Denial of prescription opioids among young adults with histories of opioid misuse

Characterizing the Use of Healthcare Access Supports Among People Who Use Drugs in Vancouver, Canada, 2017 to 2020: A Cohort Study

BACKGROUND

For structurally marginalized populations, including people who use drugs (PWUD), equitable access to healthcare can be achieved through healthcare access supports. However, few studies characterized utilization of formal (eg, outreach workers, healthcare professionals) and informal (eg, friends/family) supports. Therefore, we sought to estimate the prevalence of and factors associated with receiving each type of support among PWUD.

METHODS

We used data from 2 prospective cohort studies of PWUD in Vancouver, Canada, in 2017 to 2020. We constructed separate multivariable generalized linear mixed-effects models to identify factors associated with receiving each of the 3 types of supports (ie, healthcare professionals, outreach workers/peer navigators, and informal supports) compared to no supports.

RESULTS

Of 996 participants, 350 (35.1%) reported receiving supports in the past 6 months at baseline, through informal supports (6.2%), outreach workers (14.1%), and healthcare professionals (20.9%). In multivariable analyses, HIV positivity, chronic pain, and avoiding healthcare due to the past mistreatment were positively associated with receiving supports from each of healthcare professionals and outreach workers. Men were less likely to receive any types of the supports (all P < .05).

CONCLUSIONS

Utilization of healthcare access supports was relatively low in this sample. However, formal supports appeared to have reached PWUD exhibiting more comorbidities and experiencing discrimination in healthcare. Further efforts to make formal supports more available would benefit PWUD with unmet healthcare needs, particularly men.

Denial of prescription pain medication among people who use drugs in Vancouver, Canada

BACKGROUND

People who use drugs experience pain at two to three times the rate of the general population and yet continue to face substantial barriers to accessing appropriate and adequate treatment for pain. In light of the overdose crisis and revised opioid prescribing guidelines, we sought to identify factors associated with being denied pain medication and longitudinally investigate denial rates among people who use drugs.

METHODS

We used multivariable generalized estimating equations analyses to investigate factors associated with being denied pain medication among people who use drugs reporting pain in three prospective cohort studies in Vancouver, Canada. Analyses were restricted to study periods in which participants requested a prescription for pain from a healthcare provider. Descriptive statistics detail denial rates and actions taken by participants after being denied.

RESULTS

Among 1168 participants who requested a prescription for pain between December 2012 and March 2020, the median age was 47 years and 63.0% were male. Among 4,179 six-month observation periods, 907 (21.7%) included a report of being denied requested pain medication. In multivariable analyses, age was negatively associated with prescription denial (adjusted odds ratio [AOR] = 0.98, 95% confidence interval [CI]:0.97-0.99), while self-managing pain (AOR = 2.48, 95%CI:2.04-3.00), experiencing a non-fatal overdose (AOR = 1.51, 95%CI:1.22-1.88), engagement in opioid agonist therapy (AOR = 1.32, 95%CI:1.09-1.61), and daily use of heroin or other unregulated opioids (AOR = 1.32, 95%CI:1.05-1.66) were positively associated with being denied. Common actions taken (n = 895) after denial were accessing the unregulated drug supply (53.5%), doing nothing (30.6%), and going to a different doctor/emergency room (6.1%). The period following the introduction of new prescribing guidelines was not associated with a change in denial rates.

CONCLUSIONS

A substantial proportion of people who use drugs continue to be denied prescriptions for pain, with such denial associated with important substance use-related harms, including non-fatal overdose. Guidelines specific to the pharmaceutical management of pain among people who use drugs are needed.

Estimating the prevalence and correlates of pain among people living with HIV who use unregulated drugs in a Canadian setting

Although prevalent among people living with human immunodeficiency virus (HIV) (PLWH) and people who use unregulated drugs (PWUD), pain and its possible links to substance use patterns and engagement in HIV treatment remains poorly characterized. We sought to evaluate the prevalence and correlates of pain among a cohort of PLWH who use un-regulated drugs. Between December 2011 and November 2018, 709 participants were recruited, and data were analyzed using generalized linear mixed-effects (GLMM). At baseline, 374 (53 percent) individuals reported moderate-to-extreme pain in the previous 6 months. In a multivariable model, pain was significantly associated with nonmedical prescrip-tion-opioid use (adjusted odds ratio (AOR) = 1.63, 95 percent confidence interval (CI): 1.30-2.05), nonfatal overdose (AOR = 1.46, 95 percent CI: 1.11-1.93), self-managing pain (AOR = 2.25, 95 percent CI: 1.94-2.61), requesting pain medication in the previous 6 months (AOR = 2.01, 95 percent CI: 1.69-2.38), and ever being diagnosed with a mental illness (AOR = 1.47, 95 percent CI: 1.11-1.94). Establishing accessible pain management interventions that address the complex intersection of pain, drug use, and HIV-infection has potential to improve quality of life outcomes among this population.

Suboptimal nonmedical qualities of primary care linked with care avoidance among people who use drugs in a Canadian setting amid an integrated health care reform

BACKGROUND

People who use unregulated drugs (PWUD) often face significant barriers to-and thereby avoid seeking-health care. In Vancouver, Canada, a neighborhood-wide health care system reform began in 2016 to improve health care delivery and quality. In the wake of this reform, we sought to determine the prevalence of health care avoidance and its association with emergency department use among PWUD in this setting and examine patient-reported nonmedical qualities of health care ("responsiveness").

METHODS

The study derived data from two prospective cohort studies of community-recruited PWUD in Vancouver in 2017-18. Responsiveness was ascertained by the World Health Organizations' standardized measurements and we evaluated seven domains of responsiveness (dignity, autonomy, communication, confidentiality, prompt attention, choice of provider, and quality of basic amenities). The study used Pearson chi-squared test to examine differences in responsiveness between those who did and did not avoid care. The study team used multivariable logistic regression to determine the relationship between care avoidance due to past mistreatment and emergency department use, adjusting for potential confounders.

RESULTS

Among 889 participants, 520 (58.5%) were male, 204 (22.9%) reported avoiding health care, most commonly for chronic pain (47.4%). Overall, 6.6% to 36.2% reported suboptimal levels (i.e., not always meeting the expected quality) across all seven measured domain of responsiveness. Proportions reporting suboptimal qualities were significantly higher among those who avoided care than those who did not across all domains, including care as soon as wanted (51.0% vs. 31.8%), listened to carefully (44.1% vs. 20.4%), and involved in health care decision-making (27.9% vs. 12.7%) (all p < 0.05). In multivariable analyses, avoidance of health care was independently associated with self-reported emergency department use (adjusted odds ratio = 1.49; 95% confidence interval:1.01-2.19).

CONCLUSION

We found that almost a quarter of our sample of PWUD avoided seeking health care due to past mistreatment, and all seven measured domains of responsiveness were suboptimal and linked with avoidance. Individuals who reported avoidance of health care were significantly more likely to report emergency department use. Multi-level interventions are needed to remedy the suboptimal qualities of health care and thereby reduce care avoidance.

High prevalence of unmet healthcare need among people who use illicit drugs in a Canadian setting with publicly-funded interdisciplinary primary care clinics

BACKGROUND

People who use illicit drugs (PWUD) experience significant barriers to healthcare. However, little is known about levels of attachment to primary care (defined as having a regular family doctor or clinic they feel comfortable with) and its association with unmet healthcare needs in this population. In a Canadian setting that features novel publicly-funded interdisciplinary primary care clinics, we sought to examine the prevalence and correlates (including attachment to primary care) of unmet healthcare needs among PWUD. Methods: Data were derived from two prospective cohort studies of PWUD in Vancouver, Canada between December 2017 and November 2018. Multivariable logistic regression was used to identify factors associated with self-reported unmet healthcare needs among participants reporting any health issues. Results: In total, 743 (83.6%) of 889 eligible participants reported attachment to primary care and 220 (24.7%) reported an unmet healthcare need. In multivariable analyses, attachment to primary care at an integrated care clinic (adjusted odds ratio [AOR] = 0.14; 95% Confidence Interval [CI]: 0.06-0.34) was negatively associated with an unmet healthcare need, while being treated poorly at a healthcare facility (AOR = 5.50; 95% CI: 3.59-8.60) and self-reported chronic pain (AOR = 2.00, 95% CI: 1.30-3.01) were positively associated with an unmet healthcare need. Conclusion: Despite the high level of attachment to primary care, a quarter of our sample reported an unmet healthcare need. Our findings suggest that multi-level interventions are required to address the unmet need, including pain management and integrated care, to support PWUD with complex health needs.

Prevalence, Characteristics, and Management of Chronic Noncancer Pain Among People Who Use Drugs: A Cross-Sectional Study

INTRODUCTION

Most studies on chronic noncancer pain (CNCP) in people who use drugs (PWUD) are restricted to people attending substance use disorder treatment programs. This study assessed the prevalence of CNCP in a community-based sample of PWUD, identified factors associated with pain, and documented strategies used for pain relief.

METHODS

This was a cross-sectional study nested in an ongoing cohort of PWUD in Montreal, Canada. Questionnaires were administered to PWUD seen between February 2017 and January 2018. CNCP was defined as pain lasting three or more months and not associated with cancer.

RESULTS

A total of 417 PWUD were included (mean age = 44.6 ± 10.6 years, 84% men). The prevalence of CNCP was 44.8%, and the median pain duration (interquartile range) was 12 (5-18) years. The presence of CNCP was associated with older age (>45 years old; odds ratio [OR] = 1.8, 95% CI = 1.2-2.7), male sex (OR = 2.3, 95% CI = 1.2-4.2), poor health condition (OR = 1.9, 95% CI = 1.3-3.0), moderate to severe psychological distress (OR = 2.9, 95% CI = 1.8-4.7), and less frequent cocaine use (OR = 0.5, 95% CI = 0.3-0.9). Among CNCP participants, 20.3% used pain medication from other people, whereas 22.5% used alcohol, cannabis, or illicit drugs to relieve pain. Among those who asked for pain medication (N = 24), 29.2% faced a refusal from the doctor.

CONCLUSIONS

CNCP was common among PWUD, and a good proportion of them used substances other than prescribed pain medication to relieve pain. Close collaboration of pain and addiction specialists as well as better pain assessment and access to nonpharmacological treatments could improve pain management in PWUD.

Reasons for non-medical use of prescription opioids among young adults: Role of educational status

Non-medical use of prescription opioids (NMUPO) and related overdoses are disproportionately elevated among young adults. Efforts to understand the underlying reasons for NMUPO are critical for developing more effective prevention and intervention strategies for this group. Given the robust literature on the association between educational status and substance abuse risk, we examined the reasons for NMUPO through the lens of educational attainment among young adults. Data from the 2016 National Survey on Drug Use and Health came from an unweighted sample of 941 young adults aged 18-25 years who reported past-year NMUPO. Self-reported reasons for most recent NMUPO were compared by educational status. The most commonly-endorsed reasons for past-year NMUPO was physical pain relief (47.6%), followed by feel good/get high (19.8%), relax/relieve tension (13.2%) and experiment/see what it feels like (6.8%). Reasons for NMUPO did not differ as a function educational status (p = 0.17). These findings suggest that efforts to prevent and address opioid misuse among young adults should focus on understanding and improving pain management in this vulnerable population.

The prescription opioid epidemic: a review of qualitative studies on the progression from initial use to abuse

Most research designed to answer the “why” of the prescription opioid epidemic has relied on structured interviews, which rigidly attempt to capture the complex reasons people use opioids. In contrast this systematic literature review focuses on peer-reviewed studies that have used a qualitative approach to examine the development of an opioid-use disorder from the point of initial exposure. Rather than simply providing a “high,” opioids reportedly relieve psychological/emotional problems or provide an escape from life stressors. As use continues, avoidance of withdrawal sickness becomes an overriding concern, with all other benefits playing minor roles in persistent use. These studies indicate that terms used in structured interviews, such as “nontherapeutic use” or variations thereof, poorly capture the complex range of needs opioids satisfy. Both quantitative/structured studies and more qualitative ones, as well as more focused studies, have an important role in better informing prevention and treatment efforts.

Pain-related anxiety and opioid misuse in a racially/ethnically diverse young adult sample with moderate/severe pain

Pain problems are of significant public health concern, and with opioid-related problems and death due to overdose at an all-time high, there is significant public health importance to identify risk factors that link instances of pain to opioid misuse among persons with pain whether or not they have been prescribed opioids for pain management. Severe pain and pain-related problems have been associated with increased risk for opioid misuse, and recent research indicates that pain-related anxiety (worry about the negative consequences of pain) may contribute to a more debilitating pain experience. Additionally, pain-related anxiety has previously been linked to substance use motives and dependence for cannabis and tobacco. However, little research has examined pain-related anxiety as a transdiagnostic risk factor for opioid misuse. The current study examined the relationship between pain-related anxiety and self-reported opioid misuse (addiction, prescription denial, family concerns, detox) in a racially/ethnically diverse sample of young adults (N = 256, M _age = 22.84) reporting moderate to severe bodily pain over the previous four weeks. Results indicated that pain-related anxiety was significantly related to several indicators of opioid misuse as well as an increased number of opioid-related problems. Findings from the current study suggest that targeting pain-related anxiety may be one therapeutic strategy to reduce opioid misuse.

The prescription opioid epidemic: a review of qualitative studies on the progression from initial use to abuse

Most research designed to answer the "why" of the prescription opioid epidemic has relied on structured interviews, which rigidly attempt to capture the complex reasons people use opioids. In contrast this systematic literature review focuses on peer-reviewed studies that have used a qualitative approach to examine the development of an opioid-use disorder from the point of initial exposure. Rather than simply providing a "high," opioids reportedly relieve psychological/emotional problems or provide an escape from life stressors. As use continues, avoidance of withdrawal sickness becomes an overriding concern, with all other benefits playing minor roles in persistent use. These studies indicate that terms used in structured interviews, such as "nontherapeutic use" or variations thereof, poorly capture the complex range of needs opioids satisfy. Both quantitative/structured studies and more qualitative ones, as well as more focused studies, have an important role in better informing prevention and treatment efforts.

Associations Between Physical Pain, Pain Management, and Frequency of Nonmedical Prescription Opioid Use Among Young Adults: A Sex-specific Analysis

OBJECTIVES

We sought to determine sex-specific associations between experiences of physical pain, pain management, and frequency of nonmedical prescription opioid (NMPO) use among young adults.

METHODS

Among participants enrolled in the Rhode Island Young Adult Prescription Drug Study, we identified associations between physical pain in the past 6 months, pain history, pain management, polysubstance use, and weekly NMPO use. In sex-specific models, independent correlates of weekly NMPO use were identified via modified stepwise Poisson regression.

RESULTS

Of 199 participants, the mean age was 24.6, and 65.3% were male. The racial composition was 16.6% black, 60.8% white, and 22.1% mixed or other race. A total of 119 (59.8%) participants reported weekly or greater NMPO use. The majority of male (86.2%) and female (84.1%) participants reported ever experiencing severe pain. A majority of males (72.3%) and females (81.2%) reported that they engaged in NMPO use to treat their physical pain, and one-quarter (26.9%) of males and one-third (36.2%) of females had been denied a prescription from a doctor to treat severe pain. Among males, frequent NMPO use was independently associated with white race (P < 0.001) and reporting greater physical pain (P = 0.002). Among females, older age (P = 0.002) and monthly or greater nonmedical benzodiazepine use (P = 0.001) were independently associated with weekly NMPO use.

CONCLUSIONS

Among young men in Rhode Island, physical pain may be related to frequent NMPO use. More research is needed to identify sex-specific, pain-related factors that are linked with NMPO use to improve harm reduction and pain management interventions.

Exploring the latent trait of opioid use disorder criteria among frequent nonmedical prescription opioid users

BACKGROUND

There is a need to explore the dimensional and categorical phenotypes of criteria of opioid use disorder among frequent nonmedical users of prescription opioids (NMUPO) users.

METHODS

We used pooled data of 2011-2012 National Survey on Drug Use and Health to examine reliability and phenotypic variability in the diagnosis of OUD secondary to NMUPO in a nationally-representative sample of 18+ years-old frequent past-year NMUPO users (120+ days, n = 806). Through exploratory factor analysis (EFA) and latent class analysis (LCA), we examined 10 past-year OUD criteria. We examined associations between the latent classes and sociodemographic/psychiatric/NMUPO correlates.

RESULTS

OUD criteria were unidimensional, and a three-class model was the overall best fitting solution for characterizing individuals into phenotypes along this unidimensional continuum: a "non-symptomatic class" (40.7%), "Tolerance-Time spent class" (29.0%) with high probability of endorsing Tolerance/Time Spent criteria, and a "High-moderate symptomatic class" (30.1%). The last class was significantly associated with being male, having insurance and obtaining prescription opioids (PO) nonmedically via "doctor shopping" as compared to the non-symptomatic class. "Tolerance-Time spent class" was significantly associated with being younger (18-25 years) and obtaining PO nonmedically from family/friends as compared to the non-symptomatic class.

CONCLUSION

This study revealed the different characteristics and routes of access to PO of different classes of frequent NMUPO users. It is possible that these groups may respond to different interventions, however such conclusions would require a clinical study.

Seeking prescription opioids from physicians for nonmedical use among people who inject drugs in a Canadian setting

BACKGROUND AND OBJECTIVES

Despite the high prevalence of prescription opioid (PO) misuse, little is known about the phenomenon of seeking POs for nonmedical use among high-risk populations, such as people who inject drugs (PWID). We therefore sought to examine the prevalence and correlates of seeking POs from a physician for nonmedical use among PWID in Vancouver, Canada.

METHODS

Cross-sectional data from two open prospective cohort studies of PWID in Vancouver were collected between June 2013 and May 2014 (n = 1252). Multivariable logistic regression was used to identify factors associated with seeking POs from physicians for nonmedical use.

RESULTS

Of 1252 participants, 458 individuals (36.6%) reported ever trying to get a PO prescription from a physician for nonmedical use and, of these, 343 (74.9%, comprising 27.4% of the total sample) reported ever being successful. Variables independently and positively associated with PO-seeking behavior included older age (adjusted odds ratio [AOR] = 1.02), Caucasian ethnicity (AOR = 1.38), having ever overdosed (AOR = 1.32), having ever participated in methadone maintenance therapy (AOR = 1.90), having ever dealt drugs (AOR = 1.65), and having ever been refused a prescription for pain medication (AOR = 2.02) (all p < .05).

DISCUSSION AND CONCLUSIONS

We observed that PO-seeking behavior was common among this sample of PWID and associated with several markers of higher intensity drug use.

SCIENTIFIC SIGNIFICANCE

Our findings highlight the need to identify evidence-based public health and clinical strategies to mitigate PO misuse among PWID without compromising care for PWID with legitimate medical concerns. (Am J Addict 2016;25:275-282).

Discrepancies in addressing overdose prevention through prescription monitoring programs

BACKGROUND

State prescription monitoring programs (PMPs) purport to address the prescription opioid epidemic, but have evidenced limited effect on reducing opioid-related mortality.

METHODS

We systematically reviewed publicly available, PMP web-based materials from December, 2012 to October, 2013, to assess the degree to which overdose prevention was articulated in state PMP goals, mission statement, and accessible educational materials. The sites and available resources of 47 state PMPs with a web presence were reviewed by two independent coders for use of "overdose" and related terms. Website materials were further coded to capture five general thematic orientations: supply reduction-therapeutic, supply reduction-punitive, demand reduction, public health/research, and harm reduction oriented in content.

RESULTS

Twenty-nine of 47 (62%) PMPs did not address overdose or related terms in available online materials; six (12.8%) contained overdose-oriented messaging; and two included specific overdose prevention tools for providers. There were a median of three thematic orientations represented on the 18 state PMP websites mentioning only the term overdose, compared with a median of 4.5 thematic domains on the six PMP websites with overdose-oriented content.

CONCLUSIONS

A more comprehensive, public health orientation for PMPs that explicitly and publicly articulates their application and role in overdose prevention may increase PMP effectiveness and use.

Denial of prescription analgesia among people who inject drugs in a Canadian setting

INTRODUCTION AND AIMS

Despite the high prevalence of pain among people who inject drugs (PWIDs), clinicians may be reluctant to prescribe opioid-based analgesia to those with a history of drug use or addiction. We sought to examine the prevalence and correlates of PWIDs reporting being denied of prescription analgesia (PA). We also explored reported reasons for and actions taken after being denied PA.

DESIGN AND METHODS

Using data from two prospective cohort studies of PWIDs, multivariate logistic regression was used to identify the prevalence and correlates of reporting being denied PA. Descriptive statistics were used to characterise reasons for denials and subsequent actions.

RESULTS

Approximately two-thirds (66.5%) of our sample of 462 active PWIDs reported having ever been denied PA. We found that reporting being denied PA was significantly and positively associated with having ever been enrolled in methadone maintenance treatment (adjusted odds ratio 1.76, 95% confidence interval 1.11-2.80) and daily cocaine injection (adjusted odds ratio 2.38, 95% confidence interval 1.00-5.66). The most commonly reported reason for being denied PA was being accused of drug seeking (44.0%). Commonly reported actions taken after being denied PA included buying the requested medication off the street (40.1%) or obtaining heroin to treat pain (32.9%).

DISCUSSION AND CONCLUSIONS

These findings highlight the challenges of addressing perceived pain and the need for strategies to prevent high-risk methods of self-managing pain, such as obtaining diverted medications or illicit substances for pain. Such strategies may include integrated pain management guidelines within methadone maintenance treatment and other substance use treatment programs.

Correlates and Consequences of Opioid Misuse among High-Risk Young Adults

Background. Prescription opioids are the most frequently misused class of prescription drug among young adults aged 18–25, yet trajectories of opioid misuse and escalation are understudied. We sought to model opioid misuse patterns and relationships between opioid misuse, sociodemographic factors, and other substance uses. Methods. Participants were 575 young adults age 16–25 who had misused opioids in the last 90 days. Latent class analysis was performed with models based on years of misuse, recency of misuse, and alternate modes of administration within the past 12 months, 3 months, and 30 days. Results. Four latent classes emerged that were differentially associated with heroin, cocaine, and methamphetamine use, tranquilizer misuse, daily opioid misuse, and opioid withdrawal. Alternate modes of administering opioids were associated with increased risk for these outcomes. Sociodemographic factors, homelessness, prescription history, and history of parental drug use were significantly associated with riskier opioid misuse trajectories. Conclusion. Young adults who reported more debilitating experiences as children and adolescents misused opioids longer and engaged in higher risk alternate modes of administering opioids. Data on decisions both to use and to alter a drug's form can be combined to describe patterns of misuse over time and predict important risk behaviors.