Intertwined epidemics: national demographic trends in hospitalizations for heroin- and opioid-related overdoses, 1993-2009

Social and economic determinants of drug overdose deaths: a systematic review of spatial relationships

PURPOSE

To synthesize the available evidence on the extent to which area-level socioeconomic conditions are associated with drug overdose deaths in the United States.

METHODS

We performed a systematic review (in MEDLINE, EMBASE, PsychINFO, Web of Science, EconLit) for papers published prior to July 2022. Eligible studies quantitatively estimated the association between an area-level measure of socioeconomic conditions and drug overdose deaths in the US, and were published in English. We assessed study quality using the Effective Public Health Practice Project Quality Assessment Tool. The protocol was preregistered at Prospero (CRD42019121317).

RESULTS

We identified 28 studies that estimated area-level effects of socioeconomic conditions on drug overdose deaths in the US. Studies were scored as having moderate to serious risk of bias attributed to both confounding and in analysis. Socioeconomic conditions and drug overdose death rates were moderately associated, and this was a consistent finding across a large number of measures and differences in study designs (e.g., cross-sectional versus longitudinal), years of data analyzed, and primary unit of analysis (e.g., ZIP code, county, state).

CONCLUSIONS

This review highlights the evidence for area-level socioeconomic conditions are an important factor underlying the geospatial distribution of drug overdose deaths in the US and the need to understand the mechanisms underlying these associations to inform future policy recommendations. The current evidence base suggests that, at least in the United States, employment, income, and poverty interventions may be effective targets for preventing drug overdose mortality rates.

HIV-1 and opiates modulate miRNA profiles in extracellular vesicles

Opiate abuse increases the risk of HIV transmission and exacerbates HIV neuropathology by increasing inflammation and modulating immune cell function. Exosomal EVs(xEV) contain miRNAs that may be differentially expressed due to HIV infection or opiate abuse. Here we develop a preliminary exosomal-miRNA biomarker profile of HIV-infected PBMCs in the context of opiate use. PBMCs infected with HIV were treated with increasing dosages of morphine for 72 hours, the culture supernatants were collected, and the exosomes isolated using differential centrifugation. Exosomal miRNAs were extracted, expression levels determined via Nanostring multiplexed microRNA arrays, and analyzed with Webgestalt. The effect of the exosomes on neuronal function was determined by measuring calcium. Preliminary findings show that HIV-1 infection altered the miRNA profile of PBMC-derived EVs concurrently with opiate exposure. MicroRNA, hsa-miR-1246 was up-regulated 12-fold in the presence of morphine, relative to uninfected control. PBMCs infected with HIV-1 MN, an X4-tropic HIV-1 strain and exposed to morphine, displayed a trend which suggests potential synergistic effects between HIV-1 infection and morphine exposure promoting an increase in viral replication. Dose-dependent differences were observed in miRNA expression as a result of opiate exposure. The xEVs derived from PBMCs exposed to morphine or HIV modulated neuronal cell function. SH-SY5Y cells, treated with xEVs derived from ART-treated PBMCs, exhibited increased viability while for SH-SY5Ys exposed to xEVs derived from HIV-1 infected PBMCs viability was decreased compared to the untreated control. Exposing SH-SY5Y to xEVs derived from HIV-infected PBMCs resulted in significant decrease in calcium signaling, relative to treatment with xEVs derived from uninfected PBMCs. Overall, HIV-1 and morphine induced differential miRNA expression in PBMC-derived exosomes, potentially identifying mechanisms of action or novel therapeutic targets involved in opiate use disorder, HIV neuropathology, TNF signaling pathway, NF-κB signaling pathway, autophagy, and apoptosis in context of HIV infection.

Effect and safety of listening to music or audiobooks as a coadjuvant treatment for chronic pain patients under opioid treatment: a study protocol for an open-label, parallel-group, randomised, controlled, proof-of-concept clinical trial in a tertiary hospital in the Barcelona South Metropolitan area

BACKGROUND

Chronic non-cancer pain (CNCP) treatment's primary goal is to maintain physical and mental functioning while improving quality of life. Opioid use in CNCP patients has increased in recent years, and non-pharmacological interventions such as music listening have been proposed to counter it. Unlike other auditive stimuli, music can activate emotional-regulating and reward-regulating circuits, making it a potential tool to modulate attentional processes and regulate mood. This study's primary objective is to provide the first evidence on the distinct (separate) effects of music listening as a coadjuvant maintenance analgesic treatment in CNCP patients undergoing opioid analgesia.

METHODS AND ANALYSIS

This will be a single-centre, phase II, open-label, parallel-group, proof-of-concept randomised clinical trial with CNCP patients under a minimum 4-week regular opioid treatment. We plan to include 70 consecutive patients, which will be randomised (1:1) to either the experimental group (active music listening) or the control group (active audiobooks listening). During 28 days, both groups will listen daily (for at least 30 min and up to 1 hour) to preset playlists tailored to individual preferences.Pain intensity scores at each visit, the changes (differences) from baseline and the proportions of responders according to various definitions based on pain intensity differences will be described and compared between study arms. We will apply longitudinal data assessment methods (mixed generalised linear models) taking the patient as a cluster to assess and compare the endpoints' evolution. We will also use the mediation analysis framework to adjust for the effects of additional therapeutic measures and obtain estimates of effect with a causal interpretation.

ETHICS AND DISSEMINATION

The study protocol has been reviewed, and ethics approval has been obtained from the Bellvitge University Hospital Institutional Review Board, L'Hospitalet de Llobregat, Barcelona, Spain. The results from this study will be actively disseminated through manuscript publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05726266.

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

Introduction

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

Methods

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

Results

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

Discussion

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

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

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

Feasibility and acceptability of online opioid overdose education and naloxone distribution: Study protocol and preliminary results from a randomized pilot clinical trial

Drug overdose is the leading cause of accidental death in the United States, with over 70% of drug related fatalities resulting from the use of opioids. Federal agencies have responded to this crisis with various recommendations including enhancing harm reduction approaches such as training laypersons to administer naloxone through Opioid Overdose Education and Naloxone Distribution (OEND) programs. Several studies have demonstrated that OEND programs effectively reduce opioid overdose mortality and are both safe and cost-effective, however, they are typically implemented in urban areas as part of large medical center research programs, needle exchanges, or drug treatment programs. Individuals living in areas without these programs or services lack access to critical and life-saving OEND. The current study examined the acceptability and feasibility of online recruitment, online opioid overdose education, and remote distribution of naloxone kits. Persons who illicitly use opioids and are at risk for overdose were recruited through online media and completed an opioid use questionnaire. If interested in receiving opioid overdose and naloxone administration training, participants completed pre- and post-intervention knowledge questionnaires, engaged in audiovisual training, and were randomized to either receive a naloxone kit or be given information on where they could obtain one. Preliminary results indicate feasibility and acceptability as evidenced by strong recruitment and retention, as well as high participant satisfaction ratings. Successful implementation of remote OEND through this project supports future employment of similar remote programs to expand this critical harm reduction strategy to high-risk individuals in areas lacking traditional OEND programs.

Trial Registration #

Clinitaltrials.gov- NCT04303000.

Opioid Prescription Patterns 90 Days After Arthroscopic Rotator Cuff Repair: A 10-Year National Database Analysis

Background

Arthroscopic rotator cuff repair (ARCR) is a common procedure that typically requires opioid prescription for postoperative pain management.

Purpose

To investigate the current prescription patterns and factors influencing 90-day postoperative opioid prescription trends for opioid-naïve patients who underwent ARCR.

Study Design

Case series; Level of evidence, 4.

Methods

Opioid-naïve adult patients who underwent ARCR between January 2010 and September 2020 and had a record of opioid prescriptions during the 90-day postoperative period were identified in the PearlDiver Mariner91 national administrative database. Exclusions included patients with prior shoulder procedures, a history of chronic pain, and opioid prescription records dated earlier than 4 weeks before surgery. Covariates included age group, sex, Elixhauser Comorbidity Index, and prescriber specialty (orthopaedic or nonorthopaedic). The primary outcome-90-day postoperative morphine milligram equivalents (MMEs) prescribed per patient-was compared using univariate and multivariate regression analyses, and 90-day postoperative opioid prescription trends over the 10-year study period were analyzed with linear regression.

Results

In total, 55,345 ARCR cases were identified. The mean ± SD amount prescribed within the first 90 days was 742.4 ± 256.5 MMEs, and the median was 487.5 MMEs. Multivariate linear regression analysis predicted higher 90-day postoperative MMEs for female patients and younger patients (P < .01 for both). From 2010 to 2020, there was a 66% decrease in mean MME prescribed per patient (▵ = 660.4 MME; P < .01), with a mean reduction of 55.1 MME per patient per year. In 2020, the mean 90-day postoperative amount prescribed was 341.1 MME, which is equivalent to 51 tablets of 5-mg oxycodone (Percocet).

Conclusion

Female sex and younger age were predictors of more MME being prescribed after ARCR. While opioid prescriptions following ARCR have substantially decreased over the past decade, the amount prescribed warrants further attention.

A Randomized Trial Of Letters To Encourage Prescription Monitoring Program Use And Safe Opioid Prescribing

To facilitate safer prescribing of opioids and other drugs, nearly all states operate prescription monitoring programs (PMPs), which collect and share data on controlled substance dispensing. Policy makers have sought to raise clinicians' engagement with these programs but lack evidence on effective interventions. Working with the Minnesota Prescription Monitoring Program, we conducted a randomized trial to assess whether letters to clinicians increased program use and decreased risky coprescribing of opioids with benzodiazepines or gabapentinoids. In March 2021 we randomly assigned 12,000 coprescribers to either a control arm or one of three study arms sent differing letters. The respective letters highlighted a new mandate to check the PMP before prescribing, provided information about coprescribing risks with a list of coprescribed patients, or contained both messages combined. Letters highlighting the mandate alone or along with coprescribing information increased PMP search rates by 4.5 and 4.0 percentage points, respectively, with no significant effect on coprescribing. These letters also increased PMP account-holding rates among clinicians. Effects persisted for at least eight months. The letter with only coprescribing information had no detected effects on key outcomes. Our results support the use of simple letter interventions as evidence-based tools to increase PMP engagement and potentially facilitate better-informed prescribing.

The opioid epidemic

An opioid epidemic has been happening across the world since the 1990s and continues impact individuals, families, communities and societies around the globe. The epidemic has evolved from heroin misuse to the use of synthetic opioids that are easily manufactured and are readily available. Reasons for the continuing opioid epidemic are complex, and include factors related to mental health, addiction, chronic pain relief, and, now, the COVID-19 pandemic. Women have been disproportionally affected by the opioid epidemic and the physical and biosocial effects of opioid use specific to women are an important consideration for healthcare providers. Recent data show that the effects of the opioid epidemic on rates of opioid use disorder (OUD), overdoses, and the economy continue to rise, despite global efforts to understand the drivers and develop effective prevention and intervention strategies, programs, and policies.

Epidemiology of opioid use in pregnancy

The world has been experiencing an opioid epidemic for over 20 years, and rates of use and overdose among women, including during pregnancy, have risen markedly. Women receive more prescriptions for opioids compared to men. Data suggest that 20% of women filled at least one prescription for an opioid during their pregnancy, and the prevalence of prenatal exposure averaged 14%. Opioid use by women, especially during pregnancy and while breastfeeding, and management and treatment is complex for healthcare providers, especially related to methadone treatment, pain management during labour, neonatal opioid withdrawal syndrome, nutritional issues and maternal withdrawal. Opioid use during pregnancy has been associated with maternal, foetal and infant complications, and overdose has become a leading cause of death in post-partum women in some countries. Universal screening for opioid use disorder (OUD) is recommended in pregnancy, and prevention and treatment programs that meet the specific needs of women are important to understand and consider as the world continues to try to anticipate and respond to the realities of the opioid epidemic.

"1,000 conversations I'd rather have than that one:" A qualitative study of prescriber experiences with opioids and the impact of a prescription drug monitoring program

BACKGROUND

Prescription Drug Monitoring Programs (PDMPs) have shown impacts on a number of opioid-related outcomes but their role in clinician emotional experience of opioid prescribing has not been studied.

OBJECTIVES

This study explores the impact of PDMPs on clinician attitudes toward and comfort with opioid prescribing, their satisfaction with patient interactions involving discussion of opioid prescriptions, and their recognition of opioid use disorder (OUD) and ability to refer patients to treatment.

METHODS

Researchers conducted semi-structured interviews with five physicians and two nurse practitioners from a variety of specialties and practice environments.

RESULTS

Many participants reported negative emotions surrounding opioid-related patient encounters, with decreased anxiety related to PDMP availability. These effects were less pronounced with clinicians who had greater opioid prescribing experience (either longer careers or higher-volume pain practices). Many participants felt uncomfortable around opioid prescribing. Data from the PDMP often changed prescribing practices, sometimes leading to greater comfort writing a prescription that might have felt riskier without PDMP data. Clinicians easily recognized patient behaviors, symptoms, and prescription requests suggesting that opioid-related adverse events were accumulating, but did not usually apply a label of OUD to these situations. PDMP findings occasionally contributed to a diagnosis and treatment referral for OUD.

CONCLUSIONS

PDMP data is part of a nuanced approach to prescribing opioids. The objectivity of the data may be helpful in mitigating clinician negative emotions that are common around opioid therapy.

Is Patient Geography a Risk Factor for Chronic Opioid Use After ACDF?

The social and medical implications intrinsic to patient zip codes with high opioid fatality may reveal residence in these locations to be a risk factor predicting chronic opioid use after anterior cervical discectomy and fusion (ACDF). The purpose of this study is to determine if residence in Pennsylvania zip codes with high incidence of opioid overdose deaths is a risk factor for chronic postoperative opioid use after ACDF. Preoperative opioid usage did not vary meaningfully between high- and low-risk zip code groups. Patients in high-risk opioid overdose zip codes were significantly more likely to exhibit chronic postoperative opioid use. The Kaplan-Meier curve demonstrated that opioid discontinuation was less probable at any postoperative time for patients residing in high opioid fatality zip codes. Logistic regression found opioid tolerance, smoking, and depression to predict extended opioid use.

Drug use behaviors, trauma, and emotional affect following the overdose of a social network member: A qualitative investigation

BACKGROUND

Scant research has examined the influence of overdoses occurring in social networks (i.e., knowing someone who has overdosed) on individual overdose risk. We sought to characterize drug use behaviors of individuals following the overdose of someone in their social network.

METHODS

We conducted semi-structured interviews with 25 people who use drugs and knew someone who overdosed in the prior 90 days. All interviews were conducted in person in Rhode Island from July to October 2021. Data were stratified by drug use behaviors following the overdose of a network member (i.e., risk behaviors, protective behaviors, no change; selected a priori) and analyzed using a thematic analysis variation to identify salient themes.

RESULTS

We identified variation in the effect of knowing someone who overdosed on subsequent drug use behaviors and emotional affect. Several participants described increasing their drug use or using more types of drugs than usual to manage feelings of bereavement and trauma, and a subset of these participants described increased drug use with suicidal intention and increased suicidal ideations following the overdose event. Other participants described reducing their drug use and engaging in protective behaviors in response to heightened perceived overdose risk, protection motivation (i.e., increased motivation to protect oneself), and concern for others. Additionally, some participants reported no change in drug use behaviors, and these participants described already engaging in harm reduction practices, feeling desensitized due to frequent or repeated exposure to overdose, and ambivalence about living.

CONCLUSIONS

Findings suggest a need for enhanced investment in network-based overdose prevention interventions, as well as more robust integration of bereavement support and mental health services in settings that serve people who use drugs. The findings also suggest a need for future research to identify mediators of the effect of overdose occurring in social networks on individual overdose risk.

Effect of HCV or HIV infection on mortality among hospitalized persons who used opioids, 2000-2010

Mortality due to opioid misuse and overdose has increased substantially in the United States over the past two decades. The study objective was to describe the causes of death among persons with opioid-related hospitalizations and examine survival by Hepatitis C virus (HCV) or HIV. Opioid-related hospitalization records in Pennsylvania from 2000 to 2010 were linked to death registry files to assess cause of death, and survival from first hospital discharge date to death date, or December 31, 2010. Accelerated failure time models were used to compare survival between persons with and without HCV or HIV diagnoses. Among the 136,416 individuals with an opioid-related hospitalization, 13.0% died over a median of 56 months of follow-up; the most common causes of death were circulatory diseases (26.4%) and drug overdose (23.5%). There were 27,122 (19.9%) and 3662 (2.7%) persons who had an HCV and HIV diagnosis, respectively. Among patients aged ≥20 years, those with HCV had shorter survival time compared to those without HCV, with discrepancies more pronounced at older ages. Patients with HIV also had shorter survival time (time ratio: 0.29 [95% CI: 0.26, 0.34]) compared to without HIV. These findings show that in a cohort of patients with opioid-related hospitalizations, those with HCV or HIV diagnoses have shorter survival. This has public health implications, providing further evidence that medical providers should educate patients who use opioids about the risks of HCV and HIV infection and focus prevention and treatment to decrease mortality among patients hospitalized for opioid use.

The effects of opioid policy changes on transitions from prescription opioids to heroin, fentanyl and injection drug use: a qualitative analysis

BACKGROUND

Beginning in the 1990s, nonmedical use of prescription opioids (POs) became a major public health crisis. In response to rising rates of opioid dependence and fatal poisonings, measures were instituted to decrease the prescription, diversion, and nonmedical use of POs including prescription drug monitoring programs (PDMPs), pain clinic laws, prescription duration limits, disciplining doctors who prescribed an excessive number of POs, and the advent of abuse deterrent formulations of POs. This paper explores the unintended effects of these policies in the descriptions of why people who use opioids transitioned from PO to injection or heroin/fentanyl use.

METHODS

We conducted 148 in-depth-interviews with people who use prescription opioids nonmedically, fentanyl or heroin from a rural, urban and suburban area in three states, Connecticut, Kentucky and Wisconsin. Interviews with people who use opioids (PWUO) focused on how they initiated their opioid use and any transitions they made from PO use to heroin, fentanyl or injection drug use.

RESULTS

The majority of participants reported initiating use with POs, which they used for medical or nonmedical purposes. They described needing to take more POs or switched to heroin or fentanyl as their tolerance increased. As more policies were passed to limit opioid prescribing, participants noticed that doctors were less likely to prescribe or refill POs. This led to scarcity of POs on the street which accelerated the switch to heroin or fentanyl. These transitions likely increased risk of overdose and HIV/HCV infection.

CONCLUSIONS

A careful analysis of how and why people say they transitioned from PO to heroin or fentanyl reveals many unintended harms of policy changes to prevent overprescribing and diversion. Results highlight the importance of mitigating harms that resulted from policy changes.

Opioid use and social disadvantage in patients with chronic musculoskeletal pain

BACKGROUND

Historically, marginalized patients were prescribed less opioid medication than affluent, white patients. However, because of persistent differential access to nonopioid pain treatments, this direction of disparity in opioid prescribing may have reversed.

OBJECTIVE

To compare social disadvantage and health in patients with chronic pain who were managed with versus without chronic opioid therapy. It was hypothesized that patients routinely prescribed opioids would be more likely to live in socially disadvantaged communities and report worse health.

DESIGN

Cross-sectional analysis of a retrospective cohort defined from medical records from 2000 to 2019.

SETTING

Single tertiary safety net medical center.

PATIENTS

Adult patients with chronic musculoskeletal pain who were managed longitudinally by a physiatric group practice from at least 2011 to 2015 (n = 1173), subgrouped by chronic (≥4 years) adherent opioid usage (n = 356) versus no chronic opioid usage (n = 817).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The primary outcome was the unadjusted between-group difference in social disadvantage, defined by living in the worst national quartile of the Area Deprivation Index (ADI). An adjusted effect size was also calculated using logistic regression, with age, sex, race, and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Physical Function scores as covariates. Secondary outcomes included adjusted differences in health by chronic opioid use (measured by PROMIS).

RESULTS

Patients managed with chronic opioid therapy were more likely to live in a zip code within the most socially disadvantaged national quartile (34.9%; 95% confidence interval [CI] 29.9-39.9%; vs. 24.9%; 95% CI 21.9-28.0%; P < .001), and social disadvantage was independently associated with chronic opioid use (odds ratio [OR] 1.01 per ADI percentile [1.01-1.02]). Opioid use was also associated with meaningfully worse PROMIS Depression (3.8 points [2.4-5.1]), Anxiety (3.0 [1.4-4.5]), and Pain Interference (2.6 [1.7-3.5]) scores.

CONCLUSIONS

Patients prescribed chronic opioid treatment were more likely to live in socially disadvantaged neighborhoods, and chronic opioid use was independently associated with worse behavioral health. Improving access to multidisciplinary, nonopioid treatments for chronic pain may be key to successfully overcoming the opioid crisis.

Outcomes from the medication assisted treatment pilot program for adults with opioid use disorders in rural Colorado

BACKGROUND

As Colorado ranked among the top nationally in non-medical use of opioids, a pilot medication for opioid use disorder (MOUD) program was developed to increase the number of NPs and PAs providing MOUD in order to bring this evidence- based treatment to 2 counties showing disproportionally high opioid overdose deaths. Over the first 18 months, the MOUD Pilot Program led to 15 new health care providers receiving MOUD waiver training and 1005 patients receiving MOUD from the 3 participating organizations. Here we evaluate patient centered clinical and functional outcomes of the pilot MOUD program implemented in 2 rural counties severely affected by the opioid crisis.

METHODS

Under state-funded law (Colorado Senate Bill 17-074), three rural agencies submitted de-identified patient-level data at baseline (N = 1005) and after 6 months of treatment (N = 190, 25%) between December 2017 and January 2020. The Addiction Severity Index, PhQ9 and GAD-7 with McNemar-Bowker, and Wilcoxon Signed Rank tests analysis were used to measure patient outcomes across after participation in the program. .

RESULTS

Patients in treatment reported using less heroin (52.1% vs 20.4%), opioids (22.3% vs 11.0%), and alcohol (28.6% vs 13.1%, all P < 0.01). Patients reported improved health (53.4% vs. 68.2%, P = 0.04), less frequency of disability (8.69 vs. 6.51, P = 0.02), symptoms (29.8% vs 21.3%), pain (67.5% to 53.6), worry (45.3% vs 62.3%), anxiety (49.7% vs 23.2%), depression (54.1% vs 23.3%, all P < 0.02) after treatment.

CONCLUSIONS

This study shows decreased substance use, improved physical and mental health, and reduced symptoms after 6 months of MOUD. Although more research on retention and long-term effects is needed, data shows improved health outcomes after 6 months of MOUD. Lessons learned from implementing this pilot program informed program expansion into other rural areas in need to address some of Colorado' major public health crises.

The impact of access to addiction specialist on attitudes, beliefs and hospital-based opioid use disorder related care: A survey of hospitalist physicians

BACKGROUND

Hospitalizations for complications related to opioid use disorder (OUD) are increasing. Hospitalists care for most hospitalized patients in the United States, yet little is known about their attitudes, beliefs, and clinical practices regarding OUD-related care.

Methods: We distributed an online survey to hospitalists in the United States to measure how access to addiction specialists affected attitudes and beliefs regarding hospital-based OUD care, OUD screening practices, naloxone prescribing, and buprenorphine initiation.

Results: Among 262 respondents, 67.9% (n = 178) reported having access to addiction specialists. While 84.5% (n = 221) reported often or always caring for patients with OUD, 48.2% (n = 126) rarely or never screened for OUD, 57.1% (n = 149) rarely or never prescribed or recommended naloxone as harm reduction, and 88.9% (n = 233) rarely or never initiated buprenorphine. In multivariable analyses, compared to hospitalists without access to addiction specialists, hospitalist with access to addiction specialists were more likely to feel supported to screen and refer patients to treatment (aOR = 4.4, 95% CI 2.1 - 9.1; ρ < 0.001), to be aware of local treatment resources (aOR = 3.4, 95% CI 1.8 - 6.3; ρ < 0.001), and refer patients to treatment (aOR = 3.0, 95% CI 1.7 - 5.6; ρ < 0.001).

Conclusions: Many hospitalists do not provide life-saving treatment to patients with OUD. Access to addiction specialists may increase provision of OUD-related care by hospitalists.

Treatment Disparities Among the Black Population and Their Influence on the Equitable Management of Chronic Pain

Introduction: Growing evidence suggests disparities in the prevalence, management, progression, and outcomes of chronic, nonmalignant pain-related conditions, especially for African American patients. Objective: The purpose of this review is to explore studied causative factors that influence the management of chronic pain among African Americans, including factors that result in disparate care that may contribute to unfavorable outcomes. Methods: This narrative review is based on available literature published on this topic published within the last 10 years. Results: Assessment of chronic pain is multifaceted, often complicated by patient medical comorbidities and a complex set of biopsychosocial/spiritual/financial and legal determinants. These complexities are further exacerbated by a patient's race, by provider bias, and by structural barriers-all intersecting and culminating in disparate outcomes. Conclusions: A comprehensive analysis is needed to identify quality improvement interventions and to mitigate major barriers contributing to disparities in the management of chronic pain in the African American population.

Effects of fentanyl on acute locomotor activity, behavioral sensitization, and contextual reward in female and male rats

BACKGROUND

Although fentanyl has gained widespread prominence, there remains a lack of knowledge on this opioid synthetic agonist, particularly related to sex effects. Therefore, we conducted behavioral tests in female and male rats to measure drug abuse-related responses to fentanyl hypothesizing sex-specific responses.

METHODS

Using female and male rats, we measured the effects of acute or repeated administration of fentanyl (20 μg/kg) on locomotor activity (LMA) and behavioral sensitization in an open field test. We further measured contextual-reward and associated locomotor activity during training in a conditioned place preference (CPP) paradigm using a low (4 μg/kg) or high (16 μg/kg) dose of fentanyl. Vaginal lavage samples were collected from female rats in the CPP study, and the estrous phase was determined based on the cytological characterization.

RESULTS

Female, but not male, rats showed elevated LMA in response to acute fentanyl and behavioral sensitization to repeated administration of fentanyl. Fentanyl produced significant CPP in both sexes, but it was more potent in males. Finally, our secondary investigation of the estrous cycle on fentanyl-CPP suggests that non-estrus phases, likely reflecting high estradiol, may predict the degree of fentanyl preference in females.

CONCLUSIONS

Fentanyl was more potent and/or effective to produce LMA and LMA sensitization in females but more potent to produce CPP in males. Furthermore, the role of sex in fentanyl responses varied across endpoints, and sex differences in LMA were not predictive of sex differences in CPP.

Impact of Marijuana Legalization on Opioid Utilization in Patients Diagnosed with Pain

BACKGROUND

Given efforts to reduce opioid use, and because marijuana potentially offers a lower-risk alternative for treating chronic pain, there is interest in understanding the public health impact of marijuana legalization on opioid-related outcomes.

OBJECTIVE

Assess the impact of recreational and medical marijuana legalization on opioid utilization among patients receiving pharmacotherapy for pain.

DESIGN

Retrospective claims-based study of commercially insured patients continuously eligible for pharmacy and medical benefits from July 8, 2014 to June 30, 2017. Index pain prescription period was defined between January 8, 2015 and June 30, 2015, and longer-term opioid use examined during 2-year follow-up. Marijuana state policy on July 1, 2015, was assigned: none; medical only; or medical and recreational.

PARTICIPANTS

Patients aged 18-62 without cancer diagnosis.

MAIN MEASURES

Patient receiving (1) opioid at index; (2) > 7 days' supply of index opioid; (3) opioid during follow-up; and (4) ≥ 90 days' opioid supply during follow-up. Multivariable regression assessed associations between opioid utilization and state marijuana policy, adjusting for age, gender, overall disease burden, mental health treatment, concomitant use of benzodiazepine or muscle relaxant, and previous pain prescription.

KEY RESULTS

Of 141,711 patients, 80,955 (57.1%) resided in states with no policy; 56,494 (39.9%) with medical-only; and 4262 (3.0%) with medical and recreational. Patients in states with both policies were more likely to receive an index opioid (aOR = 1.72, 95% CI = 1.61-1.85; aOR = 1.90, 95% CI = 1.77-2.03; P < 0.001) but less likely to receive > 7 days' index supply (aOR = 0.84, 95% CI = 0.77-0.91; aOR = 0.76, 95% CI = 0.70-0.83; P < 0.001) than patients in states with no policy or medical-only, respectively. Those in states with both policies were more likely to receive a follow-up opioid (aOR = 1.87, 95% CI = 1.71-2.05; aOR = 2.20, 95% CI = 2.01-2.42; P < 0.001) than those in states with no policy or medical-only, respectively, and more likely to receive ≥ 90 cumulative follow-up opioid days' supply (aOR = 1.18, 95% CI = 1.07-1.29; P < 0.001) than those in states with no policy.

CONCLUSIONS

Our analysis does not support the supposition that access to marijuana lowers use of chronic opioids for pain.

Medical and Non-Medical Opioid Use at the Intersection of Gender and Sexual Identity: Associations with State Medical Cannabis Law Status in a U.S. National Sample of Adults

At the structural level, medical cannabis laws (MCLs) have been negatively associated with opioid prescribing practices, and sexual minority adults report disproportionately high non-medical prescription opioid use. We examined medical/non-medical prescription opioid use by intersecting sexual identity and gender and explored associations with MCLs using the 2015-2017 National Survey on Drug Use and Health, which captured sexual identity and MCL state residence for adults 18 + years (N = 126,463). Survey-weighted gender-stratified multinomial logistic models estimated adjusted relative risk ratios (aRRR) of medical vs. no prescription opioid use, and any non-medical vs. no prescription opioid use, by sexual identity and MCL, and tested moderation by MCL. Past-year medical prescription opioid use was higher among women than men across sexual identities (e.g., bisexual: 38.5% women vs. 30.2% men). Non-medical prescription opioid use was lower among women than men, except for bisexual adults (12.4% women vs. 7.6% men). MCL was associated with lower medical prescription opioid vs. no use among heterosexual women (aRRR = 0.86, 95% confidence interval [CI] = 0.81-0.91), bisexual women (aRRR = 0.74, 95% CI = 0.62-0.89), and heterosexual men (aRRR = 0.91, 95% CI = 0.85-0.97). Living in an MCL state was associated with lower non-medical vs. no use among heterosexual and bisexual women, but not among men or lesbian/gay women. MCL status did not moderate associations between sexual identity and prescription opioid outcomes. Future studies should assess whether implementing MCLs could particularly affect bisexual women who reported the highest prescription opioid use and may need targeted services.

Evaluating Montréal's harm reduction interventions for people who inject drugs: protocol for observational study and cost-effectiveness analysis

INTRODUCTION

The main harm reduction interventions for people who inject drugs (PWID) are supervised injection facilities, needle and syringe programmes and opioid agonist treatment. Current evidence supporting their implementation and operation underestimates their usefulness by excluding skin, soft tissue and vascular infections (SSTVIs) and anoxic/toxicity-related brain injury from cost-effectiveness analyses (CEA). Our goal is to conduct a comprehensive CEA of harm reduction interventions in a setting with a large, dispersed, heterogeneous population of PWID, and include prevention of SSTVIs and anoxic/toxicity-related brain injury as measures of benefit in addition to HIV, hepatitis C and overdose morbidity and mortalities averted.

METHODS AND ANALYSIS

This protocol describes how we will develop an open, retrospective cohort of adult PWID living in Québec between 1 January 2009 and 31 December 2020 using administrative health record data. By complementing this data with non-linkable paramedic dispatch records, regional monthly needle and syringe dispensation counts and repeated cross-sectional biobehavioural surveys, we will estimate the hazards of occurrence and the impact of Montréal's harm reduction interventions on the incidence of drug-use-related injuries, infections and deaths. We will synthesise results from our empirical analyses with published evidence to simulate infections and injuries in a hypothetical population of PWID in Montréal under different intervention scenarios including current levels of use and scale-up, and assess the cost-effectiveness of each intervention from the public healthcare payer's perspective.

ETHICS AND DISSEMINATION

This study was approved by McGill University's Institutional Review Board (Study Number: A08-E53-19B). We will work with community partners to disseminate results to the public and scientific community via scientific conferences, a publicly accessible report, op-ed articles and open access peer-reviewed journals.

Remifentanil self-administration in mice promotes sex-specific prefrontal cortex dysfunction underlying deficits in cognitive flexibility

Opioid-based drugs are frequently used for pain management in both males and females despite the known risk of prefrontal cortex dysfunction and cognitive impairments. Although poorly understood, loss of cognitive control following chronic drug use has been linked to decreased activation of frontal cortex regions. Here, we show that self-administration of the potent opioid, remifentanil, causes a long-lasting hypoactive basal state evidenced by a decrease in ex vivo excitability that is paralleled by an increase in firing capacity of layer 5/6 pyramidal neurons in the prelimbic, but not infralimbic region of the medial prefrontal cortex. This phenomenon was observed in females after as few as 5 days and up to 25-30 days of self-administration. In contrast, pyramidal neurons in males showed increased excitability following 10-16 days of self-administration, with hypoactive states arising only following 25-30 days of self-administration. The emergence of a hypoactive, but not hyperactive basal state following remifentanil self-administration aligned with deficits in cognitive flexibility as assessed using an operant-based attentional set-shifting task. In females, the hypoactive basal state is driven by a reduction in excitatory synaptic transmission mediated by AMPA-type glutamate receptors. Alternatively, hyper- and hypoactive states in males align selectively with decreased and increased GABA_B signaling, respectively. Chemogenetic compensation for this hypoactive state prior to testing restored cognitive flexibility, basal hypoactive state, and remifentanil-induced plasticity. These data define cellular and synaptic mechanisms by which opioids impair prefrontal function and cognitive control; indicating that interventions aimed at targeting opioid-induced adaptations should be tailored based on biological sex.

Trends in psychotropic-drug-implicated mortality: Psychotropic drugs as a contributing but non-underlying cause of death

BACKGROUND

Drug overdoses have contributed to considerable years of life lost. However, focusing solely on drug overdoses, whereby drug poisoning defines the underlying cause of death, obscures the wider burden of the drug mortality crisis. We aim to describe 21 years of trends in "psychotropic-drug-implicated deaths," those where psychotropic drugs are a contributing (but not the underlying) cause of death.

METHODS

We analyze deaths extracted from CDC WONDER from 1999-2019 to generate annual counts and rates for psychotropic-drug-implicated deaths in the United States, including by underlying cause of death and drug implicated.

RESULTS

Over 21 years, 51,446 psychotropic-drug-implicated deaths occurred (33,885 medical; 17,561 external). Both medical and external psychotropic-drug-implicated deaths rose dramatically, increasing 2.5 and 5.0 times, respectively. Diseases of the circulatory system predominated underlying causes of medical deaths (74 %). Non-drug suicide, transport accidents, and drownings constitute 54 % of external underlying causes. Among the various underlying causes of death, psychotropic-drug-implicated deaths represent a considerable proportion, especially among external causes, with the proportion greatly increasing over the observation period. The drug implicated evolves from cocaine to opioids to psychostimulants, with the latter rising considerably.

CONCLUSIONS

The drug mortality crisis extends beyond overdose and may temper improvements observed within other causes of mortality, such as cardiovascular disease, transport accidents, and drownings. As with overdoses, psychotropic-drug-implicated deaths have risen dramatically during the 21st century. They include striking increases for drugs, such as psychostimulants, receiving less attention with overdoses. Research is needed to address prevention, intervention, and policy for psychotropic-drug-implicated deaths beyond overdose mortality.

The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis

PURPOSE OF REVIEW

This review provides an update on recently published literature on the rise of illicit fentanyls, risks for overdose, combinations with other substances, e.g. stimulants, consequences, and treatment.

RECENT FINDINGS

Overdose due to illicit synthetic opioids (e.g. fentanyl and fentanyl analogs) continues to rise in the US both preceding and during the COVID-19 pandemic. Fentanyl-related overdose is rising in new geographic areas e.g. the western USA. Stimulant-related overdose is also increasing nationwide driven by methamphetamine and cocaine. Polysubstance use, e.g. the use of a stimulant along with an opioid is driving stimulant-related overdose. Other medical consequences of injection drug use are rising including HIV and hepatitis C infections. Medication approaches to treating opioid use disorder remain the standard of care and there are new promising pharmacological approaches to treating methamphetamine use disorder.

SUMMARY

A 'fourth wave' of high mortality involving methamphetamine and cocaine use has been gathering force in the USA. Availability and use of illicit fentanyls are still the major drivers of overdose deaths and the current rise in stimulant-related deaths appears entwined with the ongoing opioid epidemic.

Endogenous and exogenous opioid effects on oligodendrocyte biology and developmental brain myelination

The elevated presence of opioid receptors and their ligands throughout the developing brain points to the existence of maturational functions of the endogenous opioid system that still remain poorly understood. The alarmingly increasing rates of opioid use and abuse underscore the urgent need for clear identification of those functions and the cellular bases and molecular mechanisms underlying their physiological roles under normal and pathological conditions. This review is focused on current knowledge on the direct and indirect regulatory roles that opioids may have on oligodendrocyte development and their generation of myelin, a complex insulating membrane that not only facilitates rapid impulse conduction but also participates in mechanisms of brain plasticity and adaptation. Information is examined in relation to the importance of endogenous opioid function, as well as direct and indirect effects of opioid analogues, which like methadone and buprenorphine are used in medication-assisted therapies for opioid addiction during pregnancy and pharmacotherapy in neonatal abstinence syndrome. Potential opioid effects are also discussed regarding late myelination of the brain prefrontal cortex in adolescents and young adults. Such knowledge is fundamental for the design of safer pharmacological interventions for opioid abuse, minimizing deleterious effects in the developing nervous system.

Trends in substances involved in polysubstance overdose fatalities in Maryland, USA 2003-2019

BACKGROUND

The substances driving the overdose epidemic in the United States have changed over time. Since 2013, fentanyl-analogues have become the primary opioids driving the epidemic. Recently, polysubstance related deaths have come to the forefront of the epidemic. Therefore, we explored trends in polysubstance involvement in overdose fatalities in Maryland between 2003 and 2019.

METHODS

We used records for the Maryland Office of the Chief Medical Examiner between 2003 and 2019. First, we assessed trends in the number of drugs (1, 2, 3+) involved in overdose fatalities over time. Then, we assessed linear and quadratic trends in nine substance categories using logistic regression.

RESULTS

Overtime, the proportion of overdose deaths involving one (ß=-0.28, p < 0.001) or two (ß=-0.14, p < 0.001) drugs decreased, while deaths involving three or more drugs increased (ß = 0.31, p < 0.001). The involvement of most drugs decreased over the study period. Only cocaine (linear ß=-0.08, p < 0.001; quadratic ß = 0.29, p < 0.001) and fentanyl (linear ß = 1.67, p < 0.001; quadratic ß = 0.75, p < 0.0001) showed significant increases over time. Post hoc analyses showed that cocaine involvement only increased in the presence of fentanyl (linear ß = 1.41, p < 0.001; quadratic ß = 0.70, p < 0.001) and decreased when fentanyl was not present (linear ß=-0.81, p < 0.001; quadratic ß=-0.31, p < 0.001).

CONCLUSIONS

Polysubstance involvement in overdose fatalities has become more common over time in Maryland. Most individual substances became less common over time, while cocaine and fentanyl involvement increased. Unintentional fentanyl consumption through contaminated cocaine may be an increasingly important driver of deaths in Maryland, indicating the importance of implementing widespread harm reduction programs, especially drug checking.

Associations between baseline opioid use disorder severity, mental health and biopsychosocial functioning, with clinical responses to computer-assisted therapy treatment

Background: Increasing rates of opioid-related overdose have been identified globally. Treatment for opioid use disorders (OUD) includes medications for opioid use disorder (MOUD) alongside behavioral support. Novel approaches to behavioral support should be explored, including computer-assisted therapy (CAT) programs.Objectives: Examine differences between baseline and post-treatment measures of opioid use and biopsychosocial functioning for individuals with OUD engaging with the CAT program 'Breaking Free Online,' and the extent to which participant characteristics may be associated with post-treatment measures.Methods: 1107 individuals engaged with CAT and provided baseline and post-treatment data - 724 (65.4%) were male, 383 (34.6%) were female.Results: Significant differences between baseline and post-treatment measures were identified (all p <.0001, effect sizes range:15 -.50). Participant characteristics were associated with post-treatment measures of opioid use, opioid dependence, mental health issues, quality of life, and biopsychosocial impairment (all p <.0001). An aggregated consensus measure of clinical impairment was found to be associated with changes in opioid use and post-treatment biopsychosocial functioning measures, with those participants with greater baseline clinical impairment demonstrating a greater magnitude of improvement from baseline to post-treatment than those with lower clinical impairment.Conclusion: CAT may reduce opioid use and improve biopsychosocial functioning in individuals with OUD. CAT could therefore provide a solution to the global opioid crisis if delivered as combination behavioral support alongside MOUD. Findings also indicate that it may be important for treatment systems to identify individuals with psychosocial complexity who might require behavioral support and MOUD.

Opioid misuse and family structure: Changes and continuities in the role of marriage and children over two decades

BACKGROUND

The opioid crisis is widely felt in the United States. Scholarly attention to the crisis focuses on macro-level processes and largely neglects meso-level explanations such as family structure for opioid use behaviors. We hypothesize that married adults and adults with coresident children are at lower risk of misusing prescription pain relievers (PPR), using heroin, and using needles to inject heroin relative to adults from other family structures.

METHOD

We used National Survey on Drug Use and Health data from 2002-2018 to test our hypotheses with multivariable logistic regression.

RESULTS

We found that married adults have a lower predicted probability of each opioid use behavior relative to nonmarried adults across the study period. We also found that the presence of children is associated with reductions in all three outcomes especially for never married adults.

CONCLUSION

Individuals from all family structures are vulnerable to the opioid crisis, but never married adults without coresident children ("disconnected adults") are especially susceptible to temporal fluctuations and drive the temporal trends in PPR misuse and heroin use. These findings suggest that ongoing demographic trends where disconnected adults are a growing population may result in future rises in opioid use disorders and mortality because of divestment from U.S. social safety nets. Future research should examine the role of U.S. policies that make disconnected adults especially vulnerable to developing opioid use disorders.

When an obscurity becomes trend: social-media descriptions of tianeptine use and associated atypical drug use

Background: Originally believed to be an atypical antidepressant acting at serotonin transporters, tianeptine is now known to also be an atypical agonist at mu-opioid receptors. Its nonmedical use may be increasing amidst the broader context of novel drug and supplement use.Objectives: To analyze social-media text from current, former, and prospective tianeptine users for better understanding of their conceptualizations of tianeptine, motives for and patterns of use, and reported benefits and harms.Methods: Reddit posts were obtained and thematically coded; additional quantitative analyses were conducted.Results: A total of 210 posts mentioning tianeptine were made between 2012 and 2020. Eighteen thematic categories were identified, 10 of which were consistent with expected themes. Two independent raters coded all text, generating 1,382 unique codes, of which 1,090 were concordant (78.9% interrater agreement). Tianeptine use was frequently associated with use of other drugs, particularly kratom, phenibut, and racetams. People conceptualized and variously used tianeptine as an opioid, antidepressant, and "nootropic" (cognitive enhancer). Between 2014 and 2020, mentions of positive effects decreased, while mentions of adverse effects and withdrawal increased. Motivations for use included substitution or withdrawal mitigation for other drugs (especially opioids) and for kratom itself; self-treatment for psychiatric symptoms; and improvement of quality of life, mood, or performance. Descriptions of tolerance, withdrawal, and addiction were evident. Intravenous use was rare and strongly discouraged, with detrimental effects described.Conclusion: Tianeptine is recognized as an opioid (though not only an opioid) in online communities. Posts describe benefits, acute risks, and patterns of co-use that warrant greater clinical attention.

How the presentation of patient information and decision-support advisories influences opioid prescribing behavior: A simulation study

OBJECTIVE

The United States faces an opioid crisis. Integrating prescription drug monitoring programs into electronic health records offers promise to improve opioid prescribing practices. This study aimed to evaluate 2 different user interface designs for prescription drug monitoring program and electronic health record integration.

MATERIALS AND METHODS

Twenty-four resident physicians participated in a randomized controlled experiment using 4 simulated patient cases. In the conventional condition, prescription opioid histories were presented in tabular format, and computerized clinical decision support (CDS) was provided via interruptive modal dialogs (ie, pop-ups). The alternative condition featured a graphical opioid history, a cue to visit that history, and noninterruptive CDS. Two attending pain specialists judged prescription appropriateness.

RESULTS

Participants in the alternative condition wrote more appropriate prescriptions. When asked after the experiment, most participants stated that they preferred the alternative design to the conventional design.

CONCLUSIONS

How patient information and CDS are presented appears to have a significant influence on opioid prescribing behavior.

Opioid use at the transition to emerging adulthood: A latent class analysis of non-medical use of prescription opioids and heroin use

BACKGROUND

Although rates of nonmedical opioid use are highest in late adolescence and emerging adulthood, efforts to understand the extent of the heterogeneity in opioid misuse during this time have been limited. The current study aimed to derive and define typologies of opioid use in high school students at the onset of emerging adulthood.

METHODS

Survey responses from a statewide sample of high school students aged 18 and 19 (N = 26,223) were analyzed. Group-based comparisons between participants reporting opioid use and those not reporting opioid use were conducted. Among those reporting opioid use (n = 1,636), we conducted a latent class analysis (LCA) to identify heterogeneous subgroups of opioid users on the basis of non-medical use of prescription opioids (NMUPO) and heroin use. The resulting classes were then compared across various risk and protective factors using multinominal logistic regression.

RESULTS

Consistent differences were observed between participants using opioids and participants not using opioids, with moderate to large effect sizes. Results from LCA revealed three subclasses: NMUPO-Any Use, NMUPO To Get High, and Heroin Use. Subclass differences were observed for non-opioid substance use, mental health, and demographics.

CONCLUSIONS

Findings from this study underscore the variability of youth who engage in opioid use in late adolescence. Results also indicate that opioid use during adolescence is likely indicative of a broader set of substance use and mental health issues.

Temporal trends in rates of opioid misuse among delivery-related hospitalizations in North Carolina from 2000 to 2014

Opioid misuse during pregnancy is increasing at an alarming rate across the United States. To determine the prevalence, temporal trends, and resource usage of delivery-related hospitalizations of women who misuse opioids in North Carolina from 2000 to 2014. A retrospective, cross-sectional study was conducted using the State Inpatient Databases. Annual prevalence was calculated, and linear trends were assessed using logistic regression. Temporal trends in hospital charges and length of stay (LOS) were analyzed using ordinary least squares regression with a log_e-transformed response. Of 1,937,455 delivery-related hospitalizations in NC, 6,084 were associated with opioid misuse, a prevalence of 3.14 cases per 1,000 delivery-related discharges. During the study period, the prevalence of opioid misuse during pregnancy in NC increased 955%, from 0.9 cases per 1,000 discharges in 2000 to 9.5 cases per 1,000 discharges in 2014, an average annual rate increase of 1.18 cases (95% CI, 1.16-1.21; P < 0.0001). Median LOS for women who misuse opioids remained stable at three days, whereas the median charge per delivery-related hospitalization significantly increased from $6,311 in 2000 to $9,019 in 2010 (annual average change [AAC], 282.2; 95% CI, 182.9-381.5; P < 0.0001) and from $8,908 in 2011 to $10,864 in 2014 (AAC, 667.5; 95% CI, 275.2-1059.9; P < 0.0001). Health care providers and policymakers in NC are advised to introduce system-wide public health responses focused on prevention and increased access to evidence-based treatment that improves the health of the mothers and neonates who are exposed to opioids.

Factors Associated with Sterile Syringe Acquisition among People Who Inject Drugs in West Virginia

BACKGROUND

Syringe services programs (SSPs) are evidence-based interventions that provide essential overdose and infectious disease prevention resources to people who inject drugs (PWID). Little research has examined factors associated with sterile syringe acquisition at SSPs among rural PWID populations.

OBJECTIVES

We aim to identify factors associated with PWID in a rural county in West Virginia having recently acquired sterile syringes at an SSP.

METHODS

PWID (n = 420) completed a survey that included measures related to sociodemographics, structural vulnerabilities, and substance use. We used multivariable Poisson regression with robust variance estimation to examine independent associations with sterile syringe acquisition at an SSP.

RESULTS

Sixty-five percent of our sample reported having recently acquired sterile syringes at an SSP. Factors associated with recent sterile syringes acquisition at an SSP included: being older (aPR [adjusted prevalence ratio]: 1.011, 95% CI: 1.003-1.019), single (aPR: 0.862, 95% CI: 0.755-0.984), experiencing food insecurity (aPR: 1.233, 95% CI: 1.062-1.431), recently injecting fentanyl (aPR: 1.178, 95% CI: 1.010-1.375) and prescription opioid pain relievers (aPR: 0.681, 95% CI: 0.551-0.842), and recent naloxone acquisition (aPR: 1.360; 95% CI: 1.178-1.569). Receptive syringe sharing was inversely associated with acquiring sterile syringes at an SSP (aPR: 0.852; 95% CI: 0.741-0.979).

CONCLUSION

PWID accessing sterile syringes at an SSP was associated with several sociodemographic, structural, and substance use factors. Ensuring rural SSP operations are tailored to local PWID population-level needs is paramount to the prevention of infectious disease outbreaks and overdose fatalities.

Opioid Use Is Reduced in Patients Treated with NSAIDs After Arthroscopic Bankart Repair: A Randomized Controlled Study

Purpose

To evaluate the efficacy of oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the primary postoperative pain medication compared with standard oral opioids after arthroscopic shoulder capsulolabral (Bankart) repair for recurrent anterior shoulder instability.

Methods

This was a single-center, prospective, randomized controlled study. Patients aged 18 to 65 years indicated for arthroscopic shoulder capsulolabral repair for recurrent anterior shoulder instability were included. Postoperatively, patients were prescribed 1 of 2 analgesic regimens: (1) 30 ibuprofen (600 mg every 6 to 8 hours as needed) and 10 tablets of oxycodone/acetaminophen (5/325 mg every 6 hours as needed for breakthrough pain) or (2) 30 tablets oxycodone/acetaminophen (5/325 mg every 6 hours as needed). Subjects completed questionnaires at 24, 48, and 96 hours and 1 week after surgery, which included questions about analgesic medication usage, visual analog scale (VAS) pain score, incidence of adverse events, and patient satisfaction.

Results

Between December 2017 and May 2019, 80 patients (mean age 31.3 ± 10.4 years) were enrolled. Overall there were no significant differences in VAS pain score or patient satisfaction between the 2 groups. Patients in the opioid-only group had a significantly higher mean opioid consumption on postoperative days (PODs) 2 to 4 (5.5 versus 2.9, P = .05) and after 1 week (11.7 versus 7.9 tablets, P = .05) compared with patients in the NSAID group. Of patients in the NSAID group, 17.5% experienced adverse effects, compared with 35% in the opioid-only group.

Conclusions

Use of oral NSAIDs with limited breakthrough opioids results in significantly less opioid use after arthroscopic Bankart repair in the first postoperative week compared with opioids only. Both groups used limited amounts of opioids to control postoperative pain. There were no differences in pain levels at any time point postoperatively or satisfaction between patient groups.

Level of Evidence

II, nonblinded randomized control trial.

Differences in Opioid Overdose Mortality Rates Among Middle-Aged Adults by Race/Ethnicity and Sex, 1999-2018

OBJECTIVES

The types of opioids abused in the United States have changed from prescription opioids to heroin to fentanyl. However, the types of opioids abused may differ by demographic factors, especially among middle-aged adults. We examined national trends in opioid overdose mortality rates among middle-aged adults by race/ethnicity and sex.

METHODS

Using 1999-2018 data from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research database, we examined overdose mortality rates per 100 000 population in 2018 among adults aged 45-64 that involved natural and semisynthetic opioids, heroin, synthetic opioids (excluding methadone), and methadone. We tested for significant differences in mortality rates by race/ethnicity and sex. We plotted drug-specific trends by race/ethnicity and sex from 1999 to 2018.

RESULTS

In 2018, non-Hispanic White adults had the highest rates per 100 000 population of natural and semisynthetic overdose mortality (men: 8.7; women: 7.9; P < .001), and non-Hispanic Black adults had the highest rates of heroin (men: 17.7; women: 5.4; P < .001) and synthetic opioid (men: 36.0; women: 11.2; P < .001) overdose mortality. Men had significantly higher overdose mortality rates than women did for deaths involving natural and semisynthetic opioids, heroin, and synthetic opioids, but not methadone. From 1999 to 2018, mortality rates increased sharply for heroin and synthetic opioids, increased modestly for natural and semisynthetic opioids, and decreased for methadone. The greatest increases were among non-Hispanic Black men for heroin overdose (3.3 in 1999 to 17.7 in 2018) and synthetic opioid overdose (0.1 in 1999 to 36.0 in 2018).

CONCLUSIONS

Policy making should consider unique subgroup risks and alternative trajectories of opioid use other than people being prescribed opioids, developing opioid use disorder, subsequently moving to heroin, and then to fentanyl.

Evaluating the intended and unintended consequences of opioid-prescribing interventions on primary care in British Columbia, Canada: protocol for a retrospective population-based cohort study

INTRODUCTION

Between 2015 and 2018, there were over 40 000 opioid-related overdose events and 4551 deaths among residents in British Columbia (BC). During this time the province mobilised a variety of policy levers to encourage physicians to expand access to opioid agonist treatment and the College of Physicians and Surgeons of British Columbia (CPSBC) released a practice standard establishing legally enforceable minimum thresholds of professional behaviour in the hopes of curtailing overdose events. Our goal is to conduct a comprehensive investigation of the intended and unintended consequences of these policy changes. Specifically, we aim to understand the effects of these measures on physician prescribing behaviours, identify physician characteristics associated with uptake of the new measures, and measure the effects of the policy changes on patients' access to quality primary care.

METHODS AND ANALYSIS

This is a population-level, retrospective cohort study of all BC primary care physicians who prescribed any opioid medication for opioid-use disorder or chronic non-cancer pain during the study period, and their patients. The study period is 1 January 2013-31 December 2018, with a 1-year wash-in period (1 January 2012-31 December 2012) to exclude patients who initiated long-term opioid treatment prior to our study period or whose pain type (ie, 'chronic non-cancer', 'acute', 'cancer or palliative', or 'other') cannot be confirmed. The project combines five administrative health datasets under the authority of the BC Ministry of Health, with the CPSBC's Physician Registry, BC Cancer Agency's Cancer Registry and Vital Statistics' Mortality data. We will create measures of prescribing concordance, access, continuity, and comprehensiveness to assess primary care delivery and quality at both the physician and patient level. We will use generalised estimating equations, interrupted time series, mixed effects models, and funnel plots to identify factors related to changes in prescribing and evaluate the impact of the changes to prescribing policies. Results will be reported using appropriate Enhancing the QUAlity and Transparency Of health Research guidelines (eg, STrengthening the Reporting of OBservational studies in Epidemiology).

ETHICS AND DISSEMINATION

This study has been approved by McGill University's Institutional Review Board (#A11-M55-19A), and the University of British Columbia's Research Ethics Board (#H19-03537). We will disseminate results via a combination of open access peer-reviewed journal publications, conferences, lay summaries and OpEds.

Rural risk environments, opioid-related overdose, and infectious diseases: A multidimensional, spatial perspective

BACKGROUND

Much remains unknown in rural risk environments, despite a growing crisis in these areas. We adapt a risk environment framework to characterize rural southern Illinois and describe the relations of risk environments, opioid-related overdose, HIV, Hepatitis C, and sexually transmitted infection rates between 2015 and 2017.

METHODS

Over two dozen risk environment variables are summarized across zip-code (n = 128) or county levels (n = 16) based on availability and theoretical relevance. We calculate data attribute associations and characterize spatial and temporal dimensions of longitudinal health outcomes and the rural risk environment. We then use a "regional typology analysis" to generate data-driven risk regions and compare health outcomes.

RESULTS

Pervasive risk hotspots were identified in more populated locales with higher rates of overdose and HCV incidence, whereas emerging risk areas were isolated to more rural locales that had experienced an increase in analgesic opiate overdoses and generally lacked harm-reduction resources. At-risk areas were characterized with underlying socioeconomic vulnerability but in differing ways, reflecting a nuanced and shifting structural risk landscape.

CONCLUSIONS

Rural risk environment vulnerabilities and associated opioid-related health outcomes are multifaceted and spatially heterogeneous. More research is needed to better understand how refining geographies to more precisely define risk can support intervention efforts and further enrich investigations of the opioid epidemic.

Prescription opioid dispensing in Canada: an update on recent developments to 2018

Canada has been home to comparatively extreme developments in prescription opioid (PO) availability and related harms (e.g. morbidity, mortality) post-2000. Following persistent pan-Canadian increases in PO use, select control measures were implemented and PO dispensing levels—while only inconsistently by province—inverted, and began to plateau or decrease post-2012. We examined annual PO dispensing levels in Canada up until 2018, based on representative prescription sample data from community-based retail pharmacies. Annual prescription-based dispensing data were converted into defined daily doses/1000 population/day by province, and mainly categorized into ‘weak’ and ‘strong’ opioids. All provinces indicated decreasing trends in strong PO levels in most recent years, yet with inter-provincial differences of up to one magnitude in 2018; in about half the provinces, dispensing fell to below-2005 levels. British Columbia had the largest decline in strong PO dispensing from its peak rate (− 48.5%) in 2011. Weak opioid dispensing trends remained more inconsistent and bifurcated across Canada. The distinct effects of individual—including many provincially initiated and governed—PO control measures urgently need to be evaluated. In the meantime, recent reductions in general PO availability across Canada appear to have contributed to shortages in opioid supply for existent, sizable (including non-medical) user populations and may have contributed to recent marked increases in illicit opioid use and harms (including rising deaths).

Characteristics and outcomes of hospitalizations and readmissions for opioid dependence and overdose: nationally representative data

BACKGROUND

Despite the increasing rates of morbidity, mortality, and costs from the opioid addiction crisis, there is a paucity of literature on nationwide patterns of opioid abuse and dependence admissions and readmissions. We sought to investigate common comorbidities, readmission rates, and variables associated with readmission following index admission for opioid overdose or dependence. Methods: The 2013 Nationwide Readmission Database is a national database including data on more than 14 million US admissions. We used International Classification of Disease, Ninth Revision, Clinical Modification codes to identify index opioid abuse or dependence admissions, readmissions, and medical co-morbidities. We summarized all-cause readmission rates and reasons for readmission following index opioid dependence or overdose admission. We performed multivariable logistic regression, testing the association between characteristics of index admission and readmission. Results: 64,426 individuals were admitted for drug overdose or dependence during 2013. Of those, 30.1% were readmitted for all causes within one year and 8.7% were readmitted for opioid overdose or dependence within that year. The most common primary diagnoses on the readmission record were infection, kidney failure, drug related admission, and psychiatric admission. Predictors of readmission were smoking, male sex, younger age, alcohol, bipolar disorder, non-opioid drug use, admission to teaching hospitals in metropolitan areas, and discharge against medical advice. Conclusion: There is a high all-cause readmission rate following index admission for opioid overdose or dependence and a greater likelihood of readmission among young males with psychiatric comorbidities in metropolitan areas. Targeted interventions to address psychiatric comorbidities and transitions of care may be needed for the high-risk opioid dependence and overdose population.

Adolescent-Serving Addiction Treatment Facilities in the United States and the Availability of Medications for Opioid Use Disorder

PURPOSE

Adolescents with opioid use disorder are less likely than adults to receive medications for opioid use disorder (MOUD), yet we know little about facilities that provide addiction treatment for adolescents. We sought to describe adolescent-serving addiction treatment facilities in the U.S. and examine associations between facility characteristics and offering MOUD, leading to informed recommendations to improve treatment access.

METHODS

This cross-sectional study used the 2017 National Survey of Substance Abuse Treatment Services. Facilities were classified by whether they offered a specialized adolescent program. Covariates included facility ownership, hospital affiliation, insurance/payments, government grants, accreditation/licensure, location, levels of care, and provision of MOUD. Descriptive statistics and logistic regression compared adolescent-serving versus adult-focused facilities and identified characteristics associated with offering maintenance MOUD.

RESULTS

Among 13,585 addiction treatment facilities in the U.S., 3,537 (26.0%) offered adolescent programs. Adolescent-serving facilities were half as likely to offer maintenance MOUD as adult-focused facilities (odds ratio, .53; 95% confidence interval, .49-.58), which was offered at 23.1% (816) of adolescent-serving versus 35.9% (3,612) of adult-focused facilities. Among adolescent-serving facilities, characteristics associated with increased unadjusted odds of offering maintenance MOUD were nonprofit status, hospital affiliation, accepting insurance (particularly, private insurance), accreditation, Northeastern location, or offering inpatient services.

CONCLUSIONS

The one-quarter of U.S. addiction treatment facilities that serve adolescents are half as likely to provide MOUD as adult-focused facilities, which may explain why adolescents are less likely than adults to receive MOUD. Strategies to increase adolescent access to MOUD may consider insurance reforms/incentives, facility accreditation, and geographically targeted funding.

Associations between neighborhood-level factors and opioid-related mortality: A multi-level analysis using death certificate data

AIM

To identify associations between opioid-related mortality and neighborhood-level risk factors.

DESIGN

Cross-sectional study.

SETTING

Massachusetts, USA.

PARTICIPANTS

Using 2011-14 Massachusetts death certificate data, we identified opioid-related (n = 3089) and non-opioid-related premature deaths (n = 8729).

MEASUREMENTS

The independent variables consisted of four sets of neighborhood-level factors: (1) psychosocial, (2) economic, (3) built environment and (4) health-related. At the individual level we included the following compositional factors: age at death, sex, race/ethnicity, marital status, education, veteran status and nativity. The primary outcome of interest was opioid-related mortality.

FINDINGS

Multi-level models identified number of social associations per 10 000 [odds ratio (OR) = 0.84, P = 0.002, 95% confidence interval (CI) = 0.75-0.94] and number of hospital beds per 10 000 (OR = 0.78, P < 0.001, 95% CI = 0.68-0.88) to be inversely associated with opioid-related mortality, whereas the percentage living in poverty (OR = 1.01, P = 0.008, 95% CI = 1.00-1.01), food insecurity rate (OR = 1.21, P = 0.002, 95% CI = 1.07-1.37), number of federally qualified health centers (OR = 1.02, P = 0.028, 95% CI = 1.02-1.08) and per-capita morphine milligram equivalents of hydromorphone (OR = 1.05, P = 0.003, 95% CI = 1.01-1.08) were positively associated with opioid-related mortality.

CONCLUSIONS

Opioid-related deaths between 2011 and 2014 in the state of Massachusetts appear to be positively associated with the percentage living in poverty, food insecurity rate, number of federally qualified health centers and per-capita morphine milligram equivalents of hydromorphone, but inversely associated with number of social associations per 10 000 and number of hospital beds per 10 000.

Impact evaluations of drug decriminalisation and legal regulation on drug use, health and social harms: a systematic review

OBJECTIVES

To review the metrics and findings of studies evaluating effects of drug decriminalisation or legal regulation on drug availability, use or related health and social harms globally.

DESIGN

Systematic review with narrative synthesis.

DATA SOURCES

We searched MEDLINE, Embase, PsycINFO, Web of Science and six additional databases for publications from 1 January 1970 through 4 October 2018.

INCLUSION CRITERIA

Peer-reviewed articles or published abstracts in any language with quantitative data on drug availability, use or related health and social harms collected before and after implementation of de jure drug decriminalisation or legal regulation.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened titles, abstracts and articles for inclusion. Extraction and quality appraisal (modified Downs and Black checklist) were performed by one reviewer and checked by a second, with discrepancies resolved by a third. We coded study-level outcome measures into metric groupings and categorised the estimated direction of association between the legal change and outcomes of interest.

RESULTS

We screened 4860 titles and 221 full-texts and included 114 articles. Most (n=104, 91.2%) were from the USA, evaluated cannabis reform (n=109, 95.6%) and focussed on legal regulation (n=96, 84.2%). 224 study outcome measures were categorised into 32 metrics, most commonly prevalence (39.5% of studies), frequency (14.0%) or perceived harmfulness (10.5%) of use of the decriminalised or regulated drug; or use of tobacco, alcohol or other drugs (12.3%). Across all substance use metrics, legal reform was most often not associated with changes in use.

CONCLUSIONS

Studies evaluating drug decriminalisation and legal regulation are concentrated in the USA and on cannabis legalisation. Despite the range of outcomes potentially impacted by drug law reform, extant research is narrowly focussed, with a particular emphasis on the prevalence of use. Metrics in drug law reform evaluations require improved alignment with relevant health and social outcomes.

Opioid Pain Medication Prescription for Chronic Pain in Primary Care Centers: The Roles of Pain Acceptance, Pain Intensity, Depressive Symptoms, Pain Catastrophizing, Sex, and Age

Background: Psychological factors of patients may influence physicians’ decisions on prescribing opioid analgesics. However, few studies have sought to identify these factors. The present study had a double objective: (1) To identify the individual factors that differentiate patients who had been prescribed opioids for the management of chronic back pain from those who had not been prescribed opioids and (2) to determine which factors make significant and independent contributions to the prediction of opioid prescribing. Methods: A total of 675 patients from four primary care centers were included in the sample. Variables included sex, age, pain intensity, depressive symptoms, pain catastrophizing, and pain acceptance. Results: Although no differences were found between men and women, participants with chronic noncancer pain who were prescribed opioids were older, reported higher levels of pain intensity and depressive symptoms, and reported lower levels of pain-acceptance. An independent association was found between pain intensity and depressive symptoms and opioid prescribing. Conclusions: The findings suggest that patient factors influence physicians’ decisions on prescribing opioids. It may be useful for primary care physicians to be aware of the potential of these factors to bias their treatment decisions.

Policies affecting the supply and access of opioid analgesics: a scoping review protocol

OBJECTIVE

This scoping review aims to describe and map the range of evaluated policies that affect the supply and access of opioids for analgesic therapy.

INTRODUCTION

There has been increasing concern regarding the rise in opioid analgesic misuse and related harms, including overdose deaths. In response, policies have been developed and implemented to reduce the burden of opioid-related problems, including strategies that aim to affect the supply and/or access of opioid analgesics. However, little is known about the range and nature of these policies, including whether they have been evaluated for effectiveness and how.

INCLUSION CRITERIA

Studies to be included must evaluate the effectiveness of policies directly designed to affect the supply and/or access of opioids for analgesic therapy, and measure clinical and health services outcomes quantitatively. Studies that assessed interventions or factors impacting the use of these policies, measured only utilization of the policy itself, and/or measured outcomes regarding attitudes and behaviors towards these policies will be excluded. Literature on policies for the treatment and management of opioid abuse, overdose, or addiction will be excluded.

METHODS

Multiple databases will be searched including MEDLINE, Embase, PsycINFO, Scopus, and Web of Science using keywords, indexed terms, and phrases for the following concepts: opioid, policy, evaluation, and clinical context. Each included study will be rated using a modified version of the JBI Levels of Evidence framework. Details on included policies and their assessment will be extracted, and results presented in diagrams and tables.

Predictors and Outcomes of Invasive Mechanical Ventilation in Opioid Overdose Hospitalization in the United States

Introduction  Opioid overdose is increasingly becoming common and so is the need for invasive mechanical ventilation (IMV) for opioid overdose admissions in hospitalized patients. Respiratory failure requiring invasive mechanical ventilation is the most common reason for the admission of opioid-associated overdose patients. The aim of our study was to assess the demographic and clinical characteristics associated with the increased need for IMV in hospitalized opioid overdose patients. Methods  We analyzed all adult admissions (18 years and above) using the National Inpatient Sample (NIS) database for five years from January 1, 2010-December 31, 2014 to identify opioid overdose patients requiring invasive mechanical ventilation. We compared the demographic and clinical characteristics of opioid overdose patients requiring and not requiring mechanical ventilator support and performed univariate and multivariate analyses to determine the odds ratio (OR) of association. Results A total of 2,528,751 opioid overdose patients were identified among which 6.4% required IMV during hospitalization. The prevalence of opioid overdose and the need for IMV increased by 31% and 38%, respectively, over the study period. Multivariate logistic regression (OR (95% CI), p<0.001) determined the following to be associated with increased odds of mechanical ventilator use: (OR 1.12 (1.06-1.19)) among patients aged 25-39 years vs (1.36 (1.28-1.44)) for the age group 40-64 years when compared to 18-24 years; hospital locations in the south US region (OR 1.62 (1.49-1.75)) when compared to the northeast US region; the presence of aspiration pneumonia (OR 14.30 (13.63-15.0)), rhabdomyolysis (3.22 (3.04-3.42)), septic shock (9.15 (8.41-9.97)), and anoxic brain injury (15.5 (13.70-17.50)). Other factors associated with decreased odds of IMV include hepatitis C virus infection (OR 0.75 (0.72-0.79)) and black race (OR 0.68 (0.63-0.74)]. Opioid overdose patients requiring IMV had a higher length of stay by 8.9 ± 0.1 days, higher hospitalization cost by US$ 28,117.81 ± 373.53, and higher in-hospital mortality rate (13.4% vs 0.3%). Conclusion The prevalence of opioid overdose and the need for IMV increased over the five-year study period, reflecting an increase in the relatively high in-hospital mortality of opioid overdose patients on IMV. Patient's age, geographic location, race, and several comorbidities affect the need for invasive mechanical ventilation in hospitalized opioid overdose patients. These findings emphasize the need for a better understanding of these risk factors in creating a strategic approach for hospital care of opioid overdose patients.

A Time-Series Analysis of the Association Between Occupational Health Policies and Opioid Prescription Patterns in United States Active Duty Military Service Members From 2006 to 2018

OBJECTIVE

The Department of Defense (DoD) implemented numerous occupational health policies to guide opioid prescribing to active duty military service members (ADSM). This retrospective time series analysis evaluated the impact of DoD policies on opioid prescribing trends in ADSM from 2006 to 2018.

METHODS

Bayesian structural time-series models with a Markov chain Monte Carlo algorithm for posterior inference and a semi-local linear trend were constructed to estimate the impact of polices.

RESULTS

Results indicate annual opioid proportions significantly decreased after the introduction of occupational health policies introduced in 2011 to 2012. Collectively, occupational policies were associated with a significant reduction (6.6%) in annual opioid rates to ADSM following 2012. This observed effect was associated with approximately 121,000 less opioid prescriptions dispensed in 2018 alone.

CONCLUSIONS

Occupational health policy interventions were associated with reductions in opioid prescribing within the DoD.

High-dose prescribed opioids are associated with increased risk of heroin use among United States military veterans

Despite evidence linking increased risk of opioid use disorder with specific opioid-prescribing patterns, the relationship between these patterns and heroin use is less understood. This study aimed to determine whether dose and duration of opioid prescriptions predict subsequent heroin use in United States veterans. We analyzed data from 2002 to 2012 from the Veterans Aging Cohort Study, a prospective cohort study. We used inverse probability of censoring weighted Cox regression to examine the relationship between self-reported past year heroin use and 2 primary predictors: (1) prior receipt of a high-dose opioid prescription (≥90 mg morphine equivalent daily dose), and (2) prior receipt of a long-term opioid prescription (≥90 days). Heroin use was ascertained using most recent value of time-updated self-reported past year heroin use. Models were adjusted for HIV and hepatitis C virus infection status, sociodemographics, pain interference, posttraumatic stress disorder, depression, and use of marijuana, cocaine, methamphetamines, and unhealthy alcohol use. In the final model, prior receipt of a high-dose opioid prescription was associated with past year heroin use (adjusted hazard ratio use = 2.54, 95% confidence interval: 1.26-5.10), whereas long-term opioid receipt was not (adjusted hazard ratio = 1.09, 95% confidence interval: 0.75-1.57). Patients receiving high-dose opioid prescriptions should be monitored for heroin use. These findings support current national guidelines recommending against prescribing high-dose opioids for treating pain.

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.