Mental illness and psychotropic drug use among prescription drug overdose deaths: a medical examiner chart review

Opioid Use Among Medicare Beneficiaries With Knee Osteoarthritis: Prevalence and Correlates of Chronic Use

OBJECTIVE

To determine the prevalence of chronic and occasional opioid use and identify risk factors of opioid use among persons with knee osteoarthritis (OA).

METHODS

We used the Medicare Current Beneficiary Survey to select a knee OA cohort. We obtained data on demographics characteristics, marital status, comorbidities, insurance, and prescription medication coverage from survey data and linked Medicare claims. We included all prescribed medication records classified as opioid under the First Databank therapeutic antiarthritics or analgesics categories. We stratified individuals with knee OA into 3 opioid use groups: 1) nonusers (0 prescriptions/year), 2) occasional users (1-5 prescriptions/year), and 3) chronic users (6+ prescriptions/year). We built multivariable logistic regression models using a generalized estimating equation to determine correlates of chronic opioid use.

RESULTS

Among 3,549 Medicare beneficiaries with knee OA and a mean ± SD age of 78 ± 7 years, 68% were female, 9% were chronic users, and 21% used opioids occasionally. Multivariable analysis showed that non-Hispanic ethnicity (odds ratio [OR] 4.8, 95% confidence interval [95% CI] 2.2-10.2), divorced status (vs. married; OR 2.3, 95% CI 1.5-3.5), Medicaid eligibility (OR 1.9, 95% CI 1.3-2.7), depression (OR 1.9, 95% CI 1.5-2.5), chronic obstructive pulmonary disease (OR 1.9, 95% CI 1.4-2.5), and inability to walk without assistive devices (vs. no difficulty walking; OR 2.4, 95% CI 1.5-3.7) were independently associated with chronic opioid use.

CONCLUSION

A total of 9% of persons with knee OA use opioids chronically. Efforts to find nonopioid regimens for treating knee OA pain should be tailored to patients at high risk for chronic use.

Comparative Study of Opioid Initiation With Tramadol, Short-acting Hydrocodone, or Short-acting Oxycodone on Opioid-related Adverse Outcomes Among Chronic Noncancer Pain Patients

OBJECTIVE

To compare the safety profiles of low and high-dose tramadol, short-acting hydrocodone, and short-acting oxycodone therapies among chronic noncancer pain individuals.

MATERIALS AND METHODS

A retrospective cohort study of individuals with back/neck pain/osteoarthritis with an initial opioid prescription for tramadol, hydrocodone, or oxycodone was conducted using IQVIA PharMetrics Plus claims for Academics database (2006 to 2020). Two cohorts were created for separately studying opioid-related adverse events (overdoses, accidents, self-inflicted injuries, and violence-related injuries) and substance use disorders (opioid and nonopioid). Patients were followed from the index date until an outcome event, end of enrollment, or data end. Time-varying exposure groups were constructed and Cox regression models were estimated.

RESULTS

A total of 1,062,167 (tramadol [16.5%], hydrocodone [61.1%], and oxycodone [22.4%]) and 986,809 (tramadol [16.5%], hydrocodone [61.3%], and oxycodone [22.2%]) individuals were in the adverse event and substance use disorder cohorts. All high-dose groups had elevated risk of nearly all outcomes, compared with low-dose hydrocodone. Compared with low-dose hydrocodone, low-dose oxycodone was associated with a higher risk of opioid overdose (hazard ratio: 1.79 [1.37 to 2.33]). No difference in risk was observed between low-dose tramadol and low-dose hydrocodone (hazard ratio: 0.85 [0.64 to 1.13]). Low-dose oxycodone had higher risks of an opioid use disorder, and low-dose tramadol had a lower risk of accidents, self-inflicted injuries, and opioid use disorder compared with low-dose hydrocodone.

DISCUSSION

Low-dose oxycodone had a higher risk of opioid-related adverse outcomes compared with low-dose tramadol and hydrocodone. This should be interpreted in conjunction with the benefits of pain control and functioning associated with oxycodone use in future research.

Increasing trend in accidental pharmaceutical opioid overdose deaths and diverging overdose death correlates following the opioid prescription policy liberalization in Norway 2010-2018

BACKGROUND

During the last decade, opioid prescription policies in Norway have been liberalised and pharmaceutical opioid (PO) dispensing has increased. Against this backdrop, we examined the trends in and the correlates of accidental overdose deaths attributable to PO in the period 2010-2018 in comparison with traditional heroin overdose deaths.

METHODS

Accidental overdose deaths attributable to PO or heroin were identified through the Norwegian Cause of Death Registry (n = 1267) and cross-linked with population and patient registries. Overdose death correlates were examined using multivariable logistic regression.

FINDINGS

The trend in accidental overdose deaths attributable to PO increased significantly from 2010 to 2018. Females, people aged 50 years or older, disability pension recipients and/or those with the highest net wealth had a greater risk of a PO vs. heroin overdose death, while those dying in public spaces, living in urban areas, having recent specialized drug treatment encounters, and/or criminal charge(s) had a lower risk. Among those with primary health care encounters, those with back problems and accidents and injuries had a greater risk of a PO vs. heroin overdose death, while those with a substance use disorder had a lower risk.

CONCLUSION

The increase in accidental overdose deaths attributable to PO coincides with the period of opioid prescription policy liberalization and an increase in PO consumption in Norway. The PO and heroin overdose deaths differed in terms of the associated sociodemographic characteristics, primary and secondary health care encounters, diagnoses, and criminal charges, indicating a need for additional interventions aimed at preventing PO overdose deaths specifically.

The Impact of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic on Substance Use in the United States

The SARS-CoV-2 pandemic has been associated with dramatic increases in substance use, as marked by increased alcohol, nicotine, and cannabis sales. Lethal opioid overdoses also increased dramatically, especially during the initial phases of the epidemic when lockdowns and social isolation combined with increasing fentanyl contamination of the illicit drug supply resulted in more overdoses and fewer opportunities for rescue. Substance use, and especially inhalational drug use, increases the likelihood of both transmission and severe infection. Youth are especially vulnerable to substance use and have increased risk of long-term problems. These outcomes highlight the need for greater access to substance use treatment. Virtual treatment, which emerged as a promising format during the pandemic, may reduce access barriers. This article reviews trends in substance use during the pandemic, explores root causes of increased use and overdose, and examines the potential to increase treatment through virtual care, especially during future periods of disruption.

Mental disorder and opioid overdose: a systematic review

PURPOSE

This systematic review summarizes and presents the current state of research quantifying the relationship between mental disorder and overdose for people who use opioids.

METHODS

The protocol was published in Open Science Framework. We used the PECOS framework to frame the review question. Studies published between January 1, 2000, and January 4, 2021, from North America, Europe, the United Kingdom, Australia, and New Zealand were systematically identified and screened through searching electronic databases, citations, and by contacting experts. Risk of bias assessments were performed. Data were synthesized using the lumping technique.

RESULTS

Overall, 6512 records were screened and 38 were selected for inclusion. 37 of the 38 studies included in this review show a connection between at least one aspect of mental disorder and opioid overdose. The largest body of evidence exists for internalizing disorders generally and mood disorders specifically, followed by anxiety disorders, although there is also moderate evidence to support the relationship between thought disorders (e.g., schizophrenia, bipolar disorder) and opioid overdose. Moderate evidence also was found for the association between any disorder and overdose.

CONCLUSION

Nearly all reviewed studies found a connection between mental disorder and overdose, and the evidence suggests that having mental disorder is associated with experiencing fatal and non-fatal opioid overdose, but causal direction remains unclear.

Comparison of Characteristics of Deaths From Drug Overdose Before vs During the COVID-19 Pandemic in Rhode Island

Importance

The rate of deaths from overdose has increased during the COVID-19 pandemic, and recent US overdose mortality rates have been markedly high. However, scant data are available on the causes of this increase or subpopulations at elevated risk.

Objective

To evaluate the rates and characteristics of deaths from drug overdose before vs during the COVID-19 pandemic.

Design, Setting, and Participants

This retrospective, population-based cohort study used data from 4 statewide databases linked at the person level via the Rhode Island Data Ecosystem on adults with deaths due to overdose in Rhode Island from January 1 to August 31, 2019, and January 1 to August 31, 2020.

Main Outcomes and Measures

The rates of unintentional deaths from drug-related overdose during the 2019 and 2020 observation periods overall and by sociodemographic characteristics, drugs contributing to the cause of death, location of death, and socioeconomic factors were evaluated. In subgroup analyses restricted to Medicaid beneficiaries (n = 271), the proportions of deaths from overdose by behavioral health treatment and diagnosis claims in the year before death were also examined.

Results

A total of 470 adults who died of drug overdose were included in the analysis (353 men [75%]; mean [SD] age, 43.5 [12.1] years). The rate of deaths from overdose in Rhode Island increased 28.1%, from 29.2 per 100 000 person-years in 2019 to 37.4 per 100 000 person-years in 2020 (P = .009). Compared with 2019, rates of deaths due to overdose during 2020 were higher among men (43.2 vs 59.2 per 100 000 person-years; P = .003), non-Hispanic White individuals (31.0 vs 42.0 per 100 000 person-years; P = .005), single individuals (54.8 vs 70.4 per 100 000 person-years; P = .04), deaths involving synthetic opioids (20.8 vs 28.3 per 100 000 person-years; P = .005), and deaths occurring in a personal residence (13.2 vs 19.7 per 100 000 person-years; P = .003). A decrease in the proportion of deaths from overdose involving heroin (11 of 206 [5%] vs <2% [exact value suppressed]; P = .02) and an increase among persons experiencing job loss (16 of 206 [8%] vs 41 of 264 [16%]; P = .01) from 2019 to 2020 were observed. Among individuals who died of overdose and were Medicaid beneficiaries, the proportions of those aged 50 to 59 years with anxiety (11 of 121 [9%] vs 29 of 150 [19%]; P = .03), men with depression (27 of 121 [22%] vs 57 of 150 [38%]; P = .008), and men with anxiety (28 of 121 [23%] vs 55 of 150 [37%]; P = .02) increased during 2020 compared with 2019.

Conclusions and Relevance

In this cohort study, during the first 8 months of 2020, the rate of deaths from overdose increased in Rhode Island compared with the same period in 2019, and several emerging characteristics of deaths from drug overdose during the first year of the COVID-19 pandemic were identified. These findings may inform interventions that address macroenvironmental changes associated with the pandemic.

Psychiatric disorders in a population of deceased drug users

PURPOSE

To estimate the prevalence of psychiatric morbidity and dual diagnosis in a population of decedents with positive drug toxicology and evaluate changes over time between 2001-2002 and 2011-2012.

MATERIALS AND METHODS

A total of 520 autopsied drug users with positive toxicology were included in the study from 2001 to 2002 and from 2011 to 2012. Materials included autopsy reports, toxicological screening during autopsy and data from the Danish national health registers, including psychiatric diagnoses from psychiatric hospitals and ambulatory functions, dispensed prescription use from pharmacies and registered treatment for drug use disorders.

RESULTS

In 2001-2002, 63.3% of the decedents had only positive toxicology, 22.5% also had psychiatric morbidity, and 14.2% had a dual diagnosis. In 2011-2012, 56.4% had only positive toxicology, 26.1% also had psychiatric morbidity, and 17.5% had a dual diagnosis. None of the changes were significant. Decedents with only positive toxicology became older at time of death over time; decedents with psychiatric morbidity and a dual diagnosis did not. The prevalence of nonprescribed psychotropic medication, methadone and benzodiazepines increased.

CONCLUSION

Decedents with psychiatric morbidity and dual diagnosis did not increase their lifespan over a 10-year period. Decedents with only positive toxicology increasingly consumed nonprescribed psychotropic medication and may have suffered from undiagnosed psychiatric disorders. The prevalence of prescribed and nonprescribed benzodiazepines and methadone increased and may have contributed to premature mortality.

Sex differences in US emergency department non-fatal visits for benzodiazepine poisonings in adolescents and young adults

BACKGROUND

Benzodiazepine (BZD)-related overdose deaths have risen in the past decade and BZD misuse contributes to thousands of emergency department (ED) visits annually, with the highest rates in adolescents and young adults. Because there are gaps in understanding BZD poisoning in youth and whether differences occur by sex, we aimed to characterize BZD poisoning ED visits in young people by sex.

METHODS

BZD poisoning visits were identified in the Nationwide Emergency Department Sample, among adolescents (12-17 years) and young adults (18-29 years). Stratified by sex and age, we described ED visits for BZD poisonings in 2016, including poisoning intent, concurrent substances involved, and co-occurring mental health disorder diagnoses. With logistic regression we examined the association between intent and concurrent substance.

RESULTS

There were approximately 38,000 BZD poisoning ED visits by young people nationwide with annual population rates per 10,000 of 2.9=adolescents and 5.8=young adults. Depression was diagnosed in 40 % of female and 23 % of male BZD visits (p < 0.01). Over half of BZD poisonings in females and a third in males were intentional (p < 0.01). Male BZD visits were more likely to involve opioids or cannabis and less likely to involve antidepressants than females (p-values<0.01). In males and females, BZD poisonings concurrent with antidepressants and other psychotropic medications were more likely to be intentional than unintentional (OR range:2.1-6.3).

CONCLUSIONS

The high proportion of BZD poisonings that are intentional and include mental health disorder diagnoses, especially among young females, underscore the importance of ED mental health and suicide risk assessment with appropriate follow-up referral.

Sexual Identity and Motivations for Prescription Drug Misuse Among U.S. Adults

Purpose: Although we know that sexual minority populations, particularly bisexual individuals, tend to be at increased risk for substance use, less research has focused on prescription drug misuse (PDM). The current study is the first to assess differences in motivations for PDM by sexual identity and sex. This is important as research has established a link between certain motivations and adverse outcomes. Methods: This study used data from multiple years of the National Survey on Drug Use and Health (2015-2018). Respondents who reported past-year PDM were asked follow-up questions to identify motivations for PDM. We ran several weighted cross-tabulations to estimate the prevalence and 95% confidence intervals for motivations for PDM by sexual identity (i.e., heterosexual, lesbian or gay, and bisexual) for males and females separately. When chi-square tests were significant, post hoc comparisons using design-based multivariable regressions were conducted. Results: Prevalence rates for both PDM and substance use disorder associated with prescription drugs were higher among sexual minority adults than heterosexual adults. With regard to motives, bisexual females were more likely to endorse recreational motives (i.e., to get high) for prescription opioids, tranquilizers, and stimulants than heterosexual females. Gay males were more likely to endorse self-treatment motives (e.g., to relax, to lose weight) than both bisexual and heterosexual males. Conclusion: High prevalence rates and endorsement of recreational motives identify bisexual females as an important at-risk population. It is important for clinicians to consider how prevention, treatment, and intervention strategies focused on PDM may be improved to best target this unique population.

Patterns of prescription opioid utilization among adolescents and adults with comorbid chronic pain and mental health diagnosis

Our goal was to examine the association between mental health disorders (MHD) and subsequent risk of opioid use among commercially insured youth and adults (aged 14-64 years) with comorbid chronic noncancer pain (CNCP) conditions. We conducted a retrospective cohort study using IQVIA Health Plan Claims database from January 1, 2006, to December 31, 2015. Chronic noncancer pain was defined as any diagnosis of back, head, neck, arthritis, or chronic pain (index date). Mental health disorders were assessed in the 12 months before the index pain diagnosis. Based on days supply (none, acute, and chronic) and average daily dose (none, low, medium, and high), we constructed a 7-level categorical dependent measure of opioid use. We estimated the overall prevalence of MHD and opioid receipt. Among those with CNCP, multinomial logistic regression (AOR; 95 confidence interval) was used to estimate the association of MHD with opioid receipt. Among 879,815 individuals diagnosed with CNCP, 143,923 (16.4%) had comorbid MHD. Chronic/high-dose use of opioids was more common among those with CNCP and MHD compared to those with only CNCP. After adjusting for demographic and clinical factors, individuals with comorbid CNCP and MHD were significantly more likely to be prescribed opioids compared to those with only CNCP conditions. This effect varied by average daily dose and days supply: acute/low dose (1.08; 1.07-1.08); chronic/low dose (1.49; 1.49-1.50); acute/medium dose (1.07; 1.07-1.08); chronic/medium dose (1.61; 1.61-1.62); acute/high dose (1.03; 1.02-1.03); and chronic/high dose (1.53; 1.53-1.54). In individuals with CNCP, having a MHD was a strong predictor of prescription opioid use, particularly chronic use.

Estimating the impact of drug use on US mortality, 1999-2016

The impact of rising drug use on US mortality may extend beyond deaths coded as drug-related to include excess mortality from other causes affected by drug use. Here, we estimate the full extent of drug-associated mortality. We use annual death rates for 1999–2016 by state, sex, five-year age group, and cause of death to model the relationship between drug-coded mortality—which serves as an indicator of the population-level prevalence of drug use—and mortality from other causes. Among residents aged 15–64 living in the 50 US states, the estimated number of drug-associated deaths in 2016 (141,695) was 2.2 times the number of drug-coded deaths (63,000). Adverse trends since 2010 in midlife mortality are largely attributable to drug-associated mortality. In the absence of drug use, we estimate that the probability of dying between ages 15 and 65 would have continued to decline after 2010 among men (to 15% in 2016) and would have remained at a low level (10%) among women. Our results suggest that an additional 3.9% of men and 1.8% of women died between ages 15 and 65 in 2016 because of drug use. In terms of life expectancy beyond age 15, we estimate that drug use cost men 1.4 years and women 0.7 years, on average. In the hardest-hit state (West Virginia), drug use cost men 3.6 and women 1.9 life years. Recent declines in US life expectancy have been blamed largely on the drug epidemic. Consistent with that inference, our results imply that, in the absence of drug use, life expectancy at age 15 would have increased slightly between 2014 and 2016. Drug-associated mortality in the US is roughly double that implied by drug-coded deaths alone. The drug epidemic is exacting a heavy cost to American lives, not only from overdoses but from a variety of causes.

Screening tools for detecting problematic opioid use and potential application to community pharmacy practice: a review

Problematic opioid use, constituted by a myriad of conditions ranging from misuse to use disorders, has continued to receive an increasing amount of attention in recent years resulting from the high use of opioids in the United States coinciding with morbidity and mortality. Deaths from drug overdoses increased by over 11% between 2014 and 2015, which supports the need for identification of problematic opioid use in additional health care settings. One of these settings is community pharmacy. The community pharmacy is a unique health service setting to identify and potentially intervene with patients at risk of or exhibit problematic opioid use. Problematic opioid use can be identified using one of the various screening tools in conjunction with evaluating prescription drug monitoring systems. A total of 12 tools were identified that could be employed in community pharmacy settings for identifying problematic opioid use. This review highlights these tools and strategies for use that can be utilized in the community pharmacy, which should be adapted to individual pharmacy settings and local needs. Future research should assess pharmacy personnel's knowledge and perceptions of problematic opioid use and associated screening tools and interventions, which tools can be most effectively used in a community pharmacy, workflow needs to implement problematic opioid use screenings, and the impact of pharmacist engagement in problematic opioid use screening on patient clinical outcomes.

Predicting inadequate postoperative pain management in depressed patients: A machine learning approach

Widely-prescribed prodrug opioids (e.g., hydrocodone) require conversion by liver enzyme CYP-2D6 to exert their analgesic effects. The most commonly prescribed antidepressant, selective serotonin reuptake inhibitors (SSRIs), inhibits CYP-2D6 activity and therefore may reduce the effectiveness of prodrug opioids. We used a machine learning approach to identify patients prescribed a combination of SSRIs and prodrug opioids postoperatively and to examine the effect of this combination on postoperative pain control. Using EHR data from an academic medical center, we identified patients receiving surgery over a 9-year period. We developed and validated natural language processing (NLP) algorithms to extract depression-related information (diagnosis, SSRI use, symptoms) from structured and unstructured data elements. The primary outcome was the difference between preoperative pain score and postoperative pain at discharge, 3-week and 8-week time points. We developed computational models to predict the increase or decrease in the postoperative pain across the 3 time points by using the patient’s EHR data (e.g. medications, vitals, demographics) captured before surgery. We evaluate the generalizability of the model using 10-fold cross-validation method where the holdout test method is repeated 10 times and mean area-under-the-curve (AUC) is considered as evaluation metrics for the prediction performance. We identified 4,306 surgical patients with symptoms of depression. A total of 14.1% were prescribed both an SSRI and a prodrug opioid, 29.4% were prescribed an SSRI and a non-prodrug opioid, 18.6% were prescribed a prodrug opioid but were not on SSRIs, and 37.5% were prescribed a non-prodrug opioid but were not on SSRIs. Our NLP algorithm identified depression with a F1 score of 0.95 against manual annotation of 300 randomly sampled clinical notes. On average, patients receiving prodrug opioids had lower average pain scores (p<0.05), with the exception of the SSRI+ group at 3-weeks postoperative follow-up. However, SSRI+/Prodrug+ had significantly worse pain control at discharge, 3 and 8-week follow-up (p < .01) compared to SSRI+/Prodrug- patients, whereas there was no difference in pain control among the SSRI- patients by prodrug opioid (p>0.05). The machine learning algorithm accurately predicted the increase or decrease of the discharge, 3-week and 8-week follow-up pain scores when compared to the pre-operative pain score using 10-fold cross validation (mean area under the receiver operating characteristic curve 0.87, 0.81, and 0.69, respectively). Preoperative pain, surgery type, and opioid tolerance were the strongest predictors of postoperative pain control. We provide the first direct clinical evidence that the known ability of SSRIs to inhibit prodrug opioid effectiveness is associated with worse pain control among depressed patients. Current prescribing patterns indicate that prescribers may not account for this interaction when choosing an opioid. The study results imply that prescribers might instead choose direct acting opioids (e.g. oxycodone or morphine) in depressed patients on SSRIs.

Overview of Prescription Opioid Deaths in the Oklahoma State Medicaid Population, 2012-2016

BACKGROUND

Medicaid members are predisposed to unintentional prescription opioid overdose. However, little is known about their individual risk factors.

OBJECTIVES

To describe demographic and clinical characteristics, medical utilization, opioid use, concurrent use of benzodiazepines, risk factors, and substances involved in death for Oklahoma's Medicaid members who died of unintentional prescription opioid poisoning.

SUBJECTS

Decedents who were Medicaid eligible in Oklahoma during the year of death, had an opioid recorded in cause of death, and had ≥1 opioid prescription claim between January 1, 2011 and June 30, 2016 were cases. Controls were living Medicaid members and were matched 3:1 to cases through propensity score matching.

MEASURES

Demographics, clinical characteristics, and medical/pharmacy utilization were examined in the 12 months before the index date.

RESULTS

Of 639 members with fatal unintentional prescription opioid overdoses, 321 had ≥1 opioid prescription claim in the year before death; these were matched to 963 controls. Compared with controls, decedents had significantly greater proportions of nonopioid substance use disorders, opioid abuse/dependence, hepatitis, gastrointestinal bleeding, trauma not involving motor vehicle accidents, nonopioid poisonings, and mental illness disorders. Decedents had significantly higher daily morphine milligram equivalent doses (67.2±74.4 vs. 47.2±50.9 mg) and greater opioid/benzodiazepine overlap (70.4% vs. 35.9%). Benzodiazepines were involved in 29.3% of deaths.

CONCLUSIONS

Several comorbidities indicative of opioid use disorder and greater exposure to opioids and concomitant benzodiazepines were associated with unintentional prescription opioid overdose fatalities. Prescribers and state agencies should be aware of these addressable patient-level factors among the Medicaid population. Targeting these factors with appropriate policy interventions and education may prevent future deaths.

Preventing Opioid Overdose in the Clinic and Hospital: Analgesia and Opioid Antagonists

Drawing from existing opioid prescribing guidelines, this article describes how medical providers can reduce the risk of overdose. Through primary prevention, providers can prevent initial exposure and associated risks by educating patients, using risk stratification, minimizing opioid dose and duration, and avoiding coprescribing with sedatives. Secondary prevention efforts include monitoring patients with urine toxicology and prescription monitoring programs, and screening for opioid use disorders. Tertiary prevention includes treating opioid use disorders and providing naloxone to prevent overdose death. Specific preventive strategies may be required for those with psychiatric disorders or substance use disorders, adolescents, the elderly, and pregnant women.

Opioid Medications in the Management of Chronic Abdominal Pain

PURPOSE OF REVIEW

Chronic abdominal pain is a complex medical condition. The causes of chronic abdominal pain are extremely diverse ranging from chronic pancreatitis, Crohn's disease, to chronic pain with no clear etiology. Treatment of chronic abdominal pain remains a challenge in our clinical practice. While current interventions with celiac plexus blocks and pain medications provide some relief for these patients, but these treatments are typically less efficacious and limited by various adverse effects. Opioid medications are commonly used to manage chronic pain syndromes that are refectory to other pain management interventions. The potential problems related to opioids include misuse, abuse, constipation, nausea pruritus, et al. Moreover, according to the recent centers for disease (CDC) control report, opioid abuse has reached epidemic proportions in the USA (LJ P. Centers for Disease Control and Prevention. 2016) and accounted for 28,000 deaths in 2014. Rudd et al. (MMWR Morb Mortal Wkly Rep 64(50-51):1378-82, 2016) Given this current situation, it is apparent that a careful review of clinical evidences supporting the use of opioid medications is necessary to guide our treatment approaches in the management of complex chronic abdominal pain patients. This review is set out to analyze efficacy of opioid medications for chronic abdominal pain.

RECENT FINDINGS

The literature referenced was obtained via a computer search with Google Scholar, Pubmed, Medline, and EMbase. The search terms used included Opioid, Oxycodone, Buprenorphine, Morphine, Fentanyl, Oxymorphone, Hydromorphone, chronic abdominal pain, Crohn's disease, and pancreatitis. All studies were considered eligible for inclusion if they were clinical studies evaluating the efficacy of opioid medications for chronic abdominal pain. Two studies were found according to these criteria. Chronic abdominal pain is a challenging medical condition in our daily practice. This condition often requires opioid medications when other treatments fail. This review provided very limited clinical evidence to support long-term opioid use for chronic abdominal pain. Given recent CDC report of opioid epidemic, it is prudent to use the best medical practice with appropriate evaluation of psychological comorbidities, urine drug screening, prescription drug monitor, and opioid treatment agreements to minimize adverse side effects related to opioids. Furthermore, well-designed clinical trials are needed to evaluate the effectiveness of long-term use of opioid medications, and more clinical research on which opioid medication is more effective for chronic abdominal pain.

High enhancer, downer, withdrawal helper: Multifunctional nonmedical benzodiazepine use among young adult opioid users in New York City

BACKGROUND

Benzodiazepines are a widely prescribed psychoactive drug; in the U.S., both medical and nonmedical use of benzodiazepines has increased markedly in the past 15 years. Long-term use can lead to tolerance and dependence, and abrupt withdrawal can cause seizures or other life-threatening symptoms. Benzodiazepines are often used nonmedically in conjunction with other drugs, and with opioids in particular-a combination that can increase the risk for fatal and non-fatal overdose. This mixed-methods study examines nonmedical use of benzodiazepines among young adults in New York City and its relationship with opioid use.

METHODS

For qualitative analysis, 46 90-minute semi-structured interviews were conducted with young adult opioid users (ages 18-32). Interviews were transcribed and coded for key themes. For quantitative analysis, 464 young adult opioid users (ages 18-29) were recruited using Respondent-Driven Sampling and completed structured interviews. Benzodiazepine use was assessed via a self-report questionnaire that included measures related to nonmedical benzodiazepine and opioid use.

RESULTS

Participants reported using benzodiazepines nonmedically for a wide variety of reasons, including: to increase the high of other drugs; to lessen withdrawal symptoms; and to come down from other drugs. Benzodiazepines were described as readily available and cheap. There was a high prevalence (93%) of nonmedical benzodiazepine use among nonmedical opioid users, with 57% reporting regular nonmedical use. In bivariate analyses, drug-related risk behaviours such as polysubstance use, drug binging, heroin injection and overdose were strongly associated with regular nonmedical benzodiazepine use. In multivariate analysis, growing up in a middle-income household (earning between $51,000 and $100,000 annually), lifetime overdose experience, having ever used cocaine regularly, having ever been prescribed benzodiazepines, recent drug binging, and encouraging fellow drug users to use benzodiazepines to cope with opioid withdrawal were consistently strong predictors of regular nonmedical benzodiazepine use.

CONCLUSION

Nonmedical benzodiazepine use may be common among nonmedical opioid users due to its drug-related multi-functionality. Harm reduction messages should account for the multiple functions benzodiazepines serve in a drug-using context, and encourage drug users to tailor their endorsement of benzodiazepines to peers to include safer alternatives.

Prescription reporting with immediate medication utilization mapping (PRIMUM): development of an alert to improve narcotic prescribing

BACKGROUND

Prescription narcotic overdoses and abuse have reached alarming numbers. To address this epidemic, integrated clinical decision support within the electronic medical record (EMR) to impact prescribing behavior was developed and tested.

METHODS

A multidisciplinary Expert Panel identified risk factors for misuse, abuse, or diversion of opioids or benzodiazepines through literature reviews and consensus building for inclusion in a rule within the EMR. We ran the rule "silently" to test the rule and collect baseline data.

RESULTS

Five criteria were programmed to trigger the alert; based on data collected during a "silent" phase, thresholds for triggers were modified. The alert would have fired in 21.75 % of prescribing encounters (1.30 % of all encounters; n = 9998), suggesting the alert will have a low prescriber burden yet capture a significant number of at-risk patients.

CONCLUSIONS

While the use of the EMR to provide clinical decision support is not new, utilizing it to develop and test an intervention is novel. We successfully built an alert system to address narcotic prescribing by providing critical, objective information at the point of care. The silent phase data were useful to appropriately tune the alert and obtain support for widespread implementation. Future healthcare initiatives can utilize similar methodology to collect data prospectively via the electronic medical record to inform the development, delivery, and evaluation of interventions.

Non-prescribed use of psychoactive prescription drugs among drug-impaired drivers in Sweden

AIMS

To determine the prevalence of non-prescribed drug use among subjects suspected of drug-impaired driving with a psychoactive prescription drug, and to identify associated factors.

METHODS

Subjects investigated for drug-impaired driving in Sweden during 2006-2009 with a confirmed intake of diazepam, flunitrazepam, tramadol, zolpidem or zopiclone were identified using the Swedish Forensic Toxicology Database. Information on dispensed prescription drugs was retrieved from the Swedish Prescribed Drug Register. Non-prescribed use was our outcome, defined as a psychoactive prescription drug intake confirmed by toxicological analysis in a subject by whom it was not dispensed in the 12 months preceding the sampling. Prevalence proportions were calculated for each drug and logistic regression was used to identify associated factors.

RESULTS

In total, 2225 subjects were included. The median age (range) was 34 (15-80) years and 1864 (83.8%) subjects were male. Non-prescribed use was found in 1513 subjects (58.7%); for flunitrazepam 103 (76.3%), diazepam 1098 (74.1%), tramadol 192 (40.3%), zopiclone 60 (29.7%), and zolpidem 60 (21.2%) subjects, respectively. Younger age and multiple-substance use were associated with non-prescribed use, whereas ongoing treatment with other psychoactive drugs was negatively associated with non-prescribed use.

CONCLUSIONS

Non-prescribed use of psychoactive prescription drugs was common in subjects suspected of drug-impaired driving and was more frequent for benzodiazepines and tramadol compared to zolpidem and zopiclone. The young and multi-substance users were more likely, whereas subjects with ongoing prescribed treatment with other psychoactive drugs were less likely, to use non-prescribed drugs.

Association of Care Practices with Suicide Attempts in US Veterans Prescribed Opioid Medications for Chronic Pain Management

IMPORTANCE

Patients receiving opioid therapy are at elevated risk of attempting suicide. Guidelines recommend practices to mitigate risk, but it is not known whether these are effective.

OBJECTIVE

Our aim was to examine associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide attempt.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective analysis of administrative data for all Veteran patients prescribed any short-acting opioids on a chronic basis or any long-acting opioids from the Veterans Health Administration during fiscal year 2010.

MAIN OUTCOMES AND MEASURES

Multivariate, mixed-effects logistic regression analyses were conducted to define the associations between the risk of suicide attempt and receipt of guideline-recommended care at the individual level and rates of use of recommended care at the facility level, while accounting for patient risk factors.

RESULTS

At the individual level, having a mood disorder was highly associated with suicide attempts (odds ratios [ORs] = 3.5, 3.9; 95% confidence intervals [CIs] = 3.3-3.9, 3.3-4.6 for chronic short-acting and long-acting groups, respectively). At the facility level, patients on opioid therapy within the facilities ordering more drug screens were associated with decreased risk of suicide attempt (ORs = 0.2, 0.3; CIs = 0.1-0.3, 0.2-0.6 for chronic short-acting and long-acting groups, respectively). In addition, patients on long-acting opioid therapy within the facilities providing more follow-up after new prescriptions were associated with decreased risk of suicide attempt (OR = 0.2, CI = 0.0-0.7), and patients on long-acting opioid therapy within the facilities having higher sedative co-prescription rates were associated with increased risk of suicide attempt (OR = 20.3, CI = 1.1-382.2).

CONCLUSIONS AND RELEVANCE

Encouraging facilities to make more consistent use of drug screening, provide follow-up within 4 weeks for patients initiating new opioid prescriptions, and avoid sedative co-prescription in combination with long-acting opioids may help prevent suicide attempts. Some clinicians may selectively employ guideline-recommended practices with at-risk patients.

Parent and Metabolite Opioid Drug Concentrations in Unintentional Deaths Involving Opioid and Benzodiazepine Combinations

Effects of benzodiazepines on postmortem opioid parent and parent/metabolite blood concentration ratios were determined for fentanyl-, hydrocodone-, methadone-, or oxycodone-related accidental deaths. These opioids are partially metabolized by the CYP3A4 enzyme system, which is also affected by diazepam and alprazolam. Opioid/metabolite combinations examined were as follows: fentanyl/norfentanyl, hydrocodone/dihydrocodeine, methadone/EDDP, and oxycodone/oxymorphone. Parent opioid concentrations were analyzed for 877 deaths. Parent/metabolite concentration ratios were analyzed for 349 deaths, excluding cases with co-intoxicants present known to interfere with opioid elimination. Alprazolam in combination with diazepam significantly decreased median hydrocodone concentrations by 48% (p = 0.01) compared to hydrocodone alone. The methadone parent/metabolite concentration ratio was reduced by 35% in the presence of diazepam compared to methadone alone (p = 0.03). Benzodiazepines did not statistically significantly affect fentanyl or oxycodone concentrations. Possible factors affecting opioid concentrations and possible toxicity development, including any differential effects on specific opioids, should continue to be explored.

A Review of Opioid Overdose Prevention and Naloxone Prescribing: Implications for Translating Community Programming Into Clinical Practice

BACKGROUND

As physicians have increased opioid prescribing, overdose deaths from pharmaceutical opioids have substantially increased in the United States. Naloxone hydrochloride (naloxone), an opioid antagonist, is the standard of care for treatment of opioid induced respiratory depression. Since 1996, community-based programs have offered overdose prevention education and distributed naloxone for bystander administration to people who use opioids, particularly heroin. There is growing interest in translating overdose education and naloxone distribution (OEND) into conventional medical settings for patients who are prescribed pharmaceutical opioids. For this review, we summarized and classified existing publications on overdose education and naloxone distribution to identify evidence of effectiveness and opportunities for translation into conventional medical settings.

METHODS

For this review, we searched English language PubMed for articles on naloxone based on primary data collection from humans, including feasibility studies, program evaluations, surveys, qualitative studies, and studies comparing the effectiveness of different routes of naloxone administration. We also included cost-effectiveness studies.

RESULTS

We identified 41 articles that represented 5 categories: evaluations of OEND programs, effects of OEND programs on experiences and attitudes of participants, willingness of medical providers to prescribe naloxone, comparisons of different routes of naloxone administration, and the cost-effectiveness of naloxone.

CONCLUSIONS

Existing research suggests that people who are at risk for overdose and other bystanders are willing and able to be trained to prevent overdoses and administer naloxone. Counseling patients about the risks of opioid overdose and prescribing naloxone is an emerging clinical practice that may reduce fatalities from overdose while enhancing the safe prescribing of opioids.

Review of naloxone safety for opioid overdose: practical considerations for new technology and expanded public access

Opioid overdose and mortality have increased at an alarming rate prompting new public health initiatives to reduce drug poisoning. One initiative is to expand access to the opioid antidote naloxone. Naloxone has a long history of safe and effective use by organized healthcare systems and providers in the treatment of opioid overdose by paramedics/emergency medicine technicians, emergency medicine physicians and anesthesiologists. The safety of naloxone in a prehospital setting administered by nonhealthcare professionals has not been formally established but will likely parallel medically supervised experiences. Naloxone dose and route of administration can produce variable intensity of potential adverse reactions and opioid withdrawal symptoms: intravenous administration and higher doses produce more adverse events and more severe withdrawal symptoms in those individuals who are opioid dependent. More serious adverse reactions after naloxone administration occur rarely and may be confounded by the effects of other co-intoxicants and the effects of prolonged hypoxia. One component of the new opioid harm reduction initiative is to expand naloxone access to high-risk individuals (addicts, abusers, or patients taking high-dose or extended-release opioids for pain) and their close family or household contacts. Patients or their close contacts receive a naloxone prescription to have the medication on their person or in the home for use during an emergency. Contacts are trained on overdose recognition, rescue breathing and administration of naloxone by intramuscular injection or nasal spraying of the injection prior to the arrival of emergency medical personnel. The safety profile of naloxone in traditional medical use must be considered in this new context of outpatient prescribing, dispensing and treatment of overdose prior to paramedic arrival. New naloxone delivery products are being developed for this prehospital application of naloxone in treatment of opioid overdose and prevention of opioid-induced mortality.

Drug-related deaths between 2002 and 2013 with accent to methadone and benzodiazepines

AIM

The aim of the study is to assess the trends of overdose and drug related fatalities in the Republic of Macedonia during the 11 years.

MATERIAL AND METHODS

Cross-sectional retrospective survey and reviewed of postmortem toxicological analyses which examined fatal poisonings with illegal drugs in years 2002-2013. Information about gender, age, drug consumption, reported years were analyzed. Narcotics were confirmed with toxicological semi quantitative fluorescence polarization immunoassay (FPIA) in urine (range 250-4000 ng/ml).

RESULTS

Total of 165 deaths were observed. Out of them 145 (87.9%) were male. There is statistical significant differences between male and female DRD due to age (Mann-Whitney U Test = 925, Z = -2626, p = 0.0087). For p < 0.05 there is significant differences between genders due to cause of overdose (Pearson Chi-square = 9743, df = 4, p = 0.0449). DRD among male were mainly because of overdose due to heroin in 80 (51.17%) cases followed by DRD due to combination of methadone and BZD in 25 (11.72%) cases. Out of all DRD cases 50 (30.3%) are related to polydrug use. For p < 0.01 there is a significant differences between analyzed age groups due to cause of overdose (Pearson Chi-square = 33,886, df = 12, p = 0.0007).

CONCLUSIONS

Death cause analysis reveals the difficulties in determining the role of substitution drugs, as many other factors may be involved. The findings also highlight the importance of further enhancing treatment interventions for benzodiazepine misuse among patients on methadone substitution treatment.

Eight principles for safer opioid prescribing and cautions with benzodiazepines

The provision of long-term opioid analgesic therapy for chronic pain requires a careful risk/benefit analysis followed by clinical safety measures to identify and reduce misuse, abuse, and addiction and their associated morbidity and mortality. Multiple data sources show that benzodiazepines, prescribed for comorbid insomnia, anxiety, and mood disorders, heighten the risk of respiratory depression and other adverse outcomes when combined with opioid therapy. Evidence is presented for hazards associated with coadministration of opioids and benzodiazepines and the need for caution when initiating opioid therapy for chronic pain. Clinical recommendations follow, as drawn from 2 previously published literature reviews, one of which proffers 8 principles for safer opioid prescribing; the other review presents risks associated with benzodiazepines, suggests alternatives for co-prescribing benzodiazepines and opioids, and outlines recommendations regarding co-prescribing if alternative therapies are ineffective.

Future applications of high-resolution MS to meet the demands for pain management drug testing

Urine specimens submitted for pain management drug testing often contain multiple psychotherapeutic drugs, in addition to opioids. Immunoassay-based screen-and-confirm approaches typically used for clinical drug testing have limited sensitivity to detect therapeutic concentrations of many drugs prescribed in pain management and do not differentiate between drugs in the same class. In addition, screening for all the various illicit and prescription drugs that may be present in the pain management population requires as many as 10–20 individual immunoassays. High-resolution MS approaches have the potential to transform the way clinical drug testing is performed for pain management.

Residents with Alzheimer's disease in long-term care facilities in Hong Kong: patterns of hospitalization and emergency room use

OBJECTIVES

This study examined the frequency and predictors of hospitalization and emergency room (ER) use among residents with Alzheimer's disease at admission and after 1 year in a long-term care facility.

METHOD

This secondary analysis used data collected with the Chinese version of the Residential Assessment Instrument Minimum Data Set 2.0 during the Hong Kong Longitudinal Study on Long-Term Care Facility Residents.

RESULTS

A sample of 169 residents with Alzheimer's disease who were newly admitted between 2005 and 2010 was included in the analysis. Mixed-effects modeling was adopted to assess the associations between risk factors and the frequency of hospitalization and ER use. At admission, 27 (15.98%) respondents had been hospitalized and 19 (11.24%) required ER services during the previous 90 days. At admission, polypharmacy (β = .081, p < .01) and use of psychotropic drugs (β = ‑.506, p < .05) were significantly associated with frequency of hospitalization. At 1-year follow-up, cognitive impairment (β = .088, p < .05) and polypharmacy (β = .058, p < .001) had significant positive associations with frequency of hospitalization, as well as use of ER services (β = .084, p < .01; β = .077, p < .001, respectively). Use of psychotropic drugs had a negative association with frequency of ER use at both time points.

CONCLUSION

Practitioners should periodically observe cognitive ability, polypharmacy, and use of psychotropic drugs among long-term care residents with Alzheimer's disease.

Under- or Overtreatment of Pain in the Patient With Cancer: How to Achieve Proper Balance

Achieving balance in the appropriate use of opioids for the treatment of cancer pain is complex. The definition of “balance” is continually being modified. Palliative care professionals, pain specialists, and oncologists have long been advocating for the aggressive management of pain for patients with advanced cancer. Some progress has been made in this arena but barriers persist. Fear of addiction by patients, family members, and oncology professionals presents a serious obstacle to the provision of adequate pain control. This is further complicated by societal factors that receive extensive media coverage, such as diversion of prescribed opioids for recreational use and increasing deaths as a result of this inappropriate use of prescription opioids. This growing concern has led to more opioid regulation, which increases obstacles to pain management in this population. Another evolving concern is whether the long-term use of opioids is safe and effective. Data from the chronic nonmalignant pain literature suggest that toxicities may result and misuse has been underestimated, yet little information is available in the cancer population. These issues lead to serious questions regarding how balance might be successfully achieved for patients in an oncology setting. Can pain relief be provided while reducing negative consequences of treatment? Which patient should be prescribed what medications, in what situations, for what kind of pain, and who should be managing the pain?

Prescription drug misuse and gender

In recent years, prescription drug misuse has become a serious public health issue. A number of studies in this area have identified females to be at an increased risk for prescription drug misuse during adolescence. Guided by Agnew's general strain theory, the current research examined the relationship between prescription drug misuse and gender during adolescence. We used data from the 2010 National Survey on Drug Use and Health, a sample representative of the non-institutionalized population of the United States. Logistic regression models were estimated to examine the relationship between gender, prescription drug misuse, strain, and depression. The findings indicated that females were at an increased for prescription drug misuse. We also found support for general strain theory, as strain and depression were significantly related to prescription drug misuse. In addition, we found evidence that strain was gendered in that elements of general strain theory accounted for the relationship between prescription drug misuse and gender.

Screening for current opioid misuse and associated risk factors among patients with chronic nonalcoholic pancreatitis pain

OBJECTIVE

The objective of this study is to assess clinical variables that may be associated with risk for opioid misuse in individuals with chronic pancreatitis.

DESIGN

This study utilized a descriptive, quasi-experimental, cross sectional design.

SETTING AND PATIENTS

Three hundred seven individuals with nonalcoholic chronic pancreatitis engaged in chronic opioid therapy for pain presented to an outpatient specialty clinic at an academic medical center.

MEASURES

Participants completed the Current Opioid Misuse Measure (COMM), Brief Pain Inventory (BPI), Short Form (SF)-12 Quality of Life Measure, Center for Epidemiological Studies 10-item Depression Scale (CESD), and a single item asking about current alcohol use. Mean scores on the CESD, COMM, BPI, SF-12, and factors associated with opioid misuse measures from regression analyses were the outcome measures.

RESULTS

Mean scores on the CESD, COMM, BPI pain-on-average item, and the SF-12 physical and psychological quality of life factors (t scores) were 11.2 (standard deviation [SD] = 6.7), 8.5 (SD = 7.3), 4.8 (SD = 2.8), 39.7 (SD = 7.0), and 45 (SD = 9.0), respectively. Descriptive analyses revealed that 55% of participants scored above the clinical cutoff for depression on the CESD, and 39% scored above the cutoff for opioid misuse concerns on the COMM. Regression analyses identified several factors associated with higher opioid misuse measure scores, including increased depressive symptoms from the CESD (β = 0.38, P < 0.0001), increased pain rating at the time of the office visit (β = 0.16, P = 0.03), impairment of psychological quality of life (β = -0.27, P = 0.001) and endorsement of alcohol use (β = 0.16, P = 0.03). These factors accounted for 37% of the variance in current opioid misuse scores.

CONCLUSIONS

Depression, quality of life, pain intensity and alcohol use may be good candidate variables for prospective studies to determine clinical risk factors for opioid misuse among patients with pancreatitis.

Epidemiology of emergency department visits for opioid overdose: a population-based study

OBJECTIVES

To evaluate the rate of emergency department (ED) visits for opioid overdose and to examine whether frequent ED visits for opioid overdose are associated with more hospitalizations, near-fatal events, and health care spending.

PATIENTS AND METHODS

Retrospective cohort study of adults with at least 1 ED visit for opioid overdose between January 1, 2010, and December 31, 2011, derived from population-based data of State Emergency Department Databases and State Inpatient Databases for 2 large and diverse states: California and Florida. Main outcome measures were hospitalizations for opioid overdose, near-fatal events (overdose involving mechanical ventilation), and hospital charges during the year after the first ED visit.

RESULTS

The analytic cohort comprised 19,831 unique patients with 21,609 ED visits for opioid overdose. During a 1-year period, 7% (95% CI, 7%-7%; n=1389 patients) of the patients had frequent (2 or more) ED visits, accounting for 15% (95% CI, 14%-15%; n=3167) of all opioid overdose ED visits. Middle age, male sex, public insurance, lower household income, and comorbidities (such as chronic pulmonary disease and neurological diseases) were associated with frequent ED visits (all P<.01). Overall, 53% (95% CI, 52%-54%; n=11,412) of the ED visits for opioid overdose resulted in hospitalizations; patients with frequent ED visits for opioid overdose had a higher likelihood of hospitalization (adjusted odds ratio, 3.98; 95% CI, 3.38-4.69). In addition, 10.0% (95% CI, 10%-10%; n=2161) of the ED visits led to near-fatal events; patients with frequent ED visits had a higher likelihood of a near-fatal event (adjusted odds ratio, 2.27; 95% CI, 1.96-2.66). Total charges in Florida were $208 million (95% CI, $200-$219 million).

CONCLUSION

In this population-based cohort, we found that frequent ED visits for opioid overdose were associated with a higher likelihood of future hospitalizations and near-fatal events.

Prevalence of Axis-1 psychiatric (with focus on depression and anxiety) disorder and symptomatology among non-medical prescription opioid users in substance use treatment: systematic review and meta-analyses

Non-medical prescription opioid use (NMPOU) constitutes a substantial clinical and public health concern in North America. Although there is evidence of elevated rates of mental health problems among people with NMPOU, the extent of these correlations specifically in treatment samples has not been systematically assessed. A systematic review and meta-analysis were conducted for Axis-1 psychiatric diagnoses and symptoms with a principal focus on depression and anxiety disorders in substance use treatment samples reporting NMPOU at admission to treatment (both criteria within past 30days). 11 unique studies (all from either the United States or Canada) met inclusion criteria and were included in the meta-analysis. The pooled prevalence of 'any' mental health problems (both diagnosis and symptoms) among substance abuse treatment patients reporting NMPOU was 43% (95% CI: 32%-54%; I(2) for inter-study heterogeneity: 99.5%). The pooled prevalence of depression diagnosis among substance abuse treatment patients reporting NMPOU was 27% (95% CI: 9%-45%; I(2): 99.2%); the pooled prevalence of anxiety diagnosis in the sample was 29% (95% CI: 14%-44%; I(2): 98.7%). The prevalence rates of psychiatric problems (both diagnosis and symptoms), depression diagnosis and anxiety diagnosis are disproportionately high in substance use treatment samples reporting NMPOU relative to general population rates. Adequate and effective clinical strategies are needed to address co-occurring NMPOU and mental health in substance use treatment systems, especially given rising treatment demand for NMPOU. Efforts are needed to better understand the temporal and causal relationships among NMPOU, mental health problems, and treatment seeking in order to improve interventions.

Understanding the rural-urban differences in nonmedical prescription opioid use and abuse in the United States

Nonmedical prescription opioid misuse remains a growing public problem in need of action and is concentrated in areas of US states with large rural populations such as Kentucky, West Virginia, Alaska, and Oklahoma. We developed hypotheses regarding the influence of 4 factors: (1) greater opioid prescription in rural areas, creating availability from which illegal markets can arise; (2) an out-migration of young adults; (3) greater rural social and kinship network connections, which may facilitate drug diversion and distribution; and (4) economic stressors that may create vulnerability to drug use more generally. A systematic consideration of the contexts that create differences in availability, access, and preferences is critical to understanding how drug use context varies across geography.

Lessons learned in the abuse of pain-relief medication: a focus on healthcare costs

The increasing prevalence of chronic pain with its major societal impact and the escalating use of opioids in managing it, along with their misuse, abuse, associated fatalities and costs, are epidemics in modern medicine. Over the past two decades, multiple lessons have been learned addressing various issues of abuse. Multiple measures have already been incorporated and more are expected to be incorporated in the future, which in turn may curtail the abuse of drugs and reduce healthcare costs, but these measures may also jeopardize access to appropriate pain treatment. This manuscript describes the lessons learned from the misuse, abuse and diversion of opioids, escalating healthcare costs and the means to control this epidemic.

Factors associated with high-frequency illicit methadone use among rural Appalachian drug users

BACKGROUND

In recent years there has been a sharp increase in the use of illicit methadone as well as methadone-related overdose deaths.

OBJECTIVE

The purpose of this study was to describe factors associated with low- and high-frequency methadone use in a cohort of rural Appalachian drug users.

METHODS

Interviews assessing sociodemographics, illicit drug use and drug treatment, psychiatric disorders, health and sociometric drug network characteristics were conducted with 503 rural drug users between 2008 and 2010. A two-level mixed effects regression model was utilized to differentiate low- (one use per month or less in the past six months) versus high-frequency (daily or weekly use in the past six months) illicit methadone users.

RESULTS

The lifetime prevalence of illicit methadone use in this population was 94.7% (n = 476) and slightly less than half (46.3%) were high-frequency users. In the mixed effects regression model, initiating illicit methadone use at a younger age was associated with high-frequency illicit methadone use. Taking a prescribed medication for a physical problem, undergoing additional weeks of outpatient drug free treatment, daily OxyContin® use in the past month, and having fewer ties and second-order connections in the drug network reduced the odds of high-frequency illicit methadone use.

CONCLUSIONS

Rates of illicit methadone use and high-frequency illicit methadone use among this sample of rural drug users were considerably higher than those previously reported in the literature. Health practitioners in rural areas should routinely screen for illicit opioid use, including methadone.

Long-term opioid treatment of chronic nonmalignant pain: unproven efficacy and neglected safety?

BACKGROUND

For the past 30 years, opioids have been used to treat chronic nonmalignant pain. This study tests the following hypotheses: (1) there is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective; and (2) the main problem associated with the safety of such treatment - assessment of the risk of addiction - has been neglected.

METHODS

Scientometric analysis of the articles representing clinical research in this area was performed to assess (1) the quality of presented evidence (type of study); and (2) the duration of the treatment phase. The sufficiency of representation of addiction was assessed by counting the number of articles that represent (1) editorials; (2) articles in the top specialty journals; and (3) articles with titles clearly indicating that the addiction-related safety is involved (topic-in-title articles).

RESULTS

Not a single randomized controlled trial with opioid treatment lasting >3 months was found. All studies with a duration of opioid treatment ≥6 months (n = 16) were conducted without a proper control group. Such studies cannot provide the consistent good-quality evidence necessary for a strong clinical recommendation. There were profound differences in the number of addiction articles related specifically to chronic nonmalignant pain patients and to opioid addiction in general. An inadequate number of chronic pain-related publications were observed with all three types of counted articles: editorials, articles in the top specialty journals, and topic-in-title articles.

CONCLUSION

There is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective. The above identified signs indicating neglect of addiction associated with the opioid treatment of chronic nonmalignant pain were present.

Diversion of benzodiazepines through healthcare sources

Benzodiazepines (BZ) are often diverted from legal sources to illicit markets at various points in the distribution process beginning with a pharmaceutical manufacturer, followed by healthcare providers, and finally, to the intended users. Little is known about the extent of BZ diversion involving distribution points directly related to healthcare sources versus points further down the distribution chain. The present study examines the scope of BZ diversion, and the association between BZ dependence and the direct utilization of particular healthcare-related diversion sources among a diverse sample of prescription drug abusers in South Florida. Cross-sectional data were collected from five different groups of drug users: methadone-maintenance clients (n = 247), street drug users (n = 238), public-pay treatment clients (n = 245), private-pay treatment clients (n = 228), and stimulant-using men who have sex with men (MSM; n = 249). Findings suggest that those who are ages 26 to 35 years old, non-Hispanic White participants, private-pay treatment clients, those who are insured, and those with higher incomes had higher odds of utilizing healthcare diversion sources. Those who reported BZ dependence had 2.5 times greater odds of using a healthcare source to obtain BZs than those who did not meet criteria for dependence.

State Variation in Certifying Manner of Death and Drugs Involved in Drug Intoxication Deaths

National statistics on drug intoxication deaths are based solely on data derived from death certificates. This study examines the variation in the manner of death classification by state, and the specificity of drugs involved in drug intoxication deaths by state and by type of death investigation system. The National Vital Statistics System Multiple Cause of Death mortality files (2008–2010) were analyzed. Drug intoxication deaths were those with ICD-10 Underlying Cause of Death of X40-X44 (unintentional), X60-X64 (suicide), X85 (homicide), or Y10-Y14 (undetermined intent). Among drug intoxication deaths, deaths involving non-specified drug(s) were those with Multiple Cause of Death (MCOD) of T50.9, and no MCOD in the range T36-T50.8. State death investigation systems were categorized as follows: centralized state medical examiner offices, county/district medical examiners, hybrid, and decentralized county coroners. In 2008–2010, there was an average of over 37,250 drug intoxication deaths per year in the U.S. The manner was undetermined for 8% for the U.S., ranging from 1% to 85% among the states. During 2008–2010, 75% of the drug intoxication deaths had at least one specific drug reported on the death certificate. States with centralized state medical examiner systems had a higher percent (92%) of drugs specified than did those with other systems. Across the U.S., there is variation in the percent of drug intoxication deaths classified as having undetermined manner of death and with specific drugs identified on death certificates. This variation has significant implications for public health surveillance and for prevention efforts.

Unintentional alcohol and drug poisoning in association with substance use disorders and mood and anxiety disorders: results from the 2010 Nationwide Inpatient Sample

OBJECTIVE

To examine unintentional alcohol and drug poisoning in association with substance use disorders (SUDs) and mood and anxiety disorders.

METHOD

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) external-cause-of-injury codes on discharge records of patients ages 12+ years from the 2010 Nationwide Inpatient Sample were examined to identify cases with unintentional alcohol poisoning (E860) and/or drug poisoning (E850-E858). ICD-9-CM diagnosis codes were examined to identify comorbid alcohol dependence, drug dependence, tobacco use disorder, and mood/anxiety disorders. Poisson regression was used to derive risk ratios to assess the associations between these comorbid conditions and alcohol/drug poisoning.

RESULTS

Estimated numbers of hospitalisations related to unintentional alcohol and drug poisoning were, respectively, 5623 and 60 423 in men, and 3147 and 68 568 in women. For both sexes, the proportion with SUDs or mood/anxiety disorders was significantly higher among inpatients with alcohol and drug poisoning than among all inpatients. Estimated risk ratios indicated strong relationships of SUDs and mood/ anxiety disorders with unintentional poisoning from alcohol and drugs. The strongest association was between alcohol dependence and alcohol poisoning for both sexes. Significant associations also existed between drug dependence and drug poisoning, and mood/anxiety disorders and poisoning from alcohol and drugs.

CONCLUSIONS

SUDs and mood/anxiety disorders are key risk factors for unintentional poisoning by alcohol and drugs among inpatients in the USA. Effective treatments of these disorders should be targeted as poisoning prevention efforts. Future studies are needed to clarify a potential bias in the data due to differential inpatient mental condition screening practices.

Unintentional prescription opioid-related overdose deaths: description of decedents by next of kin or best contact, Utah, 2008-2009

BACKGROUND

Little is known about the characteristics that may predispose an individual to being at risk for fatal overdose from prescription opioids.

OBJECTIVE

To identify characteristics related to unintentional prescription opioid overdose deaths in Utah.

DESIGN

Interviews were conducted (October 2008-October 2009) with a relative or friend most knowledgeable about the decedent's life.

SUBJECTS

Analyses involved 254 decedents aged 18 or older, where cause of death included overdose on at least one prescription opioid.

KEY RESULTS

Decedents were more likely to be middle-aged, Caucasian, non-Hispanic/Latino, less educated, not married, or reside in rural areas than the general adult population in Utah. In the year prior to death, 87.4 % were prescribed prescription pain medication. Reported potential misuse prescription pain medication in the year prior to their death was high (e.g., taken more often than prescribed [52.9 %], obtained from more than one doctor during the previous year [31.6 %], and used for reasons other than treating pain [29.8 %, almost half of which "to get high"]). Compared with the general population, decedents were more likely to experience financial problems, unemployment, physical disability, mental illness (primarily depression), and to smoke cigarettes, drink alcohol, and use illicit drugs. The primary source of prescription pain medication was from a healthcare provider (91.8 %), but other sources (not mutually exclusive) included: for free from a friend or relative (24 %); from someone without their knowledge (18.2 %); purchase from a friend, relative, or acquaintance (16.4 %); and purchase from a dealer (not a pharmacy) (11.6 %).

CONCLUSIONS

The large majority of decedents were prescribed opioids for management of chronic pain and many exhibited behaviors indicative of prescribed medication misuse. Financial problems, unemployment, physical disability, depression, and substance use (including illegal drugs) were also common.

The supply chain of medicinal controlled substances: addressing the Achilles heel of drug diversion

The escalation of prescription drug abuse in the U.S. has attracted the attention of public health and safety officials as well as others puzzled by how such a tightly regulated enterprise could so easily be breached by those seeking controlled substances for nonmedical use. Prescribers and patients who use, misuse, or, in some cases, redistribute or divert these drugs have figured prominently in government strategies aimed at addressing this issue. This review departs from this paradigm and focuses on wholesale drug distributors, a highly efficient and largely behinds-the-scene link in the supply chain of controlled substances. By law, distributors are required to identify and report to the Drug Enforcement Administration (DEA) orders for controlled substances that are suspicious and may indicate drug diversion. Ten cases are examined in which distributors were each charged with failing to prevent the diversion of millions of doses of controlled substances. Special attention is given to a payment system employed by the industry that may encourage this unlawful commerce. Court records, agency and industry reports, and other published sources are used to document referenced cases and their disposition, and recommendations are offered for improving distributors' compliance with the law.

Factors associated with history of non-fatal overdose among young nonmedical users of prescription drugs

OBJECTIVES

The current study examines the prevalence and correlates of lifetime non-fatal overdose (OD) involving the nonmedical use of prescription opioids and tranquilizers among a sample of high-risk young adults in New York, NY and Los Angeles, CA.

METHODS

Data were derived from a cross-sectional study of 16-25 year old nonmedical users of prescription drugs (n=596). Unadjusted associations between OD history and socio-demographic and drug use variables were investigated in bivariate logistic regression models. Multivariate logistic regression models identified correlates of non-fatal OD.

RESULTS

Lifetime prevalence of non-fatal overdose involving prescription opioids and/or tranquilizers was 23.6%. Factors associated with increased risk of non-fatal overdose included lower social class while growing up (OR: 1.81, 95% CI: [1.15, 2.83], p<0.01), having ever received care at a psychiatric hospital (OR: 1.79, 95% CI: [1.12, 2.85], p<0.05), ever witnessing a family member OD on drugs (OR: 1.59, 95% CI: [1.02, 2.50], p<0.05), being prescribed tranquilizers (OR: 2.07, 95% CI: [1.29, 4.27], p<0.01), ever snorting or sniffing opioids (OR: 2.51, 95% CI: [1.48, 4.27], p<0.001), injecting tranquilizers (OR: 3.09, 95% CI: [1.61, 5.93], p<0.001), and past 90-day injection drug use (OR: 1.68, 95% CI: [1.03, 2.74], p<0.05). Participants who reported past 90-day stimulant misuse had lower odds of reporting OD compared to those who were not recent stimulant users (OR: 0.60, 95% CI: [0.38-0.96], p<0.05).

CONCLUSIONS

This study documents the high prevalence of experiencing non-fatal overdose among young nonmedical users of prescription drugs. Results could inform overdose prevention efforts throughout the U.S.