Factors associated with opioid overdose: a 10-year retrospective study of patients in a large integrated health care system

Accidental substance-related acute toxicity deaths in older adults in 2016 and 2017: a national chart review study

INTRODUCTION

Limited research exists on substance-related acute toxicity deaths (ATDs) in older adults (≥60 years) in Canada. This study aims to examine and describe the sociodemographic characteristics, health histories and circumstances of death for accidental ATDs among older adults.

METHODS

Following a retrospective descriptive analysis of all coroner and medical examiner files on accidental substance-related ATDs in older adults in Canada from 2016 to 2017, proportions and mortality rates for coroner and medical examiner data were compared with general population data on older adults from the 2016 Census. Chisquare tests were conducted for categorical variables where possible.

RESULTS

From 2016 to 2017, there were 705 documented accidental ATDs in older adults. Multiple substances contributed to 61% of these deaths. Fentanyl, cocaine and ethanol (alcohol) were the most common substances contributing to death. Heart disease (33%), chronic pain (27%) and depression (26%) were commonly documented. Approximately 84% of older adults had contact with health care services in the year preceding their death. Only 14% were confirmed as having their deaths witnessed.

CONCLUSIONS

Findings provide insight into the demographic, contextual and medical history factors that may influence substance-related ATDs in older adults and suggest key areas for prevention.

Quantifying a potential protective effect of buprenorphine on fatality risk during acute fentanyl exposures

INTRODUCTION

Buprenorphine is an important therapy for opioid use disorder and may also reduce the risk of fatal overdoses in fentanyl exposures. However, the role of buprenorphine in reducing this risk has not been quantified. This cross-sectional study examined the association between buprenorphine presence, decedent characteristics, and other factors with the predicted fentanyl concentrations in overdose deaths.

METHODS

The study identified unintentional fentanyl overdose decedents (n = 3036) from the West Virginia Forensic Drug Database, 2011 through mid-2020. The main outcome was fentanyl concentrations in overdose deaths in the presence and absence of buprenorphine. A multiple linear regression model examined the association of fentanyl concentrations with buprenorphine presence based on the concentrations of the parent drug buprenorphine (B) and its metabolite norbuprenorphine (N), adjusting for demographics, toxicological characteristics (presence of multiple opioids, benzodiazepines, stimulants, marijuana, and alcohol), and comorbidities. We used a B/N concentration ratio < 1 as an indirect indicator of longer-term buprenorphine exposure prior to drug overdose death.

RESULTS

The median fentanyl concentration was 65 % higher when buprenorphine was present (N = 168) vs. absent (N = 2868) (0.028 vs. 0.017 μg/mL, p < 0.001). In the multivariable model, statistically significant associations occurred between buprenorphine presence and increased fentanyl concentrations (+28.7 %) with a B/N ratio < 1. Obesity, male sex, alcohol presence, and comorbid cardiovascular diseases were statistically significantly associated with lower (-11.3 % to -20.7 %) fentanyl concentrations, whereas marijuana presence and a history of substance use disorder were associated with statistically significant higher fentanyl concentrations (+8.8 % to +31.3 %).

CONCLUSIONS

These findings suggest that sustained or longer-term buprenorphine intake might exert some protective effect on fatalities resulting from fentanyl exposure as documented by the association of higher fentanyl blood concentrations with buprenorphine presence among fatal drug overdoses. As fentanyl availability and overdose rates increase nationally, buprenorphine is a vital tool for effective opioid use disorder treatment that might also reduce the risk of fatality in an acute fentanyl exposure.

Correlates of nonfatal overdose among treatment-seeking individuals with non-heroin opioid use disorder: Findings from a pragmatic, pan-Canadian, randomized control trial

INTRODUCTION

Misuse of prescription and synthetic opioids is a primary contributor to the escalating overdose crisis in North America. However, factors associated with nonfatal overdose (NFO) in this context are poorly understood. We examined individual and socio-structural level correlates of NFO among treatment-seeking adults with an opioid use disorder (OUD) not attributed to heroin (nonheroin opioid use disorder [NH-OUD]).

METHODS

The study drew data from OPTIMA, a pan-Canadian, multicenter, pragmatic, two-arm randomized control trial comparing supervised methadone and flexible take-home dosing buprenorphine/naloxone models of care among adults with NH-OUD conducted between 2017 and 2020. We used bivariable and multivariable logistic regression to determine factors associated with a lifetime history of NFO among participants enrolled in the trial.

RESULTS

Of 267 included participants, 154 (58%) reported a NFO in their lifetime, of whom 83 (55 %) had an NFO in the last 6 months. In multivariable analyses, positive urine drug test (UDT) for methamphetamine/amphetamine (Adjusted Odds Ratio [AOR] = 2.59; 95 % confidence interval [CI]: 1.17-5.80), positive UDT for fentanyl (AOR = 2.31; 95 % CI: 1.01-5.30), receiving income assistance (AOR = 2.17; 95 % CI: 1.18-4.09) and homelessness (AOR = 2.40; 95 % CI: 1.25-4.68) were positively associated with a lifetime history of NFO.

CONCLUSIONS

We found a high prevalence of NFO history in treatment-seeking adults with NH-OUD, particularly among participants with certain drug use patterns and markers of socio-structural marginalization at the time of enrollment. Given the known impact of prior NFO on future harms, these findings highlight the need for comprehensive care approaches that address polysubstance use and social determinants of health to mitigate future overdose risk.

Predictors of fatal and nonfatal overdose after prescription of opioids for chronic pain: a systematic review and meta-analysis of observational studies

BACKGROUND

Higher doses of opioids, mental health comorbidities, co-prescription of sedatives, lower socioeconomic status and a history of opioid overdose have been reported as risk factors for opioid overdose; however, the magnitude of these associations and their credibility are unclear. We sought to identify predictors of fatal and nonfatal overdose from prescription opioids.

METHODS

We systematically searched MEDLINE, Embase, CINAHL, PsycINFO and Web of Science up to Oct. 30, 2022, for observational studies that explored predictors of opioid overdose after their prescription for chronic pain. We performed random-effects meta-analyses for all predictors reported by 2 or more studies using odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Twenty-eight studies (23 963 716 patients) reported the association of 103 predictors with fatal or nonfatal opioid overdose. Moderate- to high-certainty evidence supported large relative associations with history of overdose (OR 5.85, 95% CI 3.78-9.04), higher opioid dose (OR 2.57, 95% CI 2.08-3.18 per 90-mg increment), 3 or more prescribers (OR 4.68, 95% CI 3.57-6.12), 4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35-5.57), prescription of fentanyl (OR 2.80, 95% CI 2.30-3.41), current substance use disorder (OR 2.62, 95% CI 2.09-3.27), any mental health diagnosis (OR 2.12, 95% CI 1.73-2.61), depression (OR 2.22, 95% CI 1.57-3.14), bipolar disorder (OR 2.07, 95% CI 1.77-2.41) or pancreatitis (OR 2.00, 95% CI 1.52-2.64), with absolute risks among patients with the predictor ranging from 2-6 per 1000 for fatal overdose and 4-12 per 1000 for nonfatal overdose.

INTERPRETATION

We identified 10 predictors that were strongly associated with opioid overdose. Awareness of these predictors may facilitate shared decision-making regarding prescribing opioids for chronic pain and inform harm-reduction strategies SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (https://osf.io/vznxj/).

Detoxification, 12-step meeting attendance, and non-fatal opioid overdoses among a suburban/exurban population with opioid use disorder

BACKGROUND

Drug overdoses are the leading cause of injury death in the United States with an estimated 105,752 individuals dying from an overdose in the United States in a 12-month period ending October 2021. Given that people who have opioid use disorder (OUD) are at an increased risk of death, it is crucial to assess risk factors associated with opioid overdose to improve interventions.

OBJECTIVES

We examine factors associated with non-fatal overdose among a suburban/exurban population with OUD in Southern California.

METHODS

Participants were recruited by convenience sampling (n = 355) and were interviewed between November 2017 to August 2018. Participants were eligible for the study if they had a history of pharmaceutical opioid use.

RESULTS

A total of 198 (55.8%) participants reported at least one overdose in their lifetime. A total of 229 participants identified as male, 124 identified as female, and 2 identified as non-binary. When controlling for demographic factors, non-oral opioid administration at first opioid use (AOR 2.82, 95% CI 1.52-5.22), having a history of methadone detoxification, (AOR 2.23, 95% CI 1.27-3.91), history of buprenorphine detoxification (AOR 1.77, 95% CI 1.02-3.07), and history of 12 step attendance (AOR 1.89, 95% CI 1.12-3.20) were found to be independently and positively associated with lifetime opioid overdose.

CONCLUSIONS

Detoxification with buprenorphine and methadone was found to be associated with having a non-fatal opioid overdose. Buprenorphine and methadone should not be prescribed as a detoxification medication as long-term use of medication for OUD results in better outcomes than medication that is used short-term.

Educating Nursing Students About Chronic Pain Management and Opioids: A Research Study

BACKGROUND

Healthcare professionals' knowledge of safe use of opioids for chronic pain management is critical in preventing opioid abuse and overdose. Undergraduate curricula of health professional schools, including undergraduate nursing programs, need to improve and adopt a comprehensive educational plan regarding this issue.

METHOD

This study implemented and assessed an educational module on undergraduate nursing students' knowledge and attitudes regarding prescription opioids.

RESULTS

The educational module improved nursing students' knowledge and attitudes. Students reflected positively on the module.

CONCLUSION

Undergraduate nursing students benefited from the educational module on prescription opioids and preferred to include a similar module in their undergraduate curricula.

Novel digital approaches to the assessment of problematic opioid use

The opioid epidemic continues to contribute to loss of life through overdose and significant social and economic burdens. Many individuals who develop problematic opioid use (POU) do so after being exposed to prescribed opioid analgesics. Therefore, it is important to accurately identify and classify risk factors for POU. In this review, we discuss the etiology of POU and highlight novel approaches to identifying its risk factors. These approaches include the application of polygenic risk scores (PRS) and diverse machine learning (ML) algorithms used in tandem with data from electronic health records (EHR), clinical notes, patient demographics, and digital footprints. The implementation and synergy of these types of data and approaches can greatly assist in reducing the incidence of POU and opioid-related mortality by increasing the knowledge base of patient-related risk factors, which can help to improve prescribing practices for opioid analgesics.

Co-Occurring Opioid Use and Depressive Disorders: Patient Characteristics and Co-Occurring Health Conditions

OBJECTIVE

Among persons with opioid use disorder (OUD), co-occurring depression is linked to a greater risk of opioid misuse, overdose and suicide. Less is known about characteristics and other comorbid health conditions of persons with co-occurring opioid use and depressive disorders.

METHODS

This study used electronic health record (EHR) encounters from the Geisinger Health System prior to the fall of 2019. Adult patients were recruited from a medication-based treatment clinic and had an OUD diagnosis (N = 692). Co-occurring depression was defined by a depression diagnosis in the EHR. Multivariable logistic regression was performed to assess differences in characteristics, behavioral health and medical diagnoses, as well as opioid overdose and suicide attempt or ideation between individuals with and without comorbid depression.

RESULTS

Forty-seven percent of patients with OUD had a lifetime depression diagnosis. Individuals with co-occurring depression were more likely to be female and have comorbid chronic pain or other medical conditions. Co-occurring depression was associated with an increased likelihood of other mental health and substance use disorders, as well as opioid overdose and/or suicide attempt or ideation.

CONCLUSIONS

While it is established that co-occurring depression is associated with increased risk of overdose and suicide, this study adds that other health conditions, including chronic pain and common medical conditions, are more prevalent among persons with co-occurring depressive disorders. Results highlight the need to consider these complex health needs when developing treatment plans and services.

Tele-buprenorphine for emergency department overdose visit follow up and treatment initiation

INTRODUCTION

An ED visit for opioid overdose may be a person's only contact with the medical and behavioral health care systems and is an important opportunity to reduce risk of subsequent overdose and death. While ED initiatives to engage people with opioid use disorder (OUD) are being increasingly implemented, there are significant gaps in the receipt of services at the time of the ED encounter.

METHODS

This is a retrospective cohort study of an outreach pilot project providing real-time telehealth delivered buprenorphine initiation and referral to community harm reduction and addiction treatment services via a follow up telephone call to patients after an ED visit for an opioid overdose.

RESULTS

From January 2020 to April 2021 there were 606 patients with an ED visit for an opioid overdose eligible for a callback. Of the 606 eligible patients, 254/645 (42%) patients could be contacted and accepted service and/or treatment referrals. Fifteen patients were connected same-day to a buprenorphine prescriber for a telehealth encounter and, of connected patients, nine received a buprenorphine prescription.

CONCLUSION

A post-ED follow up telephone call protocol is an opportunity to improve treatment engagement and access to buprenorphine for patients at high risk for opioid overdose and death.

Assessing opioid overdose risk: a review of clinical prediction models utilizing patient-level data

Drug, and specifically opioid-related, overdoses remain a major public health problem in the United States. Multiple studies have examined individual risk factors associated with overdose risk, but research developing clinical risk prediction tools for overdose has only emerged in the last few years. We conducted a comprehensive review of the literature on patient-level factors associated with opioid-related overdose risk, with an emphasis on clinical risk prediction models for opioid-related overdose in the United States. Studies that developed and/or validated clinical prediction models were closely reviewed and evaluated to determine the state of the field. We identified 12 studies that reported risk prediction models for opioid-related overdose risk. Published models were developed from a variety of data sources, including Veterans Health Administration data, Medicare data, commercial insurance data, and statewide linked datasets. Studies reported model performance using measures of discrimination, usually at good-to-excellent levels, though they did not always assess calibration. C-statistics were better for models that included clinical predictors (c-statistics: 0.75-0.95) compared to models without them (c-statistics: 0.69-0.82). External validation of models was rare, and we found no studies evaluating implementation of models or risk prediction tools into clinical practice. A common feature of these models was a high rate of false positives, largely because opioid-related overdose is rare in the general population. Thus, efforts to implement prediction models into practice should take into account that published models overestimate overdose risk for many low-risk patients. Future prediction models assessing overdose risk should employ external validation and address model calibration. In order to translate findings from prediction models into clinical public health benefit, future studies should focus on developing clinical prediction tools based on prediction models, implementing these tools into clinical practice, and evaluating the impact of these models on treatment decisions, patient outcomes, and, ultimately, opioid overdose rates.

Quantifying prescribed high dose opioids in the community and risk of overdose

Background

Opioid prescribing for a range of health issues is increasing globally. The risk of fatal and non-fatal overdose is increased among people prescribed strong opioids: in high doses in the context of polypharmacy (the use of multiple medications at the same time), especially with other sedatives; and among people with multiple morbidities including cardiorespiratory, hepatic and renal conditions. This study described and quantified the prescribing of strong opioids, comorbidities and other overdose risk factors among those prescribed strong opioids, and factors associated with high/very high opioid dosage in a regional health authority in Scotland as part of a wider service improvement exercise.

Methods

Participating practices ran searches to identify patients prescribed strong opioids and their characteristics, polypharmacy, and other overdose risk factors. Data were anonymised before being analysed at practice and patient-level. Morphine Equivalent Doses were calculated for patients based on drug/dose information and classed as Low/Medium/High/Very High. Descriptive statistics were generated on the strong opioid patient population and overdose risk factors. The relationship between the prescribing of strong opioids and practice/patient-level factors was investigated using linear and logistic regression models.

Results

Eighty-five percent (46/54) of GP practices participated. 12.4% (42,382/341,240) of individuals in participating practices were prescribed opioids and, of these, one third (14,079/42,382) were prescribed strong opioids. The most common comorbidities and overdose risk factors among strong opioid recipients were pain (67.2%), cardiovascular disease (43.2%), and mental health problems (39.3%). There was a positive significant relationship between level of social deprivation among practice caseload and level of strong opioid prescribing (p < 0.001). People prescribed strong opioids tended to be older (mean 59.7 years) and female (8638, 61.4%) and, among a subset of patients, age, gender and opioid drug class were significantly associated with prescribing of High/Very High doses.

Conclusions

Our findings have identified a large population at potential risk of prescription opioid overdose. There is a need to explore pragmatic models of tailored interventions which may reduce the risk of overdose within this group and clinical practice may need to be tightened to minimise overdose risk for individuals prescribed high dose opioids.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11162-4.

Opioid prescribing and health outcomes in opioid-naive patients: Analysis of a statewide health information exchange

BACKGROUND

Widespread use of prescription opioids is associated with adverse outcomes.

OBJECTIVE

To identify factors associated with adverse health outcomes and health care use using a statewide health information exchange.

METHODS

This is a retrospective cohort study using the Indiana Network for Patient Care. Adult opioid-naive patients who received an opioid prescription between January 2012 and December 2017 were included. The outcomes included (1) a composite outcome of any combination of opioid abuse, dependence, or overdose, (2) all-cause mortality, and (3) health care use. Independent variables included opioid dosage, dispensed amount, days supply, concurrent use of short-acting (SA) and long-acting (LA) opioids, and concurrent use with benzodiazepine or gabapentinoids. Additional variables included patients' age, sex, race, modified Charlson Comorbidity Index score, mental health conditions, and medications for opioid use disorders. Factors associated with composite outcome and mortality were identified using Cox proportional hazards and reported as adjusted hazard ratio (aHR) and 95% CI. Factors associated with health care use were identified using Poisson regression and reported as adjusted incidence rate ratio (aIRR) and 95% CI.

RESULTS

1,328,287 opioid prescriptions were identified for 341,722 patients. Opioid-related factors associated with the composite outcome, mortality, and hospitalizations, respectively, included opioid dosage (aHR 1.003 [95% CI 1.001-1.006]; aHR not applicable; aIRR 1.07 [1.06-1.08]), opioid days supply (aHR 1.03 [1.02-1.03]; aHR 1.009 [1.005-1.014]; aIRR 0.94 [0.92-0.96]), concurrent SA/LA opioids (aHR 2.12 [1.78-2.54]; aHR 1.40 [1.14-1.70]; aIRR 1.40 [1.37-1.42]), and use of benzodiazepines/gabapentinoids (aHR 1.68 [1.38-2.04]; aHR 1.23 [1.01-1.51]; aIRR 1.25 [1.23-1.27]).

CONCLUSION

Many factors are associated with poor health outcomes, especially concurrent use of SA and LA opioids and overlapping prescriptions of opioids with benzodiazepines or gabapentinoids. Identification of factors associated with adverse outcomes may help identify patients at risk for poor outcomes and could inform possible interventions.

Mortality in an Opioid Treatment Program

This retrospective study examined mortality in an Opioid Treatment Program (OTP) with policies designed to admit and retain patients with as few barriers as possible. Methadone provided in the context of an OTP is known to decrease mortality and morbidity. Historically, patients have been discharged or turned away because of continued substance use. We examined patient deaths over three years in an OTP serving approximately 2400 patients daily. Demographics and causes of death were gathered from electronic health records and medical examiner reports. Pairwise comparisons were used to compare drug poisoning versus non-drug poisoning deaths. There were 155 deaths during the study period. The average age was 54, and half of the participants had positive results on their most recent drug screen. Forty one (26%) died from "drug poisoning." Drug poisoning deaths were more common among patients who: 1) had recent positive drug test results; 2) had documented alprazolam use; 3) were younger; 4) had shorter treatment durations; 5) were female. The majority of deaths were among long-term patients over 50 and were not caused by drug poisoning. These results support keeping patients in treatment despite ongoing drug use, and linking them to appropriate primary care.

Opioid overdose experiences in a sample of US adolescents and young adults: a thematic analysis

BACKGROUND AND AIMS

Opioid overdose deaths among adolescents and young adults have risen sharply in the United States over recent decades. This study aimed to explore the nature of adolescent and young adult perspectives on overdose experiences.

DESIGN

This study involved thematic analysis of interviews undertaken as part of a mixed-methods, randomized trial of extended release naltrexone (XR-NTX) versus treatment-as-usual (TAU) for adolescents and young adults (aged 15-21 years) with opioid use disorder (OUD).

SETTING

Participants were recruited during a residential treatment episode at Mountain Manor Treatment Center, in Baltimore, MD, USA.

PARTICIPANTS/CASES

As part of the qualitative component of this study, 35 adolescents/young adults completed up to three interviews: at baseline, 3 and 6 months after release from residential opioid use disorder treatment.

MEASUREMENTS

Semi-structured interviews solicited participant experiences with opioid use disorder treatment; their satisfaction with the medications used to treat opioid use disorder; counseling received; current substance use; issues related to treatment retention; their treatment goals; and their future outlook.

FINDINGS

Four broad themes emerged: (1) adolescents/young adults had difficulty identifying overdoses due to interpreting subjective symptoms and a lack of memory of the event, (2) this sample had difficulty perceiving risk that is misaligned with traditional understandings of overdose intentionality, (3) adolescents/young adults did not interpret personal overdose events as a catalyst for behavior change and (4) this sample experienced a greater impact to behavior change through witnessing an overdose of someone in their social network.

CONCLUSIONS

The sample of US adolescents and young adults in treatment for opioid use disorder expressed difficulty identifying whether or not they had experienced an overdose, expressed fluctuating intentionality for those events and did not have clear intentions to change their behavior. Witnessing an overdose appeared to be as salient an experience as going through an overdose oneself.

Characteristics of fatal opioid overdoses with stimulant involvement in Tennessee: A descriptive study using 2018 State Unintentional Drug Overdose Reporting System Data

PURPOSE

Opioid overdose deaths involving stimulants are on the rise. Demographic characteristics for these deaths to be used in prevention efforts have not been established.

METHODS

We conducted a statewide retrospective study to evaluate the characteristics of fatal opioid overdoses with stimulant involvement using 2018 Tennessee State Unintentional Drug Overdose Reporting System data. Data sources included death certificates, autopsy reports, toxicology, and prescription drug monitoring program data. Frequencies were generated to compare demographics, circumstances, opioid history, death scene information, bystander intervention, and toxicology between fatal opioid overdoses with and without stimulant involvement.

RESULTS

A total of 1183 SUDORS opioid overdose deaths occurred in Tennessee in 2018 of which 434 (36.7%) involved a stimulant. Fatal opioid overdoses involving stimulants had higher frequencies of illicit drugs on toxicology specifically marijuana, fentanyl, and heroin compared to fatal opioid overdoses without stimulants. Fatal opioid overdoses involving stimulants had higher frequencies of scene indications of injection drug use compared to fatal opioid overdoses without stimulant involvement.

CONCLUSIONS

Fatal overdoses are shifting from mainly opioid to multidrug involvement and over one-third include use of stimulants. This analysis can help public health practitioners understand the circumstances around fatal opioid overdoses involving stimulants to inform tailored prevention strategies.

Impact of benzodiazepines and polysubstance status on repeat non-fatal drug overdoses

Research has shown that benzodiazepines and mental health disorders can increase the likelihood of repeat overdose, but researchers have not explored this association in Tennessee (TN). We examined benzodiazepines, polysubstance overdose status with/without benzodiazepines, and mental health comorbidities with repeat overdose using statewide data in TN. This study analyzed TN hospital discharge data on nonfatal overdoses for patients ages 18-64 from 2012 to 2016 for 21,066 patients with an initial inpatient visit and 36,244 patients with an initial outpatient visit. The study assessed each patient at one year after initial overdose to determine likelihood of repeat overdose. We used a Cox proportional hazards model to compute hazard ratios (HRs) and 95% confidence intervals (CIs) to determine the factors associated with repeat nonfatal overdose. Repeat overdose rates, by one year after index overdose, were 12.9% of the sample for inpatients and 13.9% of the sample for outpatients. The visit factors (overdose characteristics and comorbidities determined from the initial visit) that the study found to be independently associated with repeat overdoses among inpatients were polysubstance status (HR: 0.88, 95% CI 0.78-0.99), benzodiazepine/polysubstance interaction (HR: 1.29, 95% CI 1.02-1.64), and presence of any mental health disorder (HR: 1.28, 95% CI: 1.18-1.39). For outpatients, the benzodiazepine/polysubstance interaction (HR: 1.21, 95% CI 1.01-1.44) was significant without adjusting for demographic factors. We found evidence that benzodiazepine/polysubstance status and mental health disorders were associated with repeat overdose for inpatients, and that benzodiazepine/polysubstance status was associated with repeat overdose for outpatients. Findings support the need to include polysubstance status and mental health in overdose prevention efforts.

Performance of a Predictive Model versus Prescription-Based Thresholds in Identifying Patients at Risk of Fatal Opioid Overdose

Background: Prescription Drug Monitoring Programs (PDMPs) collect controlled substance prescriptions dispensed within a state. Many PDMP programs perform targeted outreach (i.e., "unsolicited reporting") for patients who exceed numerical thresholds, however, the degree to which patients at highest risk of fatal opioid overdose are identified has not been compared with one another or with a predictive model. Methods: A retrospective analysis was performed using statewide PDMP data for Maryland residents aged 18 to 80 years with an opioid fill between April to June 2015. The outcome was opioid-related overdose death in 2015 or 2016. A multivariable logistic regression model and three PDMP thresholds were evaluated: (1) multiple provider episodes; (2) high daily average morphine milligram equivalents (MME); and (3) overlapping opioid and benzodiazepine prescriptions. Results: The validation cohort consisted of 170,433 individuals and 244 deaths. The predictive model captured more individuals who died (46.3% of total deaths) and had a higher death rate (7.12 per 1000) when the risk score cutoff (0.0030) was selected for a comparable size of high-risk individuals (n = 15,881) than those meeting the overlapping opioid/benzodiazepine prescriptions (n = 17,440; 33.2% of total deaths; 4.64 deaths per 1000) and high MME (n = 14,675; 24.6% of total deaths; 4.09 deaths per 1000) thresholds. Conclusions: The predictive model identified more individuals at risk of fatal opioid overdose as compared with PDMP thresholds commonly used for unsolicited reporting. PDMP programs could improve their targeting of unsolicited reports to reach more individuals at risk of overdose by using predictive models instead of simple threshold-based approaches.

Opioid overdose in the age of fentanyl: Risk factor differences among subpopulations of overdose survivors

BACKGROUND

Although fentanyl is the drug most frequently implicated in overdose deaths, the association between overdose risk and attitudes and behaviors surrounding fentanyl in opioid-using communities has remained understudied. Possible subpopulation differences in fentanyl-related overdose risk remain equally unexamined. This paper addresses these gaps by exploring the association between overdose and fentanyl-related attitudes/behaviors in three subpopulations of overdose survivors.

METHODS

In this cross-sectional study, we sampled 432 individuals who currently or recently used opioids from New Jersey methadone and acute residential detoxification programs. Using multinomial regression analysis, we compared overdose risk factors, including fentanyl-related attitudes/behaviors, of those who never overdosed with three subgroups of overdose survivors who experienced: 1. recent overdoses occurring after, but not before, fentanyl expansion; 2. past overdoses occurring before, but not after, fentanyl expansion; 3. persistent overdoses occurring before and after fentanyl expansion.

RESULTS

Forty percent of respondents had knowingly used fentanyl and 38% deliberately sought overdose-implicated drugs. Respondents with persistent overdoses represented under 10% of the sample but accounted for 44% of all lifetime overdoses (x̅ =8.03 vs. 1.71 for the full sample). This was also the only subgroup for whom PTSD (AOR=3.84; 95%CI=1.45-10.16; p=.01) and fentanyl-seeking (AOR=1.50; 95% CI=1.16-1.94; p=.01) were significant overdose risk factors. Those with recent overdoses engaged in frequent drug combining (AOR=2.28; 95% CI=1.19-6.98; p=.05), which could have led to inadvertent fentanyl use. Those with past overdoses were not at overdose risk from fentanyl-seeking or drug combining and had rates of methadone treatment comparable to rates of those with no overdoses.

CONCLUSION

Harm reduction strategies will need to address consumers' evolving drug preferences as fentanyl continues to saturate local drug markets. Targeting comprehensive interventions, including mental health treatment, to the small group of opioid users with longstanding overdose histories may reduce the burden of overdose in opioid-using communities.

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.

Mental health status in veterans residing in rural versus non-rural areas: results from the veterans' health study

BACKGROUND

The majority of Veterans Affair (VA) hospitals are in urban areas. We examined whether veterans residing in rural areas have lower mental health service use and poorer mental health status.

METHODS

Veterans with at least 1 warzone deployment in central and northeastern Pennsylvania were randomly selected for an interview. Mental health status, including PTSD, major depression, alcohol abuse and mental health global severity, were assessed using structured interviews. Psychiatric service use was based on self-reported utilization in the past 12 months. Results were compared between veterans residing in rural and non-rural areas. Data were also analyzed using multivariate logistic regression to minimize the influence by confounding factors.

RESULTS

A total of 1730 subjects (55% of the eligible veterans) responded to the survey and 1692 of them had complete geocode information. Those that did not have this information (n = 38), were excluded from some analyses. Veterans residing in rural areas were older, more often of the white race, married, and experienced fewer stressful events. In comparison to those residing in non-rural areas, veterans residing in rural areas had lower global mental health severity scores; they also had fewer mental health visits. In multivariate logistic regression, rural residence was associated with lower service use, but not with PTSD, major depression, alcohol abuse, and global mental health severity score after adjusting confounding factors (e.g., age, gender, marital status and education).

CONCLUSIONS

Rural residence is associated with lower mental health service use, but not with poor mental health in veterans with former warzone deployment, suggesting rural residence is possibly protective.

The role of substance use disorders in experiencing a repeat opioid overdose, and substance use treatment patterns among patients with a non-fatal opioid overdose

BACKGROUND

A non-fatal opioid overdose (NFOO) increases the risk of another overdose and identifies high-risk patients. We estimated the risk of repeat opioid overdose for patients with and without substance use disorder (SUD) diagnoses and the change in substance use treatment utilization rates associated with the first NFOO.

METHODS

We selected patients (>18 years of age) from Kaiser Permanente Northern California with a NFOO between 2009-2016 (n = 3,992). Cox proportional hazards models estimated the 1-year risk of opioid overdose associated with SUD diagnoses (opioid, alcohol, cannabis, amphetamine, sedative, and cocaine), controlling for patient characteristics. Among patients with an index NFOO, we calculated monthly utilization rates for outpatient substance use services and buprenorphine before and after the index overdose. Interrupted time series models estimated the change in level and trend in utilization rates associated with the index overdose.

RESULTS

Approximately 7.2 % of patients had a repeat opioid overdose during the year after the index NFOO. The only SUD diagnosis significantly associated with greater risk of repeat overdose was opioid use disorder (OUD) (aHR: 1.51; 95 % CI: 1.13-2.01). Before the index overdose, 4.16 % of patients received outpatient substance use services and 1.32 % received buprenorphine. The index overdose was associated with a 5.94 % (standard error: 0.77 %) absolute increase in outpatient substance use services and a 1.29 % (standard error: 0.15 %) increase in buprenorphine.

CONCLUSION

Patients with a NFOO and OUD are vulnerable to another overdose. Low initiation rates for substance use treatment after a NFOO indicate a need to address patient, provider, and system barriers.

County-level factors underlying opioid mortality in the United States

Background: Mortality from overdoses involving opioids in the United States (U.S.) has reached epidemic proportions. More research is needed to examine the underlying factors contributing to opioid-related mortality regionally. This study's objective was to identify and examine the county-level factors most closely associated with opioid-related overdose deaths across all counties in the U.S. Methods: Using a national cross-sectional ecological study design, we analyzed the relationships between 17 county-level characteristics in four categories (i.e. socio-economic, availability of medical care, health-related concerns, and demographics) with opioid mortality. Data were extracted from the Robert Wood Johnson County Health Rankings aggregate database and Centers for Disease Control and Prevention (CDC)'s Wide-ranging Online Data for Epidemiological Research (WONDER) system. Results: There were 1058 counties (33.67% of 3142 nationally) with reported opioid-related fatalities. Median opioid-related mortality was 15.61 per 100,000 persons. Multivariate regression results indicate that counties with the highest opioid-related mortality had increased rates of tobacco use, HIV, Non-Hispanic Caucasians, and females and were rural areas, but lower rates of food insecurity and uninsured adults. The rates of tobacco use and HIV had the strongest association with mortality. Availability of either mental health or primary care providers were not significantly associated with mortality. Severe housing problems, high school graduation rate, obesity, violent crime, and median household income also did not contribute to county-level differences in overdose mortality. Conclusions: Future health policies should fund further investigations and ultimately address the most influential and significant underlying county-level factors associated with opioid-related mortality.

Defining Major Depressive Disorder Cohorts Using the EHR: Multiple Phenotypes Based on ICD-9 Codes and Medication Orders

Background

Major Depressive Disorder (MDD) is one of the most common mental illnesses and a leading cause of disability worldwide. Electronic Health Records (EHR) allow researchers to conduct unprecedented large-scale observational studies investigating MDD, its disease development and its interaction with other health outcomes. While there exist methods to classify patients as clear cases or controls, given specific data requirements, there are presently no simple, generalizable, and validated methods to classify an entire patient population into varying groups of depression likelihood and severity.

Methods

We have tested a simple, pragmatic electronic phenotype algorithm that classifies patients into one of five mutually exclusive, ordinal groups, varying in depression phenotype. Using data from an integrated health system on 278,026 patients from a 10-year study period we have tested the convergent validity of these constructs using measures of external validation, including patterns of psychiatric prescriptions, symptom severity, indicators of suicidality, comorbidity, mortality, health care utilization, and polygenic risk scores for MDD.

Results

We found consistent patterns of increasing morbidity and/or adverse outcomes across the five groups, providing evidence for convergent validity.

Limitations

The study population is from a single rural integrated health system which is predominantly white, possibly limiting its generalizability.

Conclusion

Our study provides initial evidence that a simple algorithm, generalizable to most EHR data sets, provides categories with meaningful face and convergent validity that can be used for stratification of an entire patient population.

Endogenous opiates and behavior: 2017

This paper is the fortieth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2017 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Predictors of Current DSM-5 PTSD Diagnosis and Symptom Severity Among Deployed Veterans: Significance of Predisposition, Stress Exposure, and Genetics

BACKGROUND

Previously we reported a genetic risk score significantly improved PTSD prediction among a trauma-exposed civilian population. In the current study, we sought to assess this prediction among a trauma-exposed military population.

METHODS

We examined current PTSD diagnosis and PTSD symptom severity among a random sample of 1042 community-based US military veterans. Main effects and interaction effects were assessed for PTSD genetic risk by trauma exposure using cross-product terms for PTSD x trauma exposures, including combat, lifetime trauma, and adverse childhood exposures. The PTSD risk variants studied were within genetic loci previously associated with PTSD, including CRHR1, CHRNA5, RORA, and FKBP5 genetic variants, which were used to calculate a total PTSD genetic risk score (range=0-8, mean=3.6, SD=1.4).

RESULTS

Based on DSM-5 PTSD criteria, 7.1% of veterans (95% CI=5.6-8.8) met criteria for current PTSD. The PTSD genetic risk count was significantly higher among PTSD cases vs non-cases (3.92 vs 3.55, p=0.027). Since the PTSD genetic risk score was not significant in the PTSD diagnosis model, we assessed this association using PTSD symptom severity. Because these symptom data were skewed (mean=9.54, SD=12.71, range=0-76), we used negative binomial regression to assess this outcome. This symptom model included a PTSD genetic risk score, demographic factors, trauma exposures, current insomnia, current depression, concussion history, and attention-deficit disorder, expressed as incident rate ratios (IRR), which is an estimate of one-unit increase in PTSD severity, given other variables are held constant. Variables in the final model included age and sex (both p<0.001), PTSD genetic risk (IRR=1.02, p=0.028), warzone tours (IRR=0.94, p=0.003), childhood abuse (IRR=1.50, p<0.0001), current depression (IRR=1.89, p<0.0001), current insomnia (IRR=2.58, p<0.0001), low social support (IRR=1.19, p<0.0001), attention-deficit disorder (IRR=1.51, p<0.0001), agreeable personality (IRR=0.77, p<0.0001), and concussion (IRR=1.38, p<0.0001). Significant interactions were detected for combat and lifetime trauma exposure by PTSD genetic risk (both p<0.0001), suggesting that the impact of trauma exposures on PTSD severity was lower when the PTSD genetic risk was higher.

CONCLUSION

Both warzone and non-warzone factors predicted current PTSD symptoms among veterans, including a PTSD genetic risk score. Interaction effects were detected for combat exposure and lifetime trauma by genetic risk score for PTSD symptoms, suggesting that PTSD symptom manifestation was more dependent on PTSD risk variants than the level of trauma or combat exposure. This suggests that controlling for other factors, the absence of genetic risk variants may confer PTSD resilience. Further research is planned.

Prescribing patterns before and after a non-fatal drug overdose using Tennessee's controlled substance monitoring database linked to hospital discharge data

We performed a statewide evaluation of prescribing patterns of controlled substances (CS) before and after an overdose, using Tennessee's Hospital Discharge Data System and the Controlled Substance Monitoring Database (CSMD). Adults' first non-fatal overdose discharges either from the emergency department (ED) or inpatient (IP) stay occurring between 2013 and 2016 were linked to prescriptions in the CSMD. The difference in the proportion of patients filling a prescription before versus after an overdose was calculated. Included were 49,398 patients with an overdose and a prescription record; most (60.5%) were treated in the ED. Among any drug type overdose the percentage of patients who filled a CS prescription within a year of experiencing an overdose was as follows: opioid analgesics: 59.1%, benzodiazepines: 37.3%, stimulants: 5.0%, muscle relaxants: 3.4%, concurrent opioid-benzodiazepines: 24.0% with the percent difference from before to after similar in both settings. Among patients treated for an opioid overdose, this represented a decrease in opioid analgesics filled by 9.7% (95%CI: -11.2, -8.3) among those treated in the ED, and by 7.1% (95% CI: -8.3, -5.9) among treated inpatients. Among patients treated for a heroin overdose, 12.2% (95%CI: -15.2, -9.3) fewer of those treated in the ED and 8.8% (95%CI: -15.0, -2.7%) fewer of treated inpatients filled a CS prescription in that year. The most common opioid analgesics included hydrocodone and oxycodone. The number of patients filling buprenorphine for treatment increased in the year after overdoses associated with any drug or opioids but decreased among those treated for a heroin overdose.

Predictors of Overdose Death Among High-Risk Emergency Department Patients With Substance-Related Encounters: A Data Linkage Cohort Study

STUDY OBJECTIVE

Persons with substance use disorders frequently utilize emergency department (ED) services, creating an opportunity for intervention and referral to addiction treatment and harm-reduction services. However, EDs may not have the appropriate tools to distinguish which patients are at greatest risk for negative outcomes. We link hospital ED and medical examiner mortality databases in one state to identify individual-level risk factors associated with overdose death among ED patients with substance-related encounters.

METHODS

This retrospective cohort study linked Maryland statewide ED hospital claims records for adults with nonfatal overdose or substance use disorder encounters in 2014 to 2015 with medical examiner mortality records in 2015 to 2016. Logistic regression was used to identify factors in hospital records associated with risk of opioid overdose death. Predicted probabilities for overdose death were calculated for hypothetical patients with different combinations of overdose and substance use diagnostic histories.

RESULTS

A total of 139,252 patients had substance-related ED encounters in 2014 to 2015. Of these patients, 963 later experienced an opioid overdose death, indicating a case fatality rate of 69.2 per 10,000 patients, 6 times higher than that of patients who used the ED for any cause. Factors most strongly associated with death included having both an opioid and another substance use disorder (adjusted odds ratio 2.88; 95% confidence interval 2.04 to 4.07), having greater than or equal to 3 previous nonfatal overdoses (adjusted odds ratio 2.89; 95% confidence interval 1.54 to 5.43), and having a previous nonfatal overdose involving heroin (adjusted odds ratio 2.24; 95% confidence interval 1.64 to 3.05).

CONCLUSION

These results highlight important differences in overdose risk among patients receiving care in EDs for substance-related conditions. The findings demonstrate the potential utility of incorporating routine data from patient records to assess risk of future negative outcomes and identify primary targets for initiation and linkage to lifesaving care.

Findings from the recovery initiation and management after overdose (RIMO) pilot study experiment

This pilot study evaluated the feasibility of the Recovery Initiation and Management after Overdose (RIMO) intervention to link individuals to medication-assisted treatment (MAT) following an opioid overdose. The study team worked with the Chicago Fire Department to train Emergency Medical Service (EMS) teams to request permission from individuals after an opioid overdose reversal to release their contact information; individuals were subsequently contacted by the study team for participation. A mixed-methods study design comprised: (1) an experimental pilot study that examined participation at each stage of the intervention and compared the odds of treatment received for individuals who were randomly assigned to either the RIMO intervention (n = 16) or a passive referral control (n = 17); and (2) a focus group that was subsequently conducted with participants in the RIMO group to obtain their feedback on the intervention components. Quantitative data was collected on participant characteristics at study intake and treatment received was based on self-report at a 30-day follow-up. The RIMO group had higher odds of receiving any treatment for opioid use (OR = 7.94) and any MAT (OR = 20.2), and received significantly more days of opioid treatment (Ms=15.2 vs. 3.4) and more days of MAT in the 30 days post-randomization (Ms=11.2 vs. 0.76), relative to the control group (all p < .05). Qualitative data illustrated that participants valued the assertive outreach, engagement, and persistent follow-up components of RIMO, which differed from their prior experiences. The pilot study suggests that the RIMO intervention is able to address the challenges of linking and engaging individuals into MAT after an opioid overdose.

Visual Dysfunction and Associated Co-morbidities as Predictors of Mild Traumatic Brain Injury Seen Among Veterans in Non-VA Facilities: Implications for Clinical Practice

Introduction

Traumatic brain injury (TBI) and post-traumatic stress disorder are considered the signature injuries of the Iraq and Afghanistan conflicts. With the extensive use of improvised explosive devices by the enemy, the concussive effects from blast have a greater potential to cause mild TBI (mTBI) in military Service Members. These mTBI can be associated with other physical and psychological health problems, including mTBI-induced visual processing and eye movement dysfunctions. Our study assessed if any visual dysfunctions existed in those surveyed in non-Veterans Administration (VA) facilities who had suffered mTBI (concussive effect), in addition to the presence of concussion-related co-morbidities.

Materials and Methods

As part of a larger study involving veterans from different service eras, we surveyed 235 Veterans who had served during the Iraq and/or Afghanistan conflict era. Data for the study were collected using diagnostic telephone interviews of these veterans who were outpatients of the Geisinger Health System. We assess visual dysfunction in this sample and compare visual dysfunctions of those who had suffered a mTBI (concussive effect), as well as co-morbidities, with those in the cohort who had not suffered concussion effects.

Results

Of those veterans who experienced visual dysfunctions, our results reflected that the visual symptoms were significant for concussion with the subjects surveyed, even though all had experienced a mTBI event greater than five years ago. Although we did find an association with concussion and visual symptoms, the association for concussion was strongest with the finding of greater than or equal to three current TBI symptoms, therefore we found this to be the best predictor of previous concussion among the veterans.

Conclusions

Veterans from the Iraq/Afghanistan era who had suffered concussive blast effects (mTBI) can present with covert visual dysfunction as well as additional physical and psychological health problems. The primary eye care providers, especially those in a non-military/VA facility, who encounter these veterans need to be aware of the predictors of mTBI, with the aim of uncovering visual dysfunctions and other associated co-morbidities.

Underreporting of Hepatitis B and C virus infections - Pennsylvania, 2001-2015

Context

In Pennsylvania, reporting of viral hepatitis B (HBV) and viral hepatitis C (HCV) infections to CDC has been mandated since 2002. Underreporting of HBV and HCV infections has long been identified as a problem. Few reports have described the accuracy of state surveillance case registries for recording clinically-confirmed cases of HBV and HCV infections, or the characteristics of populations associated with lower rates of reporting.

Objective

The primary objective of the current study is to estimate the proportion of HBV and HCV infections that went unreported to the Pennsylvania Department of Health (PDoH), among patients in the Geisinger Health System of Pennsylvania. As a secondary objective, we study the association between underreporting of HBV and HCV infections to PDoH, and the select patient characteristics of interest: sex, age group, race/ethnicity, rural status, and year of initial diagnosis.

Design

Per medical record review, the study population was limited to Geisinger Health System patients, residing in Pennsylvania, who were diagnosed with a chronic HBV and/or HCV infection, between 2001 and 2015. Geisinger Health System patient medical records were matched to surveillance records of confirmed cases reported to the Pennsylvania Department of Health (PDoH). To quantify the extent that underreporting occurred among the Geisinger Health System study participants, we calculated the proportion of study participants that were not reported to PDoH as confirmed cases of HBV or HCV infections. An analysis of adjusted prevalence ratio estimates was conducted to study the association between underreporting of HBV and HCV infections to PDoH, and the select patient characteristics of interest.

Results

Geisinger Health System patients living with HBV were reported to PDoH 88.4% (152 of 172) of the time; patients living with HCV were reported to PDoH 94.6% (2,257 of 2,386) of the time; and patients who were co-infected with both viruses were reported to PDoH 72.0% (18 of 25) of the time. Patients living with HCV had an increased likelihood of being reported if they were: less than or equal to age 30 vs ages 65+ {PR = 1.2, [95%CI, (1.1, 1.3)]}, and if they received their initial diagnosis of HCV during the 2010–2015 time period vs the 1990–1999 time period {PR = 1.08, [95%CI, (1.05, 1.12)]}.

Conclusion

The findings in this study are promising, and suggests that PDoH has largely been successful with tracking and monitoring viral hepatitis B and C infections, among persons that were tested for HBV and/or HCV. Additional efforts should be placed on decreasing underreporting rates of HCV infections among seniors (ages 65 and over), and persons who are co-infected with HBV and HCV.

Patterns of health care utilization among people who overdosed from illegal drugs: a descriptive analysis using the BC Provincial Overdose Cohort

INTRODUCTION

British Columbia (BC) declared a public health emergency in April 2016 in response to a rapid rise in overdose deaths. Further understanding of health care utilization is needed to inform prevention strategies for individuals who overdose from illegal drugs.

METHODS

The Provincial Overdose Cohort includes linked administrative data on health care utilization by individuals who experienced an illegal drug overdose event in BC between 1 January 2015 and 30 November 2016. Overdose cases were identified using data from ambulance services, coroners' investigations, poison control centre calls and hospital, emergency department and physician administrative records. In total, 10 455 overdose cases were identified and compared with 52 275 controls matched on age, sex and area of residence for a descriptive analysis of health care utilization.

RESULTS

Two-thirds (66%) of overdose cases were male and about half (49%) were 20-39 years old. Over half of the cases (54%) visited the emergency department and about one-quarter (26%) were admitted to hospital in the year before the overdose event, compared with 17% and 9% of controls, respectively. Nevertheless, nearly onefifth (19%) of cases were recorded leaving the emergency department without being seen or against medical advice. High proportions of both cases (75%) and controls (72%) visited community-based physicians. Substance use and mental health-related concerns were the most common diagnoses among people who went on to overdose.

CONCLUSION

People who overdosed frequently accessed the health care system in the year before the overdose event. In light of the high rates of health care use, there may be opportunities to identify at-risk individuals before they overdose and connect them with targeted programs and evidence-based interventions. Further work using the BC Provincial Overdose Cohort will focus on identifying risk factors for overdose events and death by overdose.

Development and characteristics of the Provincial Overdose Cohort in British Columbia, Canada

Introduction

British Columbia (BC), Canada declared a public health emergency in April 2016 for opioid overdose. Comprehensive data was needed to identify risk factors, inform interventions, and evaluate response actions. We describe the development of an overdose cohort, including linkage strategy, case definitions, and data governance model, and present the resulting characteristics, including data linkage yields and case overlap among data sources.

Methods

Overdose events from hospital admissions, physician visits, poison centre and ambulance calls, emergency department visits, and coroner’s data were grouped into episodes if records were present in multiple sources. A minimum of five years of universal health care records (all prescription dispensations, fee-for-service physician billings, emergency department visits and hospitalizations) were appended for each individual. A 20% random sample of BC residents and a 1:5 matched case-control set were generated. Consultation and prioritization ensured analysts worked to address questions to directly inform public health actions.

Results

10,456 individuals suffered 14,292 overdoses from January 1, 2015 to Nov 30, 2016. Only 28% of overdose events were found in more than one dataset with the unique contribution of cases highest from ambulance records (32%). Compared with fatal overdoses, non-fatal events more often involved females, younger individuals (20 to 29 years) and those 60 or older. In 78% of illegal drug deaths, there was no associated ambulance response. In the year prior to first recorded overdose, 60% of individuals had at least one ED visit, 31% at least one hospital admission, 80% at least one physician visit, and 87% had filled at least one prescription in a community pharmacy.

Conclusion

While resource-intensive to establish, a linked cohort is useful for characterizing the full extent of the epidemic, defining sub-populations at risk, and patterns of contact with the health system. Overdose studies in other jurisdictions should consider the inclusion of multiple data sources.

Patterns and history of prescription drug use among opioid-related drug overdose cases in British Columbia, Canada, 2015-2016

BACKGROUND

British Columbia is the epicenter of the current fentanyl-related overdose crisis in Canada. Our study characterizes prescribing histories of people who had an opioid-related overdose compared to matched controls.

METHODS

We examined linked administrative data for individuals who overdosed between January 1, 2015 and November 30, 2016. Past prescriptions over five years were assessed for opioids for pain, opioid agonist therapy, benzodiazepines/z-drugs, antidepressants, antipsychotics, gabapentinoids, mood stabilizers and anti-epileptics, muscle relaxants, and other sedating medications. Prescribing history of 9964 cases was compared with that of 49,820 matched controls.

RESULTS

Overdose cases were more likely to be prescribed opioids for pain and to have used prescription opioids on a long-term basis in the previous five years compared to controls. However, at the time of overdose, 92% of men and 86% of women did not have an active opioid for pain prescription, and approximately half had not filled one in the past five years. Those who overdosed tended to have more prescriptions for psychotropic substances than controls. Fewer than 10% of cases had an active prescription for opioid agonist therapy and most were not on treatment in the past.

CONCLUSIONS

Low prevalence of active prescriptions for opioids for pain at the time of overdose suggests that opioid prescribing plays a limited short-term impact in the current fentanyl-related crisis of overdoses. While liberal opioid prescribing practices may have contributed to the development of the current overdose crisis, regulation and enforcement of clinicians' prescribing practices will likely have limited impact in reducing overdoses.

Grapheme-Color Synesthesia is Associated with PTSD Among Deployed Veterans: Confirmation of Previous Findings and Need for Additional Research

Post-traumatic stress disorder (PTSD) is related to alteration in neuropsychological functioning, including visual and other cognitive processes. Grapheme-color synesthesia is a phenomenon in which a letter or number elicits response of a concurrent image or color perception. Since we earlier reported an association between grapheme-color synesthesia and PTSD, our objective in the current study was to validate this association among a new study group and assess risk factors. For this, we surveyed 1,730 military veterans who have been outpatients in the Geisinger Clinic, a multi-hospital system in Pennsylvania, USA. All the study veterans served in a warzone deployment. The association between PTSD and Grapheme-color synesthesia was evaluated. The average age of veterans was 59.6 years among whom 95.1% were male. Current PTSD prevalence rate was observed to be 7.6% (95% C.I. = 6.5-9.0) and in 3.4% of veterans (95% C.I. = 2.7-4.4) grapheme-color synesthesia was found to be positive. Initial bivariate analyses suggested that synesthesia was associated with current PTSD [odds ratio (OR) = 3.3, p<0.001]. Multivariable stepwise logistic regression evaluating the age, sex, education, trauma exposure, current psychological stress, psychotropic medication use, combat exposure, history of concussion, and current depression, confirmed this association (OR = 2.33, p = 0.019). The present study corroborated that Grapheme-color synesthesia was linked to PTSD among a second cohort of deployed military veterans. Further research is recommended in order to validate this observation and to determine whether synesthesia is a risk factor for PTSD.

Evaluation of US Food and Drug Administration-recommended abuse-potential questions in chronic pain patients without history of recreational opioid use: results and plan for research

Background

Existing patient-reported outcome (PRO) assessments that measure the human abuse potential for opioid analgesics have been tested exclusively in experienced recreational opioid users, as required by US Food and Drug Administration (FDA) guidance.

Methods

The goals of the current studies were to modify items from FDA-recommended abuse potential PRO assessments to specify the analgesic benefits versus the euphoric effects of opioids and to ascertain the clarity, understandability, appropriateness, and validity of the modified questions. This was achieved by conducting cognitive debriefing interviews (CDIs) with patients (≥18 and <65 years) who have chronic pain, were prescribed an opioid daily dose of at least 80 morphine-equivalent milligrams (>30 days to ≤180 days from the date of interview), and did not have a history of recreational opioid use.

Results

Participants in study 1 (n=30) and study 2 (n=7) had a better understanding of the items designed to measure the concepts of drug liking and items designed to measure the desire to take a drug again when reasons for liking and desire to take again were included in the item wording (namely, “due to pain relief ” and “excluding pain relief ”). Most participants indicated no interest in taking their medication for reasons other than pain relief.

Conclusion

Modification of questions in the PRO assessment improved patient understanding of “drug liking” and “desire to take again.” Patients with chronic pain who were not recreational opioid users understood the difference between the analgesic and euphoric effects of an opioid drug. The modified questions should assist future researchers in providing a more accurate assessment of the abuse potential of an opioid, as required by regulatory agencies.

Applying Machine Learning to Linked Administrative and Clinical Data to Enhance the Detection of Homelessness among Vulnerable Veterans

U.S. military veterans who were discharged from service for misconduct are at high risk for homelessness. Stratifying homelessness risk based on both military service factors and clinical characteristics could facilitate targeted provision of preventive services to those at critical risk. Using administrative data from the Department of Defense and Veterans Health Administration for 25,821 misconduct-discharged Veterans, we developed a dataset that included demographic and clinical characteristics corresponding to 12-months, 3-months, and 1-month preceding the first documentation of homelessness (or a matched index encounter for those without homelessness). Clinical time-trend features were extracted and included as additional model inputs. We developed several random forest models to classify homelessness risk. Models based on 1- and 3-months of data performed roughly as well as those based on 12-months of data. In best-performing models, 70% of those identified as at high-risk became homeless; 30% identified as at moderate risk became homeless (AUC=0.80; recall=0.64, specificity=0.82). Findings suggest the viability of risk stratification for targeting resources.

Medical, psychosocial, and treatment predictors of opioid overdose among high risk opioid users

INTRODUCTION

Drug overdoses are the leading cause of accidental death in the United States. It is imperative to explore predictors of opioid overdose in order to facilitate targeted treatment and prevention efforts. The present study was conducted as an exploratory examination of the factors associated with having a past opioid overdose.

METHODS

Participants (N = 244) from substance treatment facilities, inpatient services following ER admittance, or involved within the drug court system and who reported opioid use in the past 6 months were recruited in this study. Measures of opioid use and history were used to determine characteristics associated with previous experience of a non-fatal opioid overdose.

RESULTS

Opioid users who were Caucasian and used a combination of prescription opioids and heroin were more likely to have experienced a prior overdose. Opioid user characteristics associated with greater odds of experiencing a prior overdose included: witnessing a friend overdose (OR 4.21), having chronic hepatitis C virus (HCV) infection (OR 2.44), reporting a higher frequency of buprenorphine treatment episodes (OR 1.55), and having a higher frequency of witnessing others overdose (OR 1.42). Greater frequency of methadone treatment episodes was related to decreased odds of experiencing an overdose (OR 0.67).

CONCLUSION

Overall, this study demonstrated certain demographic and drug use factors associated with elevated risk for an overdose. Understanding the risk factors associated with drug overdose can lead to targeted naloxone training and distribution to prevent fatal overdoses.

Mental Health Impact of Homecoming Experience Among 1730 Formerly Deployed Veterans From the Vietnam War to Current Conflicts: Results From the Veterans' Health Study

We examined the effects of homecoming support on current mental health among 1730 deployed veterans from Vietnam, Iraq/Afghanistan, Persian Gulf, and other conflicts. The prevalence of current posttraumatic stress disorder (PTSD) was 5.4%, current depression was 8.3%, and 5.4% had suicidal thoughts in the past month. Overall, 26% of veterans had low homecoming support, which was more prevalent among Vietnam veterans (44.3%, p < 0.001). In multivariable logistic regressions, controlling for demographics, combat exposure, number of deployments, trauma history, and operational theater, low postdeployment support was associated with PTSD (odds ratio, 2.13; p = 0.032) and suicidality (odds ratio, 1.91; p < 0.030), but not depression. For suicidality, an interaction was detected for homecoming by theater status, whereby Iraq/Afghanistan veterans with lower homecoming support had a higher probability of suicidal thoughts (p = 0.002). Thus, years after deployment, lower homecoming support was associated with current PTSD and suicidality, regardless of theater and warzone exposures. For suicidality, lower support had a greater impact on Iraq/Afghanistan veterans.

Methodologic limitations of prescription opioid safety research and recommendations for improving the evidence base

PURPOSE

The ongoing opioid epidemic has claimed more than a quarter million Americans' lives over the past 15 years. The epidemic began with an escalation of prescription opioid deaths and has now evolved to include secondary waves of illicit heroin and fentanyl deaths, while the deaths due to prescription opioid overdoses are still increasing. In response, the Centers for Disease Control and Prevention (CDC) moved to limit opioid prescribing with the release of opioid prescribing guidelines for chronic noncancer pain in March 2016. The guidelines represent a logical and timely federal response to this growing crisis. However, CDC acknowledged that the evidence base linking opioid prescribing to opioid use disorders and overdose was grades 3 and 4.

METHODS

Motivated by the need to strengthen the evidence base, this review details limitations of the opioid safety studies cited in the CDC guidelines with a focus on methodological limitations related to internal and external validity.

RESULTS

Internal validity concerns were related to poor confounding control, variable misclassification, selection bias, competing risks, and potential competing interventions. External validity concerns arose from the use of limited source populations, historical data (in a fast-changing epidemic), and issues with handling of cancer and acute pain patients' data. We provide a nonexhaustive list of 7 recommendations to address these limitations in future opioid safety studies.

CONCLUSION

Strengthening the opioid safety evidence base will aid any future revisions of the CDC guidelines and enhance their prevention impact.

Prescribing naloxone for opioid overdose intervention

To provide an update on prescription of naloxone as a harm-reduction strategy, PubMed was searched to identify publications relevant to naloxone prescribing for reversal of opioid overdose. Opportunities now exist to expand naloxone use, although evidence suggests these are often missed or underexploited. The US FDA has approved an intranasal naloxone spray and an autoinjector naloxone formulation for community use. Effective use of naloxone in community settings requires screening to identify patients at risk of opioid overdose, discussing naloxone use with patients and their relatives, and providing appropriate training. The tools exist to expand the use of naloxone more widely into the community, thereby creating an opportunity to reduce opioid overdose fatalities.

A Review of the Opioid Epidemic: What Do We Do About It?

The opioid epidemic, with its noticeable increase in opioid prescriptions and related misuse, abuse and resultant deaths in the previous 12 years, is a particularly North American phenomenon. Europe, and particularly low- and middle-income countries, appear to be less influenced by this problem. There is undisputable value in using opioids not only in the treatment of acute pain, but in cancer pain as well. However, opioids are progressively being prescribed more and more for chronic non-cancer pain, despite inadequate data on their efficacy. In this paper, we describe the current prevalence of opioid misuse in a number of countries and the rationale for the commencement of opioid therapy. The safe initiation and monitoring of opioid therapy as well as the need for concurrent use of interdisciplinary multimodal therapy is discussed. The possible consequences of long-term use and predictors of high opioid use and overdose are presented. In particular, the management of opioid use disorders and the prevention of opioid abuse and dependence in the young, the old and the pregnant are discussed. Measures to prevent overprescribing and to alleviate risk are described, including the tapering of opioids and the use of opioid deterrents. Finally, the paper looks at the future development of pioneering medications and technologies to potentially treat abuse. In those parts of the world with an opioid epidemic, coroners and medical examiners, private and public health agencies, and agencies that enforce the law need to cooperate in an effort to slow down and reverse the indiscriminate use of prescribing opioids in the long-term for chronic non-cancer pain. Ongoing research is needed to create ways to minimise risks of opioid use, and to provide evidence for effective strategies for treating chronic pain.

Opioid recovery initiation: Pilot test of a peer outreach and modified Recovery Management Checkup intervention for out-of-treatment opioid users

The recent surge in opioid-related overdoses and related fatalities underscores the need for assertive mechanisms for linking individuals with opioid use disorders (OUD) to medication-assisted treatment (MAT). This pilot study investigated the feasibility of an intervention that used peer outreach workers to identify out-of-treatment individuals with OUD combined with a modified version of the Recovery Management Checkup to link individuals to methadone treatment. The study was conducted in high-risk communities in Chicago over 8weeks; peer outreach workers identified 88 active opioid/heroin users; 72 were screened as eligible, and 70 showed to the study intake/initial linkage meeting. Most participants were male (73%) and African American (94%), with an average age of 52.0 (sd=7.6). Nearly all (67/70, 96%) were admitted to methadone treatment; median time from initial linkage meeting to treatment admission was 2.6days. Most were still in treatment at 30 and 60days post-intake (69% and 70%, respectively). A high-risk sub-group was identified that had ever received naloxone for an opioid overdose; they had one third of the odds of being in treatment at 30days post-intake compared with others. The intervention model holds promise as an assertive method for identifying and engaging individuals with OUD into treatment.

Prescribers' views and experiences of assessing the appropriateness of prescribed medications in a specialist addiction service

Background Mental and physical health problems are common in people with substance misuse problems and medications are often required in their management. Given the extent of prescribing for service users who attend specialist addiction services, it is important to consider how prescribers in this setting assess the appropriateness of service users’ prescribed medications. Objective To explore prescribers’ views and experiences of assessing the appropriateness of medications prescribed for service users coming in for treatment as well as the differences between prescribers. Setting A specialist addiction service in the North of England. Method A phenomenological approach was adopted. Semi-structured interviews were conducted with four nurse prescribers and eight doctors. Data were analysed using thematic framework analysis. Main outcome measure Prescribers’ views and experiences of assessing the appropriateness of prescribed medications. Results Assessment of the appropriateness of prescribed medications involved reviewing medications, assessing risk, history-taking, involvement of service users, and comparing guideline adherence and ‘successful’ prescribing. Doctors and nurse prescribers assessed the appropriateness of medications they considered to be within their competency. Doctors provided support to nurse prescribers and general practitioners (GPs) when dealing with issues around prescribing. Conclusion Assessment of the appropriateness of prescribed medications is complex. The recent reduction in medical expertise in specialist addiction services may negatively impact on the clinical management of service users. It appears that there is a need for further training of nurse prescribers and GPs so they can provide optimal care to service users.

Patterns of health care utilization and cost before and after opioid overdose: findings from 10-year longitudinal health plan claims data

Objective

To describe the longitudinal pattern of health care utilization and cost of care before and after opioid overdose (OD) over a 10-year period using health plan claims data.

Methods

Patients who had experienced opioid ODs between April 2005 and March 2015 were identified from Geisinger Health System’s electronic health records. Among these patients, a subgroup of patients who were Geisinger Health Plan (GHP) members at any point between January 2006 and December 2015 were also identified. From the corresponding GHP claims data, their all-cause health care utilization (inpatient admissions, emergency department [ED] visits, and physician office visits) and total medical costs, excluding prescription medication cost, were obtained. Per-member-per-month estimates for each month before and after the index date of opioid OD were calculated, adjusting for age, gender, plan type, year, and comorbidity via multivariate regression models.

Results

A total of 942 opioid OD patients with an average GHP enrollment period of 41.4 months were identified. ED visit rates rose rapidly starting around 19–24 months prior to the opioid OD date. Acute inpatient admission rates and total medical cost also rose rapidly starting around 12 months prior. After the OD date, the utilization rates and cost declined but tended to remain above those of the pre-OD period.

Conclusion

Opioid OD is preceded by sharp increases in utilization of acute care and cost well before the actual OD. These findings therefore suggest that early signals of OD may be detected from patterns of acute care utilization, particularly the ED visits.