examine whether DIHL had an impact on opioid-related deaths, while controlling for other laws and socioeconomic indices. A dynamic panel model was used with cases from 92 counties across 10 states and the District of Columbia between 2013 and 2018. The findings suggest that DIHL implementation has curtailed the rate of opioid mortality. Supply-interruption approaches may have merits and should be further evaluated.

Characteristics of oxycodone-related ambulance attendances: analysis of temporal trends and the effect of reformulation in Victoria, Australia from 2013 to 2018

BACKGROUND AND AIMS

In Australia, oxycodone has been associated with increasing rates of harm over time, despite reduced use, reformulation to a tamper-resistant form and in contrast to most prescription opioids. We explored characteristics of oxycodone-related ambulance attendances to understand whether presentation characteristics could explain increasing oxycodone harm.

DESIGN

Retrospective study of coded ambulance patient care records related to extramedical oxycodone use, January 2013 to September 2018.

SETTING

Victoria, Australia.

CASES

A total of 2788 oxycodone-related ambulance attendances.

MEASUREMENTS

Primary outcomes were temporal changes in characteristics of oxycodone presentations over time (from 2013 to 2018) and following reformulation. Covariates include demographic characteristics, presentation severity, mental health, substance use and poisoning intent.

FINDINGS

Average age was 41.3 (± 16.4) years with females comprising 56.4% of attendances (n = 2788). The proportion of females in oxycodone-related attendances increased over time [an average increase in the odds ratios of 5% per year (OR) = 1.05, 95% confidence interval (CI) = 1.01-1.10]. Other temporal trends included a reduced likelihood of naloxone administration (OR = 0.92, 95% CI = 0.85-1.00), heroin involvement (OR = 0.81, 95% CI = 0.66-0.99), comorbid mental health symptoms (OR = 0.87, 95% CI = 0.82-0.92) and unknown intent poisoning (OR = 0.91, 95% CI = 0.85-0.96); and a greater risk of alcohol involvement (OR = 1.06, 95% CI = 1.01-1.11), non-opioid extramedical pharmaceutical use (OR = 1.05, 95% CI = 1.01-1.10), comorbid suicidal thoughts or behaviours (OR = 1.10, 95% CI = 1.05-1.15) and past history of psychiatric issues (OR = 1.22, 95% CI = 1.16-1.27). Interrupted time-series analysis showed that reformulation was associated with an immediate effect on sex, severity, accidental poisoning and unknown intent poisoning, although these were not sustained over time. Alcohol involvement in the attendance (OR = 1.43, 95% CI = 1.17-1.74, i.e. an average increase in the odds of 43% per year), Glasgow Coma Scale (OR = 1.28, 95%CI 1.04 - 1.57), a previous history of psychiatric issues (OR = 0.80, 95% CI = 0.70-0.92, i.e. an average decrease in the odds of 20% per year, heroin involvement (OR = 0.22, 95% CI = 0.05 - 0.98) and illicit drug use (OR = 0.45, 95% CI = 0.23 - 0.87) showed statistically significant relative changes following the reformulation.

CONCLUSIONS

The characteristics of oxycodone presentations in Australian ambulances attendances appear to be changing over time, including more female presentations; increasing alcohol use, extramedical use of non-opioid pharmaceuticals and suicidal thoughts or behaviours and decreasing heroin and illicit drug involvement.

Cannabis and its therapeutic value in the ageing population: Attitudes of health-care providers

OBJECTIVE(S)

To explore the attitudes of health-care providers and the perceived barriers and facilitators regarding the use of cannabis-containing medicines (CCMs) in older patients.

METHODS

Semi-structured interviews with eleven health-care providers in rural New South Wales (NSW). A thematic analysis was performed.

RESULTS

Themes and recommendations include attitudes towards CCMs for therapeutic purposes, their perceived uses, side effects, barriers to use and prescription (stigma, regulation, access and driving), difficulties encountered with the Special Access Scheme (SAS) and the need for ongoing research and education. An ecological framework demonstrated the complex interactions between patients and health-care providers and their social, community and political environment.

CONCLUSION

Providers' attitudes towards CCM use in older patients are generally positive; however, there is a need for further high-quality evidence on efficacy and safety, alongside improved CCM education and training, to reduce barriers to their implementation. Barriers to prescription and access continue to evolve on personal, organisational and systemic levels.

The Pain Nurse Practitioner and Pain Nurse's Role and Views on Opioid Management in Australia: A National Questionnaire Survey

BACKGROUND

The demand for access to Australian pain management services is growing. The dual crisis of opioid misuse and chronic pain, means pain nurses and nurse practitioners (NPs) have a unique opportunity to meet clinical demands and advance their scope of practice.

AIMS

To understand the role of pain nurses and pain NPs across Australia and explore their perceptions of current opioid management.

DESIGN

This cross-sectional study involved pain nurses or pain NPs working in Australia who are a members of a pain interest group, which are subgroups of The Australian Pain Society.

METHODS

This cross-sectional study involved pain nurses or pain NPs working in Australia who are a members of a pain interest group, which are subgroups of The Australian Pain Society. Survey respondents were contacted via the eight nursing Pain Interest Groups in Australia.

RESULTS

Acute pain management (92.7%) and chronic pain management (80.5%) were the primary services provided, with pain specialty nurses providing nurse education (100.0%), patient support, clinician education, and policy development. Pain nurses believed there was an over prescription of opioid analgesics in Australia (97.6%), with NPs able to reduce opioid medication doses as part of opioid harm mitigation.

CONCLUSIONS

Pain nurses have a breadth of knowledge and experience highlight they can contribute to opioid management in the future, with the support of policy and organizations.

Impact of a policy change restricting access to codeine on prescription opioid-related emergency department presentations: an interrupted time series analysis

ABSTRACT

Codeine is one of the most commonly used opioid analgesics. Significant codeine-related morbidity and mortality prompted regulatory responses, with the up-scheduling of codeine combination analgesics to prescription-only medicines implemented in Australia in February 2018. This study investigated the impact of codeine up-scheduling on the number of codeine and other (noncodeine) prescription opioid-related emergency department (ED) presentations in a large metropolitan tertiary hospital. Clinical features of these presentations were also examined. Interrupted time series analyses assessed monthly changes in ED presentations from June 2016 to November 2019. In the month immediately after up-scheduling, there was a significant reduction of 3.97 codeine-related presentations (B = -3.97, P = 0.022), indicating a 29.66% level change, followed by a significant change in trend to fewer monthly codeine-related presentations (B = -0.38, P = 0.005). Noncodeine prescription opioid-related (B = -1.90, P = 0.446) and ED presentations overall (B = -118.04, P = 0.140) remained unchanged immediately post-up-scheduling, with a significant change in trend from upward to downward for noncodeine (B = -0.76; P = 0.002) and ED presentations overall (B = -19.34, P = 0.022). A significant reduction of 4.58 (B = -4.58, P = 0.009) in codeine presentations involving subsequent hospital admission immediately post-up-scheduling was found; but no immediate reduction in codeine-related suicide-related overdoses, length of inpatient stay, or re-presentations (P > 0.0125; adjusted for multiple comparisons). Restricting supply of codeine to prescription-only may have resulted in less harmful codeine-related use in the community, without a corresponding immediate decrease in other opioid-related harms.

Trends in opioid prescribing in Australia: a systematic review

Objective This review systematically identified studies that estimated the prevalence of prescription opioid use in Australia, assessed the prevalence estimates for bias and identified areas for future research. Methods Literature published after 2000 containing a potentially representative estimate of prescription opioid use in adults, in the community setting, in Australia was included in this review. Studies that solely assessed opioid replacement, illicit opioid usage or acute hospital in-patient use were excluded. Databases searched included PubMed, EMBASE, Web of Science and the grey literature. Results The search identified 2253 peer-reviewed publications, with 34 requiring full-text review. Of these, 20 were included in the final qualitative analysis, in addition to four publications from the grey literature. Most studies included analysed prescription claims data for medicines dispensed via Australia's national medicines subsidy scheme (the Pharmaceutical Benefits Scheme). Although data sources were good quality, all prevalence estimates were at least at moderate risk of bias, predominantly due to incompleteness of data or potential confounding. Included publications demonstrated a significant rise in opioid use up to 2017 (including a 15-fold increase in prescriptions dispensed over the 20 years to 2015), predominantly driven by a sharp rise in oxycodone use. Although opioid prescription numbers continue to escalate, usage, as measured by oral morphine equivalent per capita, may have plateaued since 2014. Codeine remains the most prevalently obtained opioid, followed by oxycodone and tramadol. There was a substantial delay (median 30 months; interquartile range 20-37 months) to publication of opioid usage data from time of availability. Conclusions Australia has experienced a marked increase in opioid prescribing since the 1990s. Current published literature is restricted to incomplete, delayed and historical data, limiting the ability of clinicians and policy makers to intervene appropriately. What is known about the topic? Opioid prescriptions in Australia have continued to increase since the 1990s and may be mirroring the epidemic being seen in the US. What does this paper add? This paper systematically identifies all publications that have examined the prevalence of prescription opioid use in Australia since 2000, and only identified prevalence estimates that were at moderate or high risk of bias, and found significant delays to publication of these estimates. What are the implications for practitioners? Because published literature on the prevalence of prescription opioid consumption is restricted to incomplete, delayed and historical data, the ability of clinicians and policy makers to appropriately intervene to curb prescription opioid use is limited. A national policy of real-time monitoring and reporting of opioid prescribing may support improvements in practice.

Role of pharmacists in optimising opioid therapy for chronic non-malignant pain; A systematic review

BACKGROUND

Opioid optimisation is a global issue in Chronic Non-malignant Pain (CNMP) management.

OBJECTIVE

This systematic review aims to assess the effectiveness of interventions delivered by pharmacists in outpatient clinical settings, community pharmacies and primary care services in optimising opioid therapy for people with CNMP and to explore stakeholders' opinions about role of pharmacists in optimising opioid therapy.

METHODS

We conducted searches in PubMed, CINAHL, Psych Info, EMBASE, ISI Web of Science and Conference Proceedings and International Pharmaceutical Abstracts. All studies where pharmacists in outpatient clinical settings, community pharmacies and patient care services helped in optimisation of opioids in the treatment of CNMP as individuals or part of a team were included. Authors followed the 27-item PRISMA guidelines and the review was registered in PROSPERO. All authors were involved in screening and selection of studies and included studies between January 1990-June 2020. Studies not published in English language and participants with cancer pain were excluded. All the included studies were descriptively synthesized.

RESULTS

Fourteen studies were included in the final data synthesis of this review and the total number of participants in all studies was 1175. Interventions by pharmacists were successful in decreasing opioid dose in 4 studies and improved patient opioid safety in 5 studies. Stakeholders considered that the role of pharmacists in optimisation of opioid therapy for people with CNMP can be promising and should be further developed.

CONCLUSION

This systematic review gives an overview of pharmacist intervention feasibility, stakeholders' opinions and possible benefits on opioid optimisation in people with CNMP in outpatient clinical settings, community pharmacies and primary care settings. However, further research is warranted, which can guide the development of new policies and guidelines for the utilisation of pharmacists to promote opioid safety in people using prescription opioids for CNMP management.

Validation of the OWLS, a Screening Tool for Measuring Prescription Opioid Use Disorder in Primary Care

OBJECTIVE

The OWLS is a screening tool for prescription opioid use disorder designed for use in primary care. This study aimed to confirm the optimal wording, scoring methods, and cutoff for the OWLS.

DESIGN AND SETTING

Cross-sectional analysis of an online sample.

SUBJECTS

Participants comprised those with chronic noncancer pain who regularly used prescription opioids.

METHODS

Eligible participants self-completed an online version of the OWLS prescription opioid use disorder screening tool and the Composite International Diagnostic Interview Substance Abuse module. Receiver operating characteristics were calculated for three scoring methods for the OWLS, and these were compared with DSM-5 classification of any use disorder and moderate to severe opioid use disorder.

RESULTS

Among the sample (N = 324), utilizing scoring method (i) (i.e., positive endorsement ≥ response option "a little bit") and a cutoff of 3 increased the percentage of correctly classified participants, with concurrent increases in specificity and decreases in false discovery rate, and false positive rate.

CONCLUSION

OWLS utilizing scoring method (i) with a cutoff of 3 was shown to be the optimal version and scoring method of this tool. This represents a time-efficient, simple scoring method, allowing for quick and accurate screening for opioid use disorder to occur.

Examining correlations between opioid dispensing and opioid-related hospitalizations in Canada, 2007-2016

BACKGROUND

High levels of opioid-related mortality, as well as morbidity, contribute to the excessive opioid-related disease burden in North America, induced by high availability of opioids. While correlations between opioid dispensing levels and mortality outcomes are well-established, fewer evidence exists on correlations with morbidity (e.g., hospitalizations).

METHODS

We examined possible overtime correlations between medical opioid dispensing and opioid-related hospitalizations in Canada, by province, 2007-2016. For dispensing, we examined annual volumes of medical opioid dispensing derived from a representative, stratified sample of retail pharmacies across Canada. Raw dispensing information for 'strong opioids' was converted into Defined Daily Doses per 1000 population per day (DDD/1000/day). Opioid-related hospitalization rates referred to opioid poisoning-related admissions by province, for fiscal years 2007-08 to 2016-17, drawn from the national Hospital Morbidity Database. We assessed possible correlations between opioid dispensing and hospitalizations by province using the Pearson product moment correlation; correlation values (r) and confidence intervals were reported.

RESULTS

Significant correlations for overtime correlations between population-levels of opioid dispensing and opioid-related hospitalizations were observed for three provinces: Quebec (r = 0.87, CI: 0.49-0.97; p = 0.002); New Brunswick (r = 0.85;CI: 0.43-0.97; p = 0.004) and Nova Scotia (r = 0.78; CI:0.25-0.95; p = 0.012), with an additional province, Saskatchewan, (r = 0.073; CI:-0.07-0.91;p = 0.073) featuring borderline significance.

CONCLUSIONS

The correlations observed further add to evidence on opioid dispensing levels as a systemic driver of population-level harms. Notably, correlations were not identified principally in provinces with reported high contribution levels (> 50%) of illicit opioids to mortality, which are not captured by dispensing data and so may have distorted or concealed potential correlation effects due to contamination.

Comparing rates and characteristics of ambulance attendances related to extramedical use of pharmaceutical opioids in Victoria, Australia from 2013 to 2018

BACKGROUND AND AIMS

Despite increases in opioid prescribing and related morbidity and mortality, few studies have comprehensively documented harms across opioid types. We examined a population-wide indicator of extramedical pharmaceutical opioid-related harm to determine if the supply-adjusted rates of ambulance presentations, the severity of presentations or other attendance characteristics differed by opioid type.

DESIGN

Retrospective observational study of coded ambulance patient care records related to extramedical pharmaceutical opioid use, January 2013 to September 2018.

SETTING

Australia CASES: Primary analyses used Victorian data (n = 9823), with available data from other Australian jurisdictions (n = 4338) used to determine generalizability.

MEASUREMENTS

We calculated supply-adjusted rates of attendances using Poisson regression, and used multinomial logistic regression to compare demographic, presentation severity, mental health, substance use and other characteristics of attendances associated with seven pharmaceutical opioids.

FINDINGS

In Victoria, the highest rates of attendance [per 100 000 oral morphine equivalent mg (OME)] were for codeine (0.273/100 000) and oxycodone (0.113/100 000). The lowest rates were for fentanyl (0.019/100 000) and tapentadol (0.005/100 000). Oxycodone-naloxone rates (0.031/100 000) were lower than for oxycodone as a single ingredient (0.113/100 000). Fentanyl-related attendances were associated with the most severe characteristics, most likely to be an accidental overdose, most likely to have naloxone administered and least likely to be transferred to hospital. In contrast, codeine-related attendances were more likely to involve suicidal thoughts/behaviours, younger females and be transported to hospital. Supply-adjusted attendance rates for individual opioids were stable over time. Victorian states were broadly consistent with non-Victorian states.

CONCLUSIONS

In Australia, rates and characteristics of opioid-related harm vary by opioid type. Supply-adjusted ambulance attendance rates appear to be both stable over time and unaffected by large changes in supply.

Post-discharge opioid prescribing after laparoscopic appendicectomy and cholecystectomy

BACKGROUND

Opioid over-prescription following surgery is a significant public health issue in most developed countries. Multiple studies have been conducted in the USA demonstrating and investigating the issue; however, there is a lack of literature addressing this topic in the Australian setting. The aim of this study is to review prescribing practices at an Australian tertiary referral hospital on discharge in patients having undergone laparoscopic cholecystectomy (LC) or laparoscopic appendicetomy (LA). Additionally, to identify potential factors which influence medical officer prescribing practices.

METHODS

A retrospective observational study on opioid prescribing practice on all patients who underwent LC or LA over a 12-month period at an Australian tertiary referral hospital.

RESULTS

A total of 435 patients (223 LC, 214 LA) were prescribed a mean opioid dose on discharge of 25 oral morphine milli-equivalents (range 0-180 morphine milli-equivalents). Less opioids were prescribed following elective procedures (42% versus 10%, P < 0.001). There is a downward trend of opioid prescribing on discharge as the Junior Medical Officer clinical year progresses (P < 0.001).

CONCLUSIONS

This study demonstrates a lower rate of opiate prescription on discharge for LC and LA in an Australian setting when compared to the US data. There is a wide diversity of prescribing demonstrated. This indicates the need for better training of opioid prescribers to reduce over-prescribing.

Recent trends in heroin and pharmaceutical opioid-related harms in Victoria, Australia up to 2018

AIMS

To characterize the trajectory in the years leading up to 2018 in pharmaceutical opioid and heroin morbidity in Victoria, Australia, and to assess the effect on that trajectory of reformulation of oxycodone to a form that could not be easily snorted or injected.

DESIGN

Interrupted time-series analyses of population-level data before versus after reformulation of oxycodone, stratified by sex.

SETTING

Victoria, Australia.

PARTICIPANTS

The population of Victoria aged 12+ years.

MEASUREMENTS

Ambulance patient care and emergency department (ED) records were examined using both fixed-code and free-text fields, with each record manually cleaned and checked by trained coders. These were used to derive the output variables providing an index of harm: rates of opioid-related ambulance attendances and ED attendances for pharmaceutical opioids and heroin. The input variable was pre- versus post-oxycodone reformulation.

FINDINGS

There were 30 045 opioid-related ambulance attendances from January 2012 to October 2018 (54% heroin-related), and 10 113 ED attendances from July 2008 to June 2018 (39% heroin-related). There was an increase in the rate (events per 100 000 people per year) of all opioid ED attendances from 2008 to 2018 [increase = 0.063; 95% confidence interval (CI) = 0.049, 0.078]. Pharmaceutical opioid ED attendances decreased from 2014 onwards (slope change = -0.083; 95% CI = -0.108, -0.059). Heroin-related ED attendances increased from 2014 to 2018; 11 324 heroin-related ambulance attendances and 1980 ED attendances were observed from April 2014 to June 2018, compared with the respective estimates of 8176, and 1661 had the pre-April 2014 trend continued (ambulance slope change = 0.296, 95% CI = 0.104, 0.489; ED slope change = 0.026, 95% CI = 0.005, 0.046). The inflection point of 2014 coincided with the re-formulation of oxycodone.

CONCLUSION

In Victoria, Australia, there appears to have been a trend starting around mid-2014 of increasing heroin-related harm, and a flattening of the increase or a decrease of harms relating to pharmaceutical opioids. These changes may, in part, reflect reformulation of oxycodone to reduce the extent to which it can be injected or snorted.

Tramadol and the occurrence of seizures: a systematic review and meta-analysis

Introduction: Tramadol is a synthetic opioid which is commonly used around the world to relieve moderate to severe pain. One of the serious possible complications of its use is seizures. The present study aims to investigate and summarize the studies related to tramadol and occurrences of seizures after tramadol use and factors influencing these seizures.Methodology: Our systematic review is compliant with PRISMA guidelines. Two researchers systematically searched PubMed/Medline, Web of Sciences, and Scopus. Cohort, case-control, cross-sectional studies, and clinical trials. The risk of bias was assessed using the Newcastle-Ottawa Scale After article quality assessment, a fixed or random model, as appropriate, was used to pool the results in a meta-analysis. Heterogeneity between the studies was assessed with using I-square and Q-test. Forest plots demonstrating the point and pooled estimates were drawn.Results: A total of 51 articles with total sample size of 101 770 patients were included. The results showed that seizure event rate in the subgroups of tramadol poisoning, therapeutic dosage of tramadol, and tramadol abusers was 38% (95% CI: 27-49%), 3% (95% CI: 2-3%), 37% (95% CI: 12-62%), respectively. Tramadol dose was significantly higher in the patients with seizures than those without (mean differences: 0.82, CI 95%: 0.17-1.46). The odds for occurrence of seizures were significantly associated with male gender (pooled OR: 2.24, CI 95%: 1.80-2.77). Naloxone administration was not associated to the occurrence of seizures (pooled OR: 0.47, 95% CI: 0.15-1.49).Conclusions: Our results demonstrate that the occurrence of seizures in patients exposed to tramadol are dose-dependent and related to male gender, but not related to naloxone administration. Given that, most of the evidence derives from studies utilizing a cross-sectional design, the association of tramadol with seizures should not be considered to be definitively established.

Opioid use prior to elective surgery is strongly associated with persistent use following surgery: an analysis of 14 354 Medicare patients

Background

Persistent opioid use following total joint replacement (TJR) surgery is common; however, the association between pre‐surgical opioid use and surgery type has not been established. The objective of this study was to determine the association between pre‐surgery opioid use and persistent post‐surgery opioid use in TJR patients compared to other elective surgical patients.

Methods

This is a retrospective cohort study, of univariate and multinomial logistic regression of linked, de‐identified Medicare Benefits Schedule and Pharmaceutical Benefits Schedule data, adjusted for perioperative opioid use, age and sex. Oral morphine equivalents daily doses (OMEDD) were calculated and opioid use was categorized into three mutually exclusive categories for each observation window: low (0–5 OMEDD), moderate (5–10 OMEDD), high (10+ OMEDD). Persistent opioid use was defined as opioid use between 180 and 270 days after the date of surgery.

Results

Persistent opioid use was associated with older age, female gender and pre‐surgery opioid use. There was no increased risk for persistent opioid use for TJR patients compared to other surgical patients. The intensity of pre‐surgery opioid usage is strongly associated with persistent opioid use in all observed surgical patients.

Conclusions

Our results suggest that many patients who use opioids prior to surgery will persist in their opioid use following surgery. No association was found between persistent opioid use and TJR surgery, but rather a risk reduction compared to other elective surgeries when associations with opioid use are controlled for. Primary care clinicians and surgeons should monitor the duration and dosage of perioperative opioid use.

Who Are Dispensed the Bulk Amount of Prescription Opioids?

Background: Excessive and non-medical use of prescription opioids is a public health crisis in many settings. This study examined the distribution of user types based on duration of use, trends in and associated factors of dispensing of prescription opioids in New South Wales and Victoria, Australia. Methods: 10% sample of unit-record data of four-year dispensing of prescription opioids was analysed. Quantities dispensed were computed in defined daily dose (DDD). Multilevel models examined factors associated with the duration of dispensing and the quantity dispensed in local government areas. Results: Overall, 53% were single-quarter, 37.3% medium-episodic (dispensed 2–6 quarters), 5% long-episodic (dispensed 7–11 quarters) and 5% were chronic users (dispensed 12–14 quarters). More than 80% of opioids in terms of DDD/1000 people/day were dispensed to long-episodic and chronic users. Codeine and oxycodone were most popular items—both in terms of number of users and quantity dispensed. Duration of dispensing was significantly higher for women than men. Dispensing quantity and duration increased with increasing age and residence in relatively poor neighborhoods. Conclusions: Although only 5% were chronic users, almost 60% of opioids (in DDD/1000 people/day) were dispensed to them. Given that chronic use is linked to adverse health outcomes, and there is a progression toward chronic use, tailored interventions are required for each type of users.

Trends in methamphetamine and opioid use among clients of needle-syringe programs in Queensland, Australia: 2007-2015

INTRODUCTION AND AIMS

Needle-syringe programs (NSP) are an underutilized source of data on drug injection trends; these data are essential for informing public health interventions. We examine trends in NSP service occasions from 2007-2015.

DESIGN AND METHODS

Using standardised data from 26 NSP outlets through the Queensland NSP Minimum Data Set (QNSPMDS), trends in service occasions among clients intending to inject methamphetamine, heroin, opioid substitution therapy (OST) medications and other pharmaceutical opioids were assessed using multilevel mixed-effects negative binomial regression, adjusting for month, year, age and clustering by site.

RESULTS

Over 1.5 million service occasions were recorded in 2007-2015. Methamphetamine was the main 'drug intended to inject' (33.7%), however cf. 2007, the incidence rate ratio decreased to 0.64 (95% CI: 0.62, 0.66) in 2009, remaining low until 2015. Among clients reporting methamphetamine injection, there was a shift in the form from base to the higher-potency crystal methamphetamine since 2012. Heroin injection (22.5% service occasions) initially increased (cf. 2007), followed by a decline to 0.77 (95% CI: 0.75, 0.79) in 2015. Significant and sustained increases in OST and other pharmaceutical opioids injection were observed throughout the study period, accounting for 7.2% and 19.8% of total visits, respectively.

DISCUSSION AND CONCLUSIONS

The QNSPMDS provides unique, routinely collected, jurisdiction-wide and standardised data on the demographics of people who inject drugs, types of drugs injected and regional variations; these data are essential in informing policy, planning and program implementation. There remains significant opportunity to enhance engagement and linkage to care alongside needle-syringe provision.

Patterns and predictors of chronic opioid use in older adults: A retrospective cohort study

Background

Given the controversy around the effectiveness of opioid treatment for chronic pain and the lack of detailed guidance for prescribing opioids in older adults, the objectives of this study were to estimate the trajectories and predictors of opioid use in older adults.

Methods

Data were extracted from the National Alzheimer’s Coordinating Center (2005–2017). Group-based trajectory modeling was used to identify the patterns of opioid use (any or strong) among participants age 65+. We used multivariable logistic regression with backward selection to evaluate demographics and comorbidities as potential predictors of trajectory membership.

Results

Among 13,059 participants, four trajectories were identified for the use of both any opioids and strong opioids (minimal-users, incident chronic-users, discontinuing-users, and prevalent chronic-users). For any opioids, female sex (adjusted odds ratio = 1.23; 95% confidence interval = 1.03–1.46), black vs. white (1.47; 1.18–1.82), year of education (0.96; 0.94–0.99), type of residence (independent group vs. private: 1.77; 1.38–2.26, care facility vs. private: 1.89; 1.20–2.97), hypertension (1.44; 1.20–1.72), cardiovascular disease (1.30; 1.09–1.55), urinary incontinence (1.45; 1.19–1.78), dementia (0.73; 0.57–0.92), number of medications (1 to 4 vs. none: 0.48; 0.36–0.64, 5 or more vs. none: 0.67; 0.50–0.88), and antidepressant agent (1.38; 1.14–1.67) were associated with incident chronic-use vs. non-use. For strong opioids, female sex (1.27; 1.04–1.56), type of residence (independent group vs. private: 1.90; 1.43–2.53, care facility vs. private: 2.37; 1.44–3.90), current smoking (1.68; 1.09–2.60), hypertension (1.49; 1.21–1.83), urinary incontinence (1.45; 1.14–1.84), dementia (0.73; 0.55–0.97), number of medications (1 to 4 vs. none: 0.46; 0.32–0.65, 5 or more vs. none: 0.59; 0.42–0.83), and antidepressant agent (1.55; 1.24–1.93) were associated with incident chronic-use vs. non-use.

Conclusion

Given that chronic opioid use was more prevalent in participants who were more vulnerable (i.e., older age, with multiple comorbidities, and polypharmacy), further studies should evaluate the safety and efficacy of using opioids in this population.

Variation in Prescription Opioid Dispensing across Neighborhoods of Diverse Socioeconomic Disadvantages in Victoria, Australia

The study examined the relationship between dispensing patterns of prescription opioids, neighborhood-disadvantage-index, and standardized doses dispensed. Three-year’s dispensing data drawn from 80 local government areas (LGAs) within Victoria, Australia’s second most populous state, was analyzed. Quantities dispensed in defined daily dose (DDD)/1000-people/day were computed for LGAs of low, moderate, high, and very high socio-economic disadvantage. LGAs with various levels of dispensing, and neighborhood disadvantage were identified and mapped. A multivariable regression model examined the effect of neighborhood level disadvantage and identified other factors that are associated with standardized doses dispensed. More women were dispensed opioids than men. Dispensing increased with increasing age. Most of the LGAs with relatively high dispensing were socioeconomically disadvantaged and located outside the major cities. Dispensing gradually increased from low disadvantage to very high disadvantage areas. Dispensing of standardized doses were consistently higher in rural areas than in urban areas. Neighborhood level disadvantage, age, sex, and urbanization were significant factors in the standardized doses dispensed. As inappropriate dispensing of opioids is a major public health problem, research should facilitate understanding of utilization in small areas to enable tailored public health programs. Nationwide and consistent introduction of real-time prescription drug-monitoring programs, and structural interventions to reduce the fundamental causes of socioeconomic disadvantage and isolation are recommended.

Understanding an emerging treatment population: Protocol for and baseline characteristics of a prospective cohort of people receiving treatment for pharmaceutical opioid dependence

INTRODUCTION AND AIMS

Despite large increases in pharmaceutical opioid dependence and related mortality, few studies have focused on the characteristics and treatment experiences of those with pharmaceutical opioid dependence. We describe the formation of a prospective cohort of people receiving treatment for pharmaceutical opioid dependence and describe their baseline characteristics.

DESIGN AND METHODS

People who had entered treatment for pharmaceutical opioid dependence (n = 108) were recruited through drug treatment services in New South Wales, Australia. We describe baseline characteristics of those that commenced pharmaceutical opioids for pain or other reasons and conducted a thematic analysis of responses regarding their treatment experience.

RESULTS

Mean age was 41 years (SD 11), half were male (48%). Just over half reported lifetime heroin use (57%). Oxycodone (49%) and codeine (29%) were the most common opioids reported. Most (85%) reported past-year problematic pain, 38% reported chronic pain. Half (52%) reported moderate to severe depression symptoms. Most (66%) commenced opioids for pain, and this group were older, less likely to report a previous overdose and less likely to report use of illicit drugs compared to those commencing for other reasons. Five themes related to treatment expectations: (i) stigma; (ii) the restrictive nature of treatment; (iii) knowledge; (iv) pain; and (v) positive experience with buprenorphine.

DISCUSSION AND CONCLUSIONS

This study describes the complexities in an important emerging treatment population of pharmaceutical opioid-dependent people. Findings highlights that addressing knowledge and perceptions around treatment may be critical to address the rising mortality associated with pharmaceutical opioid dependence.

The impact of opioid analgesic prescription uptake on the costs of recovery from injury: Evidence from compensable orthopaedic road trauma patients

Long-term opioid prescribing after compensable orthopaedic injury may contribute to the 'long right tail' in the cost of recovery. The aim of this study was to estimate the effect of prescription opioid uptake on injury compensation cost, using orthopaedic road traffic injury claims data from Victoria, Australia. We used a maximum likelihood estimation that accounts for potential endogeneity associated with opioid uptake, utilizing information on the doctor's differential propensity to prescribe opioids when treating other compensable injury patients. Our results suggest that opioid recipients incurred significantly greater hospital costs, income compensation payments, and medical and paramedical expenses. Overall, income compensation was the primary driver of the claim cost difference between opioid recipients and non-recipients. The findings imply that there is scope to impose restrictions on long-term opioid usage, and to encourage the use of alternative pain relief medicines.

Pharmaceutical opioid overdose deaths and the presence of witnesses

BACKGROUND

In the past two decades, rates of pharmaceutical opioid use and harms resulting from their use (including death) have risen. The present study identified a series of fatal opioid overdoses where there was evidence that witnesses had noted symptoms consistent with overdose, and examined associated contextual factors.

METHODS

A retrospective review was undertaken utilising the Coroners Court of Victoria's Overdose Deaths Register for pharmaceutical opioid overdose deaths between 2011 and 2013. Information on the source of pharmaceutical opioids, co-contributing drugs, history of drug dependence, and mental illness was extracted and coded.

RESULTS

Pharmaceutical opioids were involved in 587 deaths, and within these, 125 cases (21%) were witnessed. The majority of these witnessed deaths (77.6%) occurred at the deceased's residence, with the witness being a partner or unrelated acquaintance who did not realise the significance of what they were witnessing. The most common contributing pharmaceutical opioids were methadone (49.6%), codeine (32.0%), and oxycodone (19.2%), with the source more often prescribed than diverted. Co-contributing drugs were involved in 110 cases, with the most common being benzodiazepines. Evidence of current dependence and mental illness was found in 53.6% of cases.

CONCLUSION

Most pharmaceutical opioid overdose deaths with a witness present occurred in the deceased's home, with symptoms of overdose being noted, but not acted upon. These findings support the trialling of education and/or naloxone to partners and family members of people who use pharmaceutical opioids in order to reduce overdose deaths.

The effect of a potentially tamper-resistant oxycodone formulation on opioid use and harm: main findings of the National Opioid Medications Abuse Deterrence (NOMAD) study

BACKGROUND

Escalation of pharmaceutical opioid use and harm in North America is well-documented, with similar issues emerging in Australia. One response is the development of tamper-resistant formulations of opioids. A potentially tamper-resistant formulation of controlled-release oxycodone was introduced in Australia in April, 2014, rapidly replacing the non-tamper-resistant formulation. Our study is the most systematic and comprehensive examination of the impact of a new opioid formulation to date, assessing the effect of tamper-resistant formulation of controlled-release oxycodone on population-level opioid use and opioid-related harm (ie, overdose, help-seeking, and treatment-seeking); and opioid use, tampering, and preference for the tamper-resistant formulation of controlled-release oxycodone compared with other drugs or formulations among sentinel populations likely to tamper with pharmaceutical opioids.

METHODS

We conducted interrupted time-series analyses of opioid sales data and multiple routinely collected health datasets, followed up a cohort of people who tamper with pharmaceutical opioids before and after the introduction of the tamper-resistant formulation of controlled-release oxycodone, and analysed annual surveys of people who inject drugs. Data were collected from several Australian states: New South Wales, South Australia, and Tasmania. Meta-analyses (weighted Z tests) were conducted to synthesise across data sources providing evidence for a given indicator.

FINDINGS

At the population level, we found reduced sales of higher strengths of controlled-release oxycodone and increased sales of other oxycodone formulations. No significant effect was observed among population-level indicators of opioid overdose, or help or treatment-seeking. Mortality data were not available for inclusion at the time of our study. Meta-analyses across sentinel populations (ie, prospective cohort, surveys of people who inject drugs, and clients of supervised injecting facilities or needle and syringe programmes) indicated reduced controlled-release oxycodone use via tampering (mainly injection), with no evidence of switching to heroin or other drug use.

INTERPRETATION

This formulation of controlled-release oxycodone reduced tampering with pharmaceutical opioids among people who inject drugs, but did not affect population-level opioid use or harm.

FUNDING

Mundipharma Australia, the Australian Government, and the National Health and Medical Research Council.

Prescribed Dose of Opioids and Overdose: A Systematic Review and Meta-Analysis of Unintentional Prescription Opioid Overdose

BACKGROUND

The rate of an unintentional drug overdose involving prescription opioids continues to rise. An understanding of the threshold dose and dose(s) associated with unintentional prescription opioid overdose will help to mitigate this epidemic.

OBJECTIVE

The objective of this systematic review is to systematically synthesise and meta-analyse studies on doses of prescription opioids and ascertain the doses of opioids that are associated with increased risk of severe opioid poisoning or mortality.

DATA SOURCES

A search of PubMed, EMBASE, CINAHL and Web of Science from inception to 16 January 2017 was conducted using search strategies and the MeSH (Medical Subject Headings) terms for studies of adult patients using prescription opioids who experienced an accidental overdose.

STUDY SELECTION

Of the 1332 studies identified, 117 were selected for full article review. Ten met the inclusion criteria for qualitative analysis, but only seven studies were meta-analysed. The included studies were in English, and participants met predetermined International Classification of Diseases (ICD) codes. Studies were excluded if they included only paediatric participants or the participants met the ICD code for intentional self-harm.

DATA EXTRACTION AND SYNTHESIS

Two researchers elaborated and validated a data extraction form. Data were then independently extracted by both reviewers as per this form. We assessed study quality using the Newcastle-Ottawa Scale (NOS) for non-randomised studies in meta-analyses. We performed a meta-regression using a random-effect model and summarised the results using relative risk (RR) and 95% confidence intervals (CIs). The threshold dose for an unintentional overdose is 20 morphine milligram equivalents (MME)/day. There were higher risks with larger doses: (1) ≤ 20 versus ≥ 21 MME/day: RR 2.81, 95% CI 1.09-7.22, p < 0.001; (2) ≤ 50 versus > 50 MME/day: RR 3.87, 95% CI 2.36-6.33, p < 0.001; (3) ≤ 100 versus > 100 MME/day: RR 4.28, 95% CI 2.61-7.1, p < 0.001; and (4) ≤ 50 versus > 50-100 MME/day: RR 3.09, 95% CI 1.84-5.18, p < 0.001). Heterogeneity was explained by the type of overdose event, inpatient or outpatient status, and length of observation. Type of pain (cancer or non-cancer pain) had no impact on heterogeneity.

LIMITATIONS

The definition of exposure in studies included in the meta-analysis was heterogeneous. Some studies defined exposure as the filling of a prescription while others defined exposure as the prescription of an opioid to the patient, and all studies assumed that patients took the prescribed opioid. Medications that may contribute to overdose, such as benzodiazepines and other drugs, were not considered.

CONCLUSIONS

A significantly increased risk of inadvertent prescription opioid overdose was found with 20-50 MME/day, with fatality more likely with opioid doses above 50 MME/day, although extensive heterogeneity was found with the dose comparisons. Clinicians should inform patients of this risk and monitor them closely.

PROTOCOL REGISTRATION

This protocol was registered with PROSPERO 2017: CRD42017058426.

Deaths from Opioid Overdosing: Implications of Coroners' Inquest Reports 2008-2012 and Annual Rise in Opioid Prescription Rates: A Population-Based Cohort Study

INTRODUCTION

In the late 1990s multiple physicians and advocacy organizations promoted increased use of opioids for the treatment of acute, chronic and cancer pain. There has been an exponential growth in opioid prescribing in the last 20 years in the United States of America, in Australia, and in other developed Western countries. There are negative consequences associated with the liberal use of opioids. The primary aim of this population-based cohort study is to investigate the opioid-related death rate in New Zealand between 1 January 2008 and 31 December 2012. The secondary aims of this cohort study are: (1) to compare the opioid-related death rate per population in New Zealand in 2001/2002 with that between 2011/2012; (2) to investigate the number of opioid prescriptions in New Zealand between 2001 and 2012; (3) to compare the opioid-related death rate per population in New Zealand between 2001 and 2012 with the number of opioid prescriptions in New Zealand between 2001 and 2012.

METHODS

Permission to access records from the Coronial Services Office in Wellington for 2008-2012 was acquired. Permission to access records for prescriptions containing opioids (dose and formulation) was obtained from the Pharmaceutical Collection.

RESULTS

The rate of opioid-related deaths in New Zealand has increased by 33% from 2001 to 2012. More than half of the opioid-related deaths between 2008 and 2012 were unintentional opioid overdoses. Opioid analgesic deaths were most likely due to methadone, morphine and codeine prescribed by healthcare professionals. That 179 of these opioid-related deaths between 2008 and 2012 were unintentional opioid overdoses, and thus could have been avoided, is tragic. This study shows that there was a steady annual increases in opioid prescriptions in New Zealand from 2001 to 2012. This rise in opioid analgesic deaths was associated with the increases in the numbers of opioid prescriptions.

CONCLUSION

A multifaceted national public health approach is needed to bring together the various stakeholders involved with pain management, opioid dependence, opioid availability and opioid diversion. There needs to be a targeted approach to educate current and future medical practitioners regarding the appropriate use of opioid prescriptions for the management of pain, as well as a strengthening of primary, secondary and tertiary resources to support medical practitioners managing their patients who suffer with pain.

Increases from 2002 to 2015 in prescription opioid overdose deaths in combination with other substances

BACKGROUND

Prescription opioid (PO) overdose deaths increased sharply over the last decade. Changes in PO deaths in combination with other psychoactive substances may provide a partial explanation.

METHODS

PO deaths from the National Multiple-Cause-of-Death Files for 2002-03 (N=15,973) and 2014-15 (N=41,491) were analyzed. We calculated (1) changes in proportions of deaths in combination with benzodiazepines, antidepressants, heroin, alcohol, cocaine between the two periods, and (2) proportions of increase in deaths attributable to each substance among PO and synthetic opioids other than methadone (SO-M) deaths, by age, gender, race/ethnicity.

RESULTS

Between 2002-03 and 2014-15, PO deaths increased 2.6 times; SO-M deaths 5.6 times, especially for ages 18-34, males, African-Americans. For PO deaths, most frequent combinations at both periods were with benzodiazepines; for SO-M, benzodiazepines, antidepressants in 2002-03, heroin, benzodiazepines in 2014-15. The largest increases occurred in combination with heroin among all PO (4.6% to 15.4%, change ratio=3.3[95%CI=3.1-3.6]), but especially SO-M deaths (1.2% to 24.5%, change ratio=21.3[95%CI=15.0-30.3]). Deaths involving cocaine decreased among PO, increased among SO-M deaths. One-fifth of increased PO or SO-M deaths were attributable to any of the five substances. Increased PO deaths were equally attributable to benzodiazepines and heroin; deaths attributable to heroin were higher among ages 18-49, males, and non-Hispanic whites. Increased SO-M deaths were attributable mostly to heroin among all groups.

CONCLUSIONS

Increased PO overdose deaths over the last decade may be partially explained by increased deaths in combination with other psychoactive substances. Use of other substances should be considered in efforts toward reducing prescription opioid overdoses.