A Brief Survey to Characterize Oxycodone Abuse Patterns in Adolescents Enrolled in Two Substance Abuse Recovery High Schools

Social-Ecological Predictors of Opioid Use Among Adolescents With Histories of Substance Use Disorders

Adolescent opioid misuse is a public health crisis, particularly among clinical populations of youth with substance misuse histories. Given the negative and often lethal consequences associated with opioid misuse among adolescents, it is essential to identify the risk and protective factors underlying early opioid misuse to inform targeted prevention efforts. Understanding the role of parental risk and protective factors is particularly paramount during the developmental stage of adolescence. Using a social-ecological framework, this study explored the associations between individual, peer, family, community, and school-level risk and protective factors and opioid use among adolescents with histories of substance use disorders (SUDs). Further, we explored the potential moderating role of poor parental monitoring in the associations between the aforementioned risk and protective factors and adolescent opioid use. Participants included 294 adolescents (M _age = 16 years; 45% female) who were recently discharged from substance use treatment, and their parents (n = 323). Results indicated that lifetime opioid use was significantly more likely among adolescents endorsing antisocial traits and those whose parents reported histories of substance abuse. Additionally, adolescents reporting more perceived availability of substances were significantly more likely to report lifetime opioid use compared to those reporting lower perceived availability of substances. Results did not indicate any significant moderation effects of parental monitoring on any associations between risk factors and lifetime opioid use. Findings generally did not support social-ecological indicators of opioid use in this high-risk population of adolescents, signaling that the social-ecological variables tested may not be salient risk factors among adolescents with SUD histories. We discuss these findings in terms of continuing care options for adolescents with SUD histories that target adolescents' antisocial traits, perceived availability of substances, and parent histories of substance abuse, including practical implications for working with families of adolescents with SUD histories.

Oxycodone in the Opioid Epidemic: High 'Liking', 'Wanting', and Abuse Liability

It is estimated that nearly a third of people who abuse drugs started with prescription opioid medicines. Approximately, 11.5 million Americans used prescription drugs recreationally in 2016, and in 2018, 46,802 Americans died as the result of an opioid overdose, including prescription opioids, heroin, and illicitly manufactured fentanyl (National Institutes on Drug Abuse (2020) Opioid Overdose Crisis. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis . Accessed 06 June 2020). Yet physicians will continue to prescribe oral opioids for moderate-to-severe pain in the absence of alternative therapeutics, underscoring the importance in understanding how drug choice can influence detrimental outcomes. One of the opioid prescription medications that led to this crisis is oxycodone, where misuse of this drug has been rampant. Being one of the most highly prescribed opioid medications for treating moderate-to-severe pain as reflected in the skyrocketed increase in retail sales of 866% between 1997 and 2007, oxycodone was initially suggested to be less addictive than morphine. The false-claimed non-addictive formulation of oxycodone, OxyContin, further contributed to the opioid crisis. Abuse was often carried out by crushing the pills for immediate burst release, typically by nasal insufflation, or by liquefying the pills for intravenous injection. Here, we review oxycodone pharmacology and abuse liability as well as present the hypothesis that oxycodone may exhibit a unique pharmacology that contributes to its high likability and abuse susceptibility. We will discuss various mechanisms that likely contribute to the high abuse rate of oxycodone including clinical drug likability, pharmacokinetics, pharmacodynamics, differences in its actions within mesolimbic reward circuity compared to other opioids, and the possibility of differential molecular and cellular receptor interactions that contribute to its selective effects. We will also discuss marketing strategies and drug difference that likely contributes to the oxycodone opioid use disorders and addiction.

Individual short-acting opioids and the risk of opioid-related adverse events in adolescents

PURPOSE

Hydrocodone, codeine, oxycodone, and tramadol are frequently prescribed to adolescents for moderate pain related to minor trauma or dental, surgical, or medical procedures. Pharmacokinetic and pharmacodynamic differences between these opioids could affect their relative safety. We aimed to compare occurrence of opioid-related adverse events in adolescents without cancer or other severe conditions taking hydrocodone, codeine, oxycodone, and tramadol.

METHODS

Retrospective cohort study of 201 940 Tennessee Medicaid enrollees 12 to 17 years of age without cancer, other severe conditions, or evidence of substance abuse with 529 731 filled prescriptions for study opioids. Adverse events were defined as an emergency department visit, hospital admission, or death related to opioid use, confirmed by medical record review. Serious events had opioid-related escalation of care, hospitalization, or death. Propensity-score adjusted hazard ratios (HRs) were calculated with hydrocodone as the reference category.

RESULTS

The incidence of opioid-related adverse events per 10 000 person-years of opioid exposure was 97.5 for hydrocodone (127 events/13 026 person-years), 91.2 for codeine (58/6,359), 229.7 for oxycodone (43/1,872), and 317.7 for tramadol (47/1479). The HRs for tramadol in comparison with hydrocodone for all and serious events were 2.98 (2.03-4.39) and 2.94 (1.81-4.75), respectively. Increased risk for tramadol was consistently present when the adverse events were restricted to those with neurologic-respiratory depression/other symptoms of possible overdose.

CONCLUSION

In adolescents without cancer or other severe conditions prescribed short-acting opioids, the incidence of both all opioid-related adverse events and more serious events with opioid-related escalation of care, hospitalization, or death was consistently greater for tramadol than for hydrocodone.

An age-based analysis of nonmedical prescription opioid use among people who use illegal drugs in Vancouver, Canada

BACKGROUND

Nonmedical prescription opioid use (NMPOU) is a serious public health problem in North America. At a population-level, previous research has identified differences in the prevalence and correlates of NMPOU among younger versus older age groups; however, less is known about age-related differences in NMPOU among people who use illegal drugs.

METHODS

Data were collected between 2013 and 2015 from two linked prospective cohort studies in Vancouver, Canada: the At-Risk Youth Study (ARYS) and the Vancouver Injection Drug Users Study (VIDUS). Factors independently associated with NMPOU among younger (ARYS) and older (VIDUS) participants were examined separately using bivariate and multivariate generalized estimating equations.

RESULTS

A total of 1162 participants were included. Among 405 eligible younger participants (Median age = 25; Inter-Quartile Range [IQR]: 22-28), 40% (n = 160) reported engaging in NMPOU at baseline; among 757 older participants (Median age = 48, IQR: 40-55), 35% (n = 262) reported engaging in NMPOU at baseline. In separate multivariate analyses of younger and older participants, NMPOU was positively and independently associated with heroin use (younger: Adjusted Odds Ratio [AOR] = 3.12, 95% Confidence Interval [CI]: 2.08-4.68; older: AOR = 2.79, 95% CI: 2.08-3.74), drug dealing (younger: AOR = 2.22, 95% CI: 1.58-3.13; older: AOR = 1.87, 95% CI: 1.40-2.49), and difficulty accessing services (younger: AOR = 1.47, 95% CI: 1.04-2.09; older: AOR = 1.74, 95% CI: 1.32-2.29). Among the youth cohort only, NMPOU was associated with younger age (AOR = 1.12, 95% CI: 1.05-1.19), crack use (AOR = 1.56, 95% CI: 1.06-2.30), and binge drug use (AOR = 1.41, 95% CI: 1.00-1.97); older participants who engaged in NMPOU were more likely to report crystal methamphetamine use (AOR = 1.97, 95% CI: 1.46-2.66), non-fatal overdose (AOR = 1.76, 95% CI: 1.20-2.60) and sex work (AOR = 1.49, 95% CI: 1.00-2.22).

DISCUSSION

The prevalence of NMPOU is similar among younger and older people who use drugs, and independently associated with markers of vulnerability among both age groups. Adults who engage in NMPOU are at risk for non-fatal overdose, which highlights the need for youth and adult-specific strategies to address NMPOU that include better access to health and social services, as well as a range of addiction treatment options for opioid use. Findings also underscore the importance of improving pain treatment strategies tailored for PWUD.

Recovery schools for improving behavioral and academic outcomes among students in recovery from substance use disorders: a systematic review

This Campbell systematic review examines the effects of recovery schools on student behavioral and academic outcomes, compared to the effects of non-recovery schools. The review summarizes evidence from one quasi-experimental study (with a total of 194 participants) that had potential serious risk of bias due to confounding. Sizable portions of youth are in recovery from substance use disorders, and many youth will return to use after receiving substance use treatment. Youth spend most of their waking hours at school, and thus schools are important social environments for youth in recovery from substance use disorders. Recovery schools have been identified as educational programs that may help support youth in recovery from substance use disorders. This review focused on two types of recovery schools: RHSs, which are schools that award secondary school diplomas and offer a range of therapeutic services in addition to standard educational curricula; and CRCs, which offer therapeutic and sober support services on college campuses. This review looked at whether recovery schools (RHSs or CRCs) affect academic success and substance use outcomes among students, compared to similar students who are not enrolled in recovery schools.

Plain language summary

There is insufficient evidence to know whether recovery high schools and collegiate recovery communities are effective: Evidence that recovery high schools (RHSs) may improve academic and substance use outcomes is based on the findings from a single study with a serious risk of bias.The review in brief: Very limited evidence addresses the effectiveness of recovery high schools (RHSs). There is no rigorous evidence on the effectiveness of collegiate recovery communities (CRCs).It is unclear whether CRCs are effective in promoting academic success and reducing substance use among college students.What is the aim of this review?: This Campbell systematic review examines the effects of recovery schools on student behavioral and academic outcomes, compared to the effects of non-recovery schools. The review summarizes evidence from one quasi-experimental study (with a total of 194 participants) that had potential serious risk of bias due to confounding.What are the main findings of this review?: Sizable portions of youth are in recovery from substance use disorders, and many youth will return to use after receiving substance use treatment. Youth spend most of their waking hours at school, and thus schools are important social environments for youth in recovery from substance use disorders. Recovery schools have been identified as educational programs that may help support youth in recovery from substance use disorders.This review focused on two types of recovery schools: RHSs, which are schools that award secondary school diplomas and offer a range of therapeutic services in addition to standard educational curricula; and CRCs, which offer therapeutic and sober support services on college campuses.This review looked at whether recovery schools (RHSs or CRCs) affect academic success and substance use outcomes among students, compared to similar students who are not enrolled in recovery schools.What studies are included?: The included study of recovery high schools used a controlled quasi-experimental pretest-posttest design and reported on the following outcomes: grade point average, truancy, school absenteeism, alcohol use, marijuana use, other drug use, and abstinence from alcohol/drugs. The included study focused on a sample of U.S. high school students. There were no eligible studies of CRCs.What do the findings of this review mean?: Findings from this review indicate insufficient evidence on the effects of recovery schools on student well-being. Although there is some indication RHSs may improve academic and substance use outcomes, this is based on the findings from a single study. There is no available evidence on the effects of CRCs.No strong conclusions can be drawn at this time, given the lack of available evidence on RHSs and CRCs, and the serious risk of bias in the one RHS study included in the review. The evidence from this review suggests there is a clear need for additional rigorous evaluations of recovery school effects prior to widespread implementation.How up-to-date is this review?: The review authors searched for studies until September 2018. This Campbell systematic review was published in 2018.

Executive Summary/Abstract

BACKGROUND: Substance use disorders (SUDs) among youth are a major public health problem. In the United States, for example, the incidence of SUDs increases steadily after age 12 and peaks among youth ages 18-23 (White, Evans, Ali, Achara-Abrahams, & King, 2009). Although not every youth who experiments with alcohol or illicit drugs is diagnosed with an SUD, approximately 7-9% of 12-24 year olds in the United States were admitted for public SUD treatment in 2013 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016). Recovery from an SUD involves reduction or complete abstinence of use, defined broadly as "voluntarily sustained control over substance use, which maximises health and wellbeing and participation in the rights, roles and responsibilities of society" (UK Drug Policy Commission, 2008). However, SUDs are often experienced as chronic conditions; among youth who successfully complete substance use treatment, approximately 45-70% return to substance use within months of treatment discharge (Anderson, Ramo, Schulte, Cummins, & Brown, 2007; Brown, D'Amico, McCarthy, & Tapert, 2001; Ramo, Prince, Roesch, & Brown, 2012; White et al., 2004). Thus, multiple treatment episodes and ongoing recovery supports after treatment are often necessary to assist with the recovery process (Brown et al., 2001; Ramo et al., 2012; White et al., 2004).Success and engagement at school and in postsecondary education are critical to healthy youth development. For youth in recovery from SUDs, school attendance, engagement, and achievement build human capital by motivating personal growth, creating new opportunities and social networks, and increasing life satisfaction and meaning (Keane, 2011; Terrion, 2012; 2014). Upon discharge from formal substance use treatment settings, schools become one of the most important social environments in the lives of youth with SUDs. Healthy school peer environments can enable youth to replace substance use behaviors and norms with healthy activities and prosocial, sober peers. Conversely, many school environments may be risky for youth in recovery from SUDs due to perceived substance use among peers, availability of drugs or alcohol, and substance-approving norms on campus (Centers for Disease Control [CDC], 2011; Spear & Skala, 1995; Wambeam, Canen, Linkenbach, & Otto, 2014).Given the many social and environmental challenges faced by youth in recovery from substance use, recovery-specific institutional supports are increasingly being linked to educational settings. The two primary types of education-based continuing care supports for youth in recovery, defined under the umbrella term of "recovery schools" for this review, are recovery high schools (RHSs) and collegiate recovery communities (CRCs). RHSs are secondary schools that provide standard high school education and award secondary school diplomas, but also include therapeutic programming aimed at promoting recovery (e.g., group check-ins, community service, counseling sessions). CRCs also provide recovery oriented support services (e.g., self-help groups, counseling sessions, sober dorms) for students, but are embedded within larger college or university settings. The primary aims of RHSs and CRCs are to promote abstinence and prevent relapse among students, and thus ultimately improve students' academic success.OBJECTIVES: This review summarized and synthesized the available research evidence on the effects of recovery schools for improving academic success and behavioural outcomes among high school and college students who are in recovery from substance use. The specific research questions that guided the review are as follows: 1. What effect does recovery school attendance (versus attending a non-recovery or traditional school setting) have on academic outcomes for students in recovery from substance use? Specifically (by program type): a. For recovery high schools: what are the effects on measures of academic achievement, high school completion, and college enrolment?b. For collegiate recovery communities: what are the effects on measures of academic achievement and college completion?2. What effect does recovery school attendance have on substance use outcomes for students in recovery from substance use? Specifically, what are the effects on alcohol, marijuana, cocaine, or other substance use?3. Do the effects of recovery schools on students' outcomes vary according to the race/ethnicity, gender, or socioeconomic status of the students?4. Do the effects of recovery schools on students' outcomes vary according to existing mental health comorbidity status or juvenile justice involvement of the students? SEARCH METHODS: We aimed to identify all published and unpublished literature on recovery schools by using a comprehensive and systematic literature search. We searched multiple electronic databases, research registers, grey literature sources, and reference lists from prior reviews; and contacted experts in the field.SELECTION CRITERIA: Studies were included in the review if they met the following criteria:Types of studies: Randomized controlled trial (RCT), quasi-randomized controlled trial (QRCT), or controlled quasi-experimental design (QED).Types of participants: Students in recovery from substance use who were enrolled part-time or full-time in secondary (high school) or postsecondary (college or university) educational institutions.Types of interventions: Recovery schools broadly defined as educational institutions, or programs at educational institutions, developed specifically for students in recovery and that address recovery needs in addition to academic development.Types of comparisons: Traditional educational programs or services that did not explicitly have a substance use recovery focus.Types of outcome measures: The review focused on primary outcomes in the following two domains: academic performance (e.g., achievement test scores, grade-point average, high school completion, school attendance, college enrolment, college completion) and substance use (alcohol, marijuana, cocaine, heroin, stimulant, mixed drug use, or other illicit drug use). Studies that met all other eligibility criteria were considered eligible for the narrative review portion of this review even if they did not report outcomes in one of the primary outcome domains.Other criteria: Studies must have been reported between 1978 and 2016. The search was not restricted by geography, language, publication status, or any other study characteristic.DATA COLLECTION AND ANALYSIS: Two reviewers independently screened all titles and abstracts of records identified in the systematic search. Records that were clearly ineligible or irrelevant were excluded at the title/abstract phase; all other records were retrieved in full-text and screened for eligibility by two independent reviewers. Any discrepancies in eligibility assessments were discussed and resolved via consensus. Studies that met the inclusion criteria were coded by two independent reviewers using a structured data extraction form; any disagreements in coding were resolved via discussion and consensus. If members of the review team had conducted any of the primary studies eligible for the review, external and independent data collectors extracted data from those studies. Risk of bias was assessed using the ROBINS-I tool for non-randomized study designs (Sterne, Higgins, & Reeves, 2016).Inverse variance weighted random effects meta-analyses were planned to synthesize effect sizes across studies, as well as heterogeneity analysis, subgroup analysis, sensitivity analysis, and publication bias analysis. However, these synthesis methods were not used given that only one study met the inclusion criteria for the review. Instead, effect sizes (and their corresponding 95% confidence intervals) were reported for all eligible outcomes reported in the study.RESULTS: Only one study met criteria for inclusion in the review. This study used a QED to examine the effects of RHSs on high school students' academic and substance use outcomes. No eligible studies examining CRCs were identified in the search.The results from the one eligible RHS study indicated that after adjusting for pretest values, students in the RHS condition reported levels of grade point averages (= 0.26, 95% CI [-0.04, 0.56]), truancy (= 0.01, 95% CI [-0.29, 0.31]), and alcohol use (= 0.23, 95% CI [-0.07, 0.53]) similar to participants in the comparison condition. However, students in the RHS condition reported improvements in absenteeism (= 0.56, 95% CI [0.25, 0.87]), abstinence from alcohol/drugs (OR = 4.36, 95% CI [1.19, 15.98]), marijuana use (= 0.51, 95% CI [0.20, 0.82]), and other drug use (= 0.45, 95% CI [0.14, 0.76]).Overall, there was a serious risk of bias in the one included study. The study had a serious risk of bias due to confounding, low risk of bias due to selection of participants into the study, moderate risk of bias due to classification of interventions, inconclusive risk of bias due to deviations from intended interventions, inconclusive risk of bias due to missing data, moderate risk of bias in measurement of outcomes, and low risk of bias in selection of reported results.AUTHORS' CONCLUSIONS: There is insufficient evidence regarding the effectiveness of RHSs and CRCs for improving academic and substance use outcomes among students in recovery from SUDs. Only one identified study examined the effectiveness of RHSs. Although the study reported some beneficial effects, the results must be interpreted with caution given the study's potential risk of bias due to confounding and limited external validity. No identified studies examined the effectiveness of CRCs across the outcomes of interest in this review, so it is unclear what effects these programs may have on students' academic and behavioral outcomes.The paucity of evidence on the effectiveness of recovery schools, as documented in this review, thus suggest the need for caution in the widespread adoption of recovery schools for students in recovery from SUDs. Given the lack of empirical support for these recovery schools, additional rigorous evaluation studies are needed to replicate the findings from the one study included in the review. Furthermore, additional research examining the costs of recovery schools may be needed, to help school administrators determine the potential cost-benefits associated with recovery schools.

Who attends recovery high schools after substance use treatment? A descriptive analysis of school aged youth

Recovery high schools (RHSs) are an alternative high school option for adolescents with substance use disorders (SUDs), designed to provide a recovery-focused learning environment. The aims of this study were to examine the characteristics of youth who choose to attend RHSs, and to compare them with local and national comparison samples of youth in recovery from SUDs who were not enrolled in RHSs. We conducted secondary analysis of existing data to compare characteristics of youth in three samples: (1) adolescents with SUDs who enrolled in RHSs in Minnesota, Texas, and Wisconsin after discharge from treatment (RHSs; n = 171, 51% male, 86% White, 4% African American, 5% Hispanic); (2) a contemporaneously recruited local comparison sample of students with SUDs who did not enroll in RHSs (n = 123, 60% male, 77% White, 5% African American, 12% Hispanic); and (3) a national comparison sample of U.S. adolescents receiving SUD treatment (n = 12,967, 73% male, 37% White, 15% African American, 30% Hispanic). Students enrolled in RHSs had elevated levels of risk factors for substance use and relapse relative to both the local and national comparison samples. For instance, RHS students reported higher rates of pre-treatment drug use, past mental health treatment, and higher rates of post-treatment physical health problems than adolescents in the national comparison sample. We conclude that RHSs serve a population with greater co-occurring problem severity than the typical adolescent in SUD treatment; programming offered at RHSs should attend to these complex patterns of risk factors. SUD service delivery policy should consider RHSs as an intensive recovery support model for the most high-risk students with SUDs.

Gender difference in prescription opioid abuse: A focus on oxycodone and hydrocodone

Several data gathered in the last decade indicate an increase of abuse of prescription opioid drugs oxycodone (OXY) and hydrocodone (HYDRO) in women. However, to date there are no conclusive evidences investigating the gender-dependent abuse liability of prescription opioids. This study aims to supply a specific focus on women's data through a selective summary of the literature analyzing gender differences in the pharmacokinetic and pharmacodynamic dimension of OXY and HYDRO. Findings from this study suggest that the majority of OXY and HYDRO pharmacokinetic and pharmacodynamic effects do not differ according to gender, though confirming a significant difference in the incidence of adverse effects as demonstrated by the increased gastrointestinal adverse reactions in female subjects. Although the majority of recent clinical studies include an equal number of female and male subjects, the main outcome parameters do not relate specifically to gender differences. Due to the gender influence in activity of CYP3A4 and its crucial role in metabolism of both OXY than HYDRO, we suggest that assessing pharmacokinetic and pharmacodynamic interactions in clinical studies may be useful to clarify the effect of the higher CYP3A4 activity in female in relation to CYP2D6 genotype. Overall, considering the paucity of data regarding gender differences in European Union, this work highlights that impact of new abuse deterrent formulations should be assessed with a special focus on data concerning female subjects.

Social Influence on Adolescent Polysubstance Use: The Escalation to Opioid Use

BACKGROUND

Fewer than 9% of 12-17 year olds in need (∼146,000 of 1.7 million) receive inpatient or outpatient substance abuse recovery services or other mental health services (SAMHSA, 2012). The literature on adolescent addiction is sparse, however, as most published addiction recovery efforts involve adult populations-often college students.

OBJECTIVES

The present study examined social influences on escalating substance use (from tobacco, alcohol, and marijuana use to polysubstance use involving opioids) for students enrolled in recovery high schools.

METHODS

A sample of 31 adolescents enrolled in substance use recovery high schools were surveyed on their patterns of substance use leading to their abuse of opioids.

RESULTS

Youth who begin their substance use as young as age 8 are often pressured by peer culture to do so and come from substance-using families. Their escalation in polysubstance use to a pattern including opioids was also most often attributed to peer influence over several years. Conclusions/Importance: This paper is one of scant few that address patterns of use in high school students. Perhaps most salient from this study are the tertiary prevention implications: similar to their adult counterparts, students enrolled in recovery high school programs are likely from substance-using families and have combined complex constellations of substances including opioids by dint of their relationships with substance-using peers.

Trends in prescription opioid use in pediatric emergency department patients

OBJECTIVE

In recent years, there has been increased emphasis on treating pain in emergency departments (EDs), coinciding with mounting concerns regarding the abuse potential of prescription opioids. In this study, we describe trends in opioid prescribing in pediatric patients in the US EDs over the past decade.

METHODS

Data from the 2001-2010 National Hospital Ambulatory Medical Care Survey were analyzed and pain-related visits were identified. Pain-related ED visits by pediatric patients (≤19 y) where an opioid analgesic was administered or prescribed were tabulated by age category and year. Specific opioids analyzed included codeine, hydrocodone, hydromorphone, morphine, and oxycodone. The use patterns of nonopioid pain relievers were also investigated. Results were further stratified by Drug Enforcement Agency schedule and pain-related diagnosis.

RESULTS

The overall use of opioid analgesics in pain-related pediatric ED visits increased from 11.2% to 14.5% between 2001 and 2010 (P = 0.015). The use of Drug Enforcement Agency schedule II agents doubled from 3.6% in 2001 to 7.0% in 2010 (P < 0.001), whereas there was no significant increase in the use of schedule III, IV, and V agents (P = 0.34). Hydrocodone was the most frequently prescribed opioid analgesic. Increased opioid use was most dramatic in ED visits that involved adolescents. There was no significant increase in the use of nonopioid analgesics in pediatric ED patients (P = 0.086).

CONCLUSIONS

Opioid use for pain-related pediatric ED visits has increased significantly from 2001 to 2010, particularly among adolescents. Emergency department providers must be vigilant in balancing pain relief with minimizing the adverse effects of opioid analgesics.

Pharmacokinetics, tolerability, and safety of intranasal administration of reformulated OxyContin(®) tablets compared with original OxyContin (®) tablets in healthy adults

BACKGROUND AND OBJECTIVE

Reformulated OxyContin(®) (oxycodone-HCl controlled release) tablets (ORF) became available in the United States in August 2010. The original formulation of OxyContin(®) (oxycodone-HCl controlled release) tablets (OC) used a delivery system that did not provide inherent resistance to crushing and dissolving. The objective of this study was to compare the pharmacokinetics, tolerability, and safety of finely crushed ORF tablets, coarsely crushed ORF tablets, and finely crushed OC tablets.

METHODS

This randomized, single-blind, single-dose, single-center, six-sequence, triple-treatment, triple-period crossover study enrolled eligible healthy adults (aged 18-55 years inclusive). The study evaluated the pharmacokinetics, tolerability, and safety of intranasally administered ORF, both finely crushed and coarsely crushed, as well as finely crushed OC tablets. Plasma oxycodone concentrations were quantified and analyzed to determine the maximum observed plasma concentration (C max), time to maximum plasma concentration (t max), area under the plasma concentration-time curve from hour 0 to the last measurable plasma concentration (AUC(last)), and area under the plasma concentration-time curve extrapolated to infinity (AUC(∞)). The abuse quotient (AQ), calculated as C(max)/t(max), served as an index of the average rate of increase in drug concentration from dosing to t max. Intranasal tolerability rating scales (discomfort, itching, burning, pain, runny nose, and stuffiness) and intranasal endoscopy were conducted. Safety assessments included adverse events, vital signs, pulse oximetry (SpO2), and electrocardiograms.

RESULTS

Of 83 subjects screened and enrolled, 30 were randomized to period 1, with 1 subject subsequently discontinuing due to the subject's choice. Mean C max values for finely crushed ORF (17.1 ng/mL) and coarsely crushed ORF (15.5 ng/mL) were lower than that for finely crushed OC (22.2 ng/mL). Median t max for finely crushed OC (1.0 h) was shorter than that for either finely crushed ORF (2.0 h) or coarsely crushed ORF (3.0 h). Mean AQ values were approximately 66 and 80 % lower, respectively, for finely crushed ORF and coarsely crushed ORF than that for finely crushed OC. Finely crushed ORF, coarsely crushed ORF, and finely crushed OC demonstrated similar total oxycodone exposures (AUC(∞)). Insufflation of ORF produced greater nasal discomfort and stuffiness than finely crushed OC, although the latter produced higher runny nose scores. No significant difference was found in other nasal tolerability measures. The overall safety profile was as expected following opioid administration in healthy subjects.

CONCLUSIONS

In contrast to OC, both finely and coarsely crushed ORF retained some control of oxycodone release. Reduced C(max) and increased t max for ORF resulted in lower AQ scores for ORF compared with OC. ORF was associated with greater intranasal irritation than OC. These data suggest that ORF has a lower intranasal abuse potential than OC.

Abuse potential, pharmacokinetics, pharmacodynamics, and safety of intranasally administered crushed oxycodone HCl abuse-deterrent controlled-release tablets in recreational opioid users

The objective of this study was to evaluate abuse potential, pharmacokinetics, pharmacodynamics, and safety of intranasally administered, crushed reformulated OxyContin® (oxycodone HCl controlled-release) tablets (ORF), relative to crushed original OxyContin® (OC), oxycodone powder (Oxy API), and OC placebo. This randomized, double-blind, positive- and placebo-controlled crossover study enrolled healthy, adult, nonphysically dependent recreational opioid users with recent history of intranasal drug abuse (N = 27). Active treatments contained oxycodone (30 mg). Pharmacokinetics, pharmacodynamics (e.g., Overall Drug Liking [ODL], Take Drug Again [TDA], and High Visual Analog Scales [VAS]; Subjective Drug Value [SDV]; pupillometry; intranasal irritation), and safety (e.g., adverse events, vital signs, laboratory tests) were assessed to 24 hours postdose. Crushed ORF administration yielded reduced oxycodone Cmax and increased Tmax versus crushed OC and Oxy API. Peak effects for pharmacodynamic measures were delayed with ORF (1-2 hours) versus OC and Oxy API (0.5-1 hour). ODL, TDA, High VAS, and SDV Emax values were significantly lower (P ≤ .05) and some intranasal irritation ratings were greater for ORF versus OC and Oxy API. No significant or unexpected safety findings were observed. Compared with OC and Oxy API, intranasally administered ORF was associated with lower and delayed peak plasma concentrations, decreased drug-liking, and decreased intranasal tolerability. This suggests that ORF has a decreased potential for intranasal oxycodone abuse. There were no significant or unexpected safety findings. As is true for all abuse potential studies, epidemiological or other appropriate post-marketing studies are required to assess the impact of the reduction in intranasal oxycodone abuse potential observed in the present study on real-world patterns of ORF misuse, abuse, and diversion.

Updates in the general approach to the pediatric poisoned patient

Poison prevention remains essential to prevent the most vulnerable population from becoming exposed to potentially lethal toxins. The evaluation of a child presumed to have been exposed to a toxic substance should include a precise history of the exposure, a physical examination, and knowledge of current ingestions and recreational practices. New treatments and research guiding therapy continue to evolve. Poison centers and medical toxicologists can be consulted to assist with the diagnosis of medicinal/drug overdoses, for advice about the pitfalls inherent in stabilizing children who have been exposed to toxic compounds, and for treatment recommendations based on the latest research.