National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999-2009

Differences in Opioid Prescribing Among Generalist Physicians, Nurse Practitioners, and Physician Assistants

OBJECTIVE

To determine if there are differences in opioid prescribing among generalist physicians, nurse practitioners (NPs), and physician assistants (PAs) to Medicare Part D beneficiaries.

DESIGN

Serial cross-sectional analysis of prescription claims from 2013 to 2016 using publicly available data from the Centers for Medicare and Medicaid Services.

SUBJECTS

All generalist physicians, NPs, and PAs who provided more than 10 total prescription claims between 2013 and 2016 were included. These prescribers were subsetted as practicing in a primary care, urgent care, or hospital-based setting.

METHODS

The main outcomes were total opioid claims and opioid claims as a proportion of all claims in patients treated by these prescribers in each of the three settings of interest. Binomial regression was used to generate marginal estimates to allow comparison of the volume of claims by these prescribers with adjustment for practice setting, gender, years of practice, median income of the ZIP code, state fixed effects, and relevant interaction terms.

RESULTS

There were 36,999 generalist clinicians (physicians, NPs, and PAs) with at least one year of Part D prescription drug claims data between 2013 and 2016. The number of adjusted total opioid claims across these four years for physicians was 660 (95% confidence interval [CI] = 660-661), for NPs was 755 (95% CI = 753-757), and for PAs was 812 (95% CI = 811-814).

CONCLUSIONS

We find relatively high rates of opioid prescribing among NPs and PAs, especially at the upper margins. This suggests that well-designed interventions to improve the safety of NP and PA opioid prescribing, along with that of their physician colleagues, could be especially beneficial.

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

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

Pharmacologic Considerations for Opioid Use in Kidney Disease

Individuals with kidney disease have a high prevalence of chronic noncancer pain. Although opioids are not a recommended treatment option for chronic noncancer pain in the general population, a higher percentage of individuals with kidney disease receive opioid prescriptions for chronic pain. Individuals with kidney disease have an increased risk for opioid adverse events because of changes related to kidney disease progression, normative aging, and the pharmacology of opioid medications. Despite the frequent prescription of opioids for chronic noncancer pain among those with kidney disease, there are no guidelines for opioid management in this population. This article reviews the pharmacologic challenges of opioid use in relation to the physiologic changes occurring in kidney disease and normative aging. We highlight how understanding opioid pharmacology and human physiology can support safe practices of opioid management in patients with kidney disease who require opioids for chronic noncancer pain.

Predicting the Future Course of Opioid Overdose Mortality: An Example From Two US States

BACKGROUND

The rapid growth of opioid abuse and the related mortality across the United States has spurred the development of predictive models for the allocation of public health resources. These models should characterize heterogeneous growth across states using a drug epidemic framework that enables assessments of epidemic onset, rates of growth, and limited capacities for epidemic growth.

METHODS

We used opioid overdose mortality data for 146 North and South Carolina counties from 2001 through 2014 to compare the retrodictive and predictive performance of a logistic growth model that parameterizes onsets, growth, and carrying capacity within a traditional Bayesian Poisson space-time model.

RESULTS

In fitting the models to past data, the performance of the logistic growth model was superior to the standard Bayesian Poisson space-time model (deviance information criterion: 8,088 vs. 8,256), with reduced spatial and independent errors. Predictively, the logistic model more accurately estimated fatality rates 1, 2, and 3 years in the future (root mean squared error medians were lower for 95.7% of counties from 2012 to 2014). Capacity limits were higher in counties with greater population size, percent population age 45-64, and percent white population. Epidemic onset was associated with greater same-year and past-year incidence of overdose hospitalizations.

CONCLUSION

Growth in annual rates of opioid fatalities was capacity limited, heterogeneous across counties, and spatially correlated, requiring spatial epidemic models for the accurate and reliable prediction of future outcomes related to opioid abuse. Indicators of risk are identifiable and can be used to predict future mortality outcomes.

Opioid Use in the Nondialysis Chronic Kidney Disease Population

Although pain is a common and burdensome condition in patients with chronic kidney disease (CKD), little is known about the use and safety of opioids in this patient population. Recommendations regarding opioid use in patients with CKD are based on pharmacokinetic data, extrapolation from non-CKD studies, and from clinical experience. Given the potential increased risk for opioid-related adverse events in patients with reduced kidney function, health care providers may be hesitant to prescribe opioids, resulting in inadequate pain control. This review summarizes current studies of opioid use in patients with CKD, highlights special considerations, and proposes an opioid prescribing strategy for this unique patient population. Specifically, oral hydromorphone, transdermal fentanyl, and buprenorphine should be considered as the first-line opioids for patients with CKD if opioid management is indicated. A stepwise approach such as the Screen-Quantify-Use opioids-Adjust-Reassess-Engage prescribing strategy proposed here is critical to ensure optimal pain control while minimizing the side effects and adverse events of opioids. The effects of opioids on clinically relevant outcomes in the CKD population remains to be explored in future studies.

Brief Training on Medication-Assisted Treatment Improves Community Mental Health Clinicians' Confidence and Readiness to Address Substance Use Disorders

Despite the availability and effectiveness of medication-assisted treatment (MAT) for substance use disorders (SUDs), utilization of these medications remains suboptimal, especially in public sector settings. A key limitation is clinicians' reluctance to include MAT in their routine practice due, in part, to low confidence about managing SUDs and limited awareness of the disease model of addiction. This study evaluates the impact of a 1-day MAT training for community mental health clinicians using a 30-item pre- and post-training questionnaire. Of the 109 clinicians who attended the training, 107 completed the pre- and post-training questionnaires. Factor analysis of the questionnaire identified two domains: readiness to address SUDs among patients (factor 1) and understanding SUDs as diseases (factor 2). Post training, there was a significant change in both factor 1 (p = .00001) and factor 2 (p = .00003), indicating that a brief MAT training can increase clinicians' confidence and readiness to address SUDs and improve their understanding of the disease model of addiction.

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

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

Directing Technology Addiction Research in Information Systems

Technology-related addictions have become common in many societies. Consequently, IS research has started examining such issues. In these embryonic stages of research, this line of work has already shown some promise in terms of understanding and tackling technology addiction problems. Nevertheless, there is a need to step back and understand the roots of technology-related addictions and how their foundations evolved in reference disciplines in order to be able to conduct more scientifically informed research on such issues. This study, therefore, explains the concept of behavioral addictions (the family of addictions to which technology-related addictions presumably belong), reviews the field's history and evolution, explains the relevant brain circuitry, and discusses similarities and differences between behavioral and substance addictions. A synthesis of this information provides eight key observations and recommendations that should help the field move forward.

Opioid Consumption and Time to Return to Work After Percutaneous Osteotomy in Foot Surgery

Surgeries involving the foot and ankle are painful procedures, with many patients unwilling to discontinue prescribed narcotics at 3 months postoperatively. Percutaneous techniques allow for smaller incisions and minimal soft tissue disruption. Fifty consecutive patients underwent outpatient percutaneous foot surgery. Data were collected on pain medication taken and time to return to work. A mean of 3.3 tablets of oxycodone were consumed during the first 2 weeks. No patient was taking narcotics after 2 weeks. Mean time to return to work was 18.9 days. Percutaneous foot and ankle surgery led to a significant reduction in narcotic consumption. [Orthopedics. 2020;43(4):e334-e337.].

Opioid Prescribing and Use Patterns in Postsurgical Facial Trauma Patients

BACKGROUND

Facial fractures are painful injuries routinely managed by opioids after surgical repair. Studies have identified patient risk factors and prescribing patterns associated with opioid use in medicine and general surgery; however, little is known about these entities in the facial trauma population.

METHODS

A retrospective cohort study of opioid-naive patients undergoing surgical repair of facial fractures was conducted using the Truven Health MarketScan Commercial Claims and Encounters (2006 to 2015) and Medicaid Multi-State Databases (2011 to 2015). Eligible procedures included nasal, nasoorbitoethmoid, orbital, mandible, and Le Fort fracture repair. Opioid type, daily dosage, and prescription duration were analyzed. Multivariable logistic regression was performed to determine independent predictors of prescription refill.

RESULTS

A total of 20,191 patients undergoing surgical repair of facial fractures were identified. Of these, 15,861 patients (78.6 percent) filled a perioperative opioid prescription. Refill (58.7 percent) and potentially inappropriate prescribing (39.4 percent) were common among this population. Patient factors including prior substance use (adjusted OR, 1.84; 95 percent CI, 1.63 to 2.07) and history of mental health disorder (adjusted OR, 1.43; 95 percent CI, 1.06 to 1.91) were independent predictors of refill. Increased odds of refill were seen in patients prescribed tramadol (OR, 1.98; 95 percent CI, 1.48 to 2.66) and those who underwent multiple surgical repairs (OR, 3.38; 95 percent CI, 2.54 to 4.50).

CONCLUSIONS

Refill and potentially inappropriate prescribing occurred at high rates in facial trauma patients undergoing surgical repair. Additional studies are needed to develop guidelines for proper opioid prescribing in this population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Use of Opioids Increases With Age in Older Adults: An Observational Study (2005-2017)

Aim

Pain is increasingly treated with opioids. Potential harms of opioid therapy disproportionally affect older patients. This study aims to provide information on trends, nature and duration of opioid prescribing to older adults, in primary care and to explore differences between older patients from different ages.

Methods

Primary care data (2005-2017) were derived from routine electronic medical records of patients in Nivel Primary Care Database. All opioid prescriptions with Anatomical Therapeutic Chemical Classification (ATC) code N02A were selected (except for codeine). Diagnoses were recorded using the International Classification of Primary Care (ICPC). Patients were categorized in three age groups (65-74, 75-84, and ≥85 years). Descriptive analyses were used to describe the trend of opioid prescriptions for specific opioids, the duration of use and underlying diagnoses.

Results

283,600 patients were included of which 32,287 had at least one opioid prescription in 2017. An increase in the number of older adults who received at least one opioid was seen between 2005 and 2017. The oldest patients were more likely to be prescribed an opioid, especially when it comes to strong opioids, the increase in the volume of prescribing was highest in this group. Moreover, over 40% of the oldest patients used strong opioids chronically. Strong opioids were mostly prescribed for musculoskeletal diagnoses. Cancer was the second most common diagnosis for strong opioids in the younger subgroups, whereas less specified diagnoses were as second in the oldest subgroup.

Conclusion

Opioid prescription changes with increasing age in frequency, nature, and duration, despite higher harm risks among older patients. Because of the high prevalence of chronic use, it is important to monitor the patient throughout the treatment and to critically evaluate the initiation and continuation of opioid prescriptions.

Risk factors for heroin use following release from jail or prison in adults in a Central Appalachian state between 2012-2017

Background

Corrections-involved adults with a history of opioid use disorder are at elevated risk of opioid overdose following release from correctional settings. Increased opioid prescribing restrictions and monitoring during a time when heroin is becoming cheaper and ubiquitous means that adults who misused prescription opioids prior to incarceration may be reentering communities at greater risk for heroin exposure and use.

Objectives

Determine risk factors of post-release heroin use among a sample of adults who participated in corrections-based drug treatment in Kentucky released between 2012 and 2017.

Methods

Survey data obtained as part of an ongoing evaluation of corrections-based drug treatment were examined.

Results

The final sample (N = 1,563) was majority male (80.9%). Nearly 11.0% reported past-year heroin use following their release. Depressive symptoms, polydrug use, and urban proximity were more common among participants reporting post-release heroin use. Heroin use 30 days prior to incarceration was associated with a 432.1% increase in odds of heroin use subsequent to incarceration. Post-release suicidal ideation increased odds of heroin use by 154.2%, whereas reporting satisfaction from social interactions decreased odds of use by nearly 60%. Post-release use of cocaine and diverted buprenorphine were associated with increased likelihood of heroin use during this time period, increasing odds by 469.1% and 265.9%, respectively. Residing in Central Appalachia subsequent to incarceration was associated with decreased likelihood of use.

Conclusions

In this sample, post-release heroin use was associated with concerning features, such as polydrug use, lack of social satisfaction, and suicidal ideation. These features can serve as clear targets for clinical intervention.

Characterizing non-heroin opioid overdoses using electronic health records

INTRODUCTION

The opioid epidemic is a modern public health emergency. Common interventions to alleviate the opioid epidemic aim to discourage excessive prescription of opioids. However, these methods often take place over large municipal areas (state-level) and may fail to address the diversity that exists within each opioid case (individual-level). An intervention to combat the opioid epidemic that takes place at the individual-level would be preferable.

METHODS

This research leverages computational tools and methods to characterize the opioid epidemic at the individual-level using the electronic health record data from a large, academic medical center. To better understand the characteristics of patients with opioid use disorder (OUD) we leveraged a self-controlled analysis to compare the healthcare encounters before and after an individual's first overdose event recorded within the data. We further contrast these patients with matched, non-OUD controls to demonstrate the unique qualities of the OUD cohort.

RESULTS

Our research confirms that the rate of opioid overdoses in our hospital significantly increased between 2006 and 2015 (P < 0.001), at an average rate of 9% per year. We further found that the period just prior to the first overdose is marked by conditions of pain or malignancy, which may suggest that overdose stems from pharmaceutical opioids prescribed for these conditions.

CONCLUSIONS

Informatics-based methodologies, like those presented here, may play a role in better understanding those individuals who suffer from opioid dependency and overdose, and may lead to future research and interventions that could successfully prevent morbidity and mortality associated with this epidemic.

Trends in Drug Poisoning Deaths Among Adolescents and Young Adults in the United States, 2006-2015

OBJECTIVE

Despite the rising toll of drug poisoning deaths in the United States, the extent of the problem among adolescents and young adults ages 15-24 years has received relatively little attention. We examined sociodemographic characteristics and state trends in drug poisoning deaths among adolescents and young adults from 2006 to 2015 and estimated the costs of drug poisoning mortality in this population.

METHOD

We used the National Vital Statistics System's Multiple Cause of Death files from 2006 to 2015. We analyzed trends using Joinpoint regression analysis and calculated total costs of drug poisoning deaths, including medical costs, work loss costs, and quality of life loss, based on widely used cost estimates.

RESULTS

Drug poisoning death rates (per 100,000 population) in adolescents and young adults increased from 8.1 in 2006 to 9.7 in 2015. The rates increased significantly for Whites (1.7% per year) and Asian/Pacific Islanders (4.3% per year) from 2006 to 2015 and for Blacks (11.8% per year) from 2009 to 2015. By U.S. region, the rates increased significantly in the Midwest (4.4% per year) from 2006 to 2015 and in the Northeast (11.0% per year) from 2009 to 2015. Trends varied by age group, intent for drug poisoning, drug category (i.e., opioids, pharmaceutical drugs excluding opioids, illicit drugs excluding opioids, and unspecified drugs), urbanization level, and state. The estimated costs of drug poisoning deaths among adolescents and young adults totaled approximately $35 billion in 2015.

CONCLUSIONS

Trends in drug poisoning deaths and estimated costs inform state-specific prevention and intervention efforts.

Social media as an emerging tool for reducing prescription opioid misuse risk factors

Interventions are urgently needed to reduce prescription opioid misuse risk factors, including anxiety and concomitant use of sedatives. However, only a limited number of randomized controlled opioid intervention trials have been conducted. We sought to determine whether an online behavior change/support community, compared to a control Facebook group, could reduce anxiety and opioid misuse among chronic pain patients. 51 high-risk non-cancer chronic pain patients were randomly assigned to either a Harnessing Online Peer Education (HOPE) peer-led online behavior change intervention or a control group (no peer leaders) on Facebook for 12 weeks. Inclusion criteria were: 18 years or older, a UCLA Health System patient, prescribed an opioid for non-cancer chronic pain between 3 and 12 months ago, and a score of ≥9 on the Current Opioid Misuse Measure (COMM) and/or concomitant use of benzodiazepines. Participation in the online community was voluntary. Patients completed baseline and follow-up assessments on Generalized Anxiety Disorder screener (GAD-7), COMM, and frequency of social media discussions about pain and opioid use. Compared to control group participants, intervention participants showed a baseline-to-follow-up decrease in anxiety, and more frequently used social media to discuss pain, prescription opioid use, coping strategies, places to seek help, and alternative therapies for pain. Both groups showed a baseline to follow-up decrease in COMM score. Preliminary results support the use an online community interventions as a low-cost tool to decrease risk for prescription opioid misuse and its complications.

Acute stressors and clinical characteristics differentiate death by suicide, accident, or natural causes among illicit and prescription opiate users

BACKGROUND

Opiate misuse has reached epidemic levels. Prevention efforts depend on distinguishing opiate users from abusers. The current study compared opioid users who died by natural cases, accidents, and suicide using psychological autopsy methods. Groups were compared on substance use characteristics, treatment history, experiences of negative life events, and circumstances at the time of death.

METHODS

Substance use and suicide risk were evaluated using psychological autopsy methods in 63 decedents with positive toxicology for opiates at death divided into three groups: adults dying by suicide (n = 19), accident (n = 19), and natural causes (n = 25). Groups were compared on several dependent measures, using chi-square analyses to examine categorical variables and one-way analyses of variance (ANOVA) to examine continuous variables.

RESULTS

Individuals who died by suicide were similar in many ways to adults who died by an accidental overdose. However, suicide completers were more likely to have struggled with severe depression, and previously attempted suicide, whereas the accidental overdose sample was more likely to display a chronic pattern of severe drug abuse.

CONCLUSIONS

The current study helps to distinguish between opiate users who are at risk for death by an accidental or intentional overdose. In the ongoing opiate crisis, clinicians must understand the risk of overdose and the nuances of accidental behaviors compared to purposeful ones. Signs of suicidal planning, relevant psychopathology, and ongoing life stress may be useful points of intervention for stopping the increasing number of deaths among opiate users.

National U.S. time-trends in opioid use disorder hospitalizations and associated healthcare utilization and mortality

Background

The opioid epidemic is a major public health crisis in the U.S. Contemporary data on opioid use disorder (OUD) related hospitalizations are needed. Our objective was to assess whether OUD hospitalizations and associated mortality are increasing over time and examine the factors associated healthcare utilization and mortality.

Methods and findings

We examined the rates of OUD hospitalizations and associated mortality using the U.S. National Inpatient Sample (NIS) data from 1998–2016. Multivariable-adjusted logistic regression assessed the association of demographic, clinical and hospital characteristics with inpatient mortality and healthcare utilization (total hospital charges, discharge to a rehabilitation facility, length of hospital stay) during the index hospitalization for opioid use disorder. We calculated the odds ratio (OR) and 95% confidence intervals (CI). We estimated 781,767 OUD hospitalizations. The rate of OUD hospitalization and associated mortality (/100,000 overall NIS hospitalizations) increased from 59.8 and 1.2 in 1998–2000 to 190.7 and 5.9 in 2015–16, respectively. In the multivariable-adjusted analysis, the following factors were associated with worse outcomes; compared to age <34 years, older age was associated with higher risk of hospital charges above the median and length of stay >3 days, slightly higher risk of discharge to a rehabilitation facility. Higher Deyo-Charlson score was associated with higher hospital charges, length of hospital stay, and inpatient mortality. Women had lower odds of inpatient mortality than men and blacks had lower odds of mortality than whites.

Conclusions

Rising OUD hospitalizations from 1998 to 2016 and increasing associated inpatient mortality are concerning. Certain groups are at higher risk of poor utilization outcomes and inpatient mortality. Resources and healthcare policies need to focus on the high-risk group to reduce mortality and associated utilization.

Is the Gender Gap in Overdose Deaths (Still) Decreasing? An Examination of Opioid Deaths in Delaware, 2013-2017

OBJECTIVE

Drug overdoses among men have historically outnumbered those among women by a large margin. Yet, U.S. research on the first wave of the opioid epidemic involving prescription opioids has found women to be at increased risk. The current study considers if the narrowing gender gap in overdose deaths, as observed during the first wave, has continued into the most recent third wave, dominated by synthetic opioid deaths. This requires consideration of interactions between gender, age, and type of drug implicated.

METHOD

Drawing on 2013-2017 Delaware toxicology reports for a total of 890 overdose deaths involving opioids, we distinguished between four gender/age groups--women 15-44, women 45-64, men 15-44, and men 45-64--to calculate crude death rates, male-to-female death rate ratios, and younger-to-older death rate ratios by type of opioid.

RESULTS

Opioid overdose death rates during the third wave increased among both men (+102%) and women (+46%), but the larger increase among men resulted in an increase in the male-to-female death rate ratio (from 1.9 to 2.6). This trend was driven by the growing contribution of fentanyl (from 16% to 76%) and heroin overdose deaths (from 27% to 50%) compared with other opioid overdose deaths, which disproportionately affected men and younger individuals. Higher male-to-female death rate ratios were observed among older, compared with younger, individuals.

CONCLUSIONS

Overdose deaths seem to have returned to a historically familiar pattern of dominance by younger males. Our findings suggest the gender-age distribution in deaths to specific opioid types must be considered for effective intervention.

Racial/Ethnic and Gender Differences in Associations of Medication-Assisted Therapy and Reduced Opioid Use between Outpatient Treatment Admission and Discharge

Medication-assisted therapy (MAT) for opioid use disorders is an effective treatment strategy. Racial/ethnic and gender disparities in MAT utilization have been documented, but less is known about disparities in MAT outcomes. We used the Treatment Episodes Dataset-Discharges (TEDS-D; 2015- 2017) to identify outpatient treatment episodes with heroin or illicit opioids indicated at admission (n = 232,547). We used multivariate logistic regression to model the association between MAT and a reduction in opioid use between treatment admission and discharge. We explored moderation by race/ethnicity and gender by including an interaction term. We identified a strong moderating effect of race/ethnicity and gender. American Indian/Alaska Native (AI/AN) women demonstrated the strongest association between MAT (versus no MAT) and a reduction in opioid use (aOR = 6.05, 95% CI = 4.81- 7.61), while White men demonstrated the weakest association (aOR = 2.78, CI = 2.70- 2.87). Our findings could inform changes in clinical MAT settings that are based on harm reduction and the incremental transition from illicit opioids to medication-assistance among a diverse opioid use disorder population.

Lidocaine With Epinephrine Versus Bupivacaine With Epinephrine as Local Anesthetic Agents in Wide-Awake Hand Surgery: A Pilot Outcome Study of Patient’s Pain Perception

Purpose

Wide-awake local anesthesia hand surgery has many advantages over other forms of anesthesia, including faster recovery, lower cost, and improved patient safety; however, few studies compare postoperative pain and analgesic consumption after long- and short-acting anesthetics. This is important because surgeons seek to minimize opioid consumption during the opioid epidemic.

Methods

This was a double-blinded, prospective, randomized, parallel design pilot study. We randomized 61 patients to receive carpal tunnel surgery with a short-lasting regional anesthetic (lidocaine, 29 patients) or a long-lasting one (bupivacaine, 32 patients). Primary outcomes were pain levels over the first and second 24 hours. Secondary outcomes were postoperative consumption of acetaminophen and opioids over the first and second 12 hours after surgery.

Results

Pain intensity and acetaminophen consumption were significantly less in the bupivacaine group over the first 24 and 12 hours after surgery, respectively. The bupivacaine group consumed less opioids in the first 12 hours and delayed consumption of the first medication after surgery, but these results were not statistically significant. There was no difference in pain intensity or analgesic consumption between 24 and 48 hours after surgery.

Conclusions

The use of a long-term anesthetic (bupivacaine) over a short-term one (lidocaine) in awake carpal tunnel release surgery decreases postoperative pain over the initial 12 hours after surgery and delays the initiation of analgesic consumption; however, this difference is small. The amount of opioid consumption was not significantly different between groups, but both groups consumed less than 10% of the prescribed opioids. It is important to reevaluate the need for opioids in minor hand surgery and favor the use of alternatives such as nonsteroidal anti-inflammatory drugs and acetaminophen.

Type of study/level of evidence

Therapeutic I.

The benefits and implementation challenges of the first state-wide comprehensive medication for addictions program in a unified jail and prison setting

The prevalence of opioid use disorders among people who are incarcerated is high. People who are released from incarceration are at increased risk for overdose. The current study details the first year of implementation of a state-wide medications for addiction treatment (MAT) program in a unified jail and prison setting at the Rhode Island Department of Corrections in Cranston, Rhode Island. We conducted 40 semi-structured, qualitative interviews with people who were incarcerated and concurrently enrolled in the MAT program. Analysis employed a general, inductive approach in NVivo 12. We found that a majority of participants discussed program benefits such as reduced withdrawal symptoms, decreased prevalence of illicit drug use in the facility, improved general environment at the RIDOC, and increased post-release intentions to continue MAT. Suggested areas of improvement include reducing delays to first dose, increasing access to other recovery services in combination with MAT, improving staff training on stigma, and earlier access to medical discharge planning information prior to release. Our findings suggest that correctional MAT programs are acceptable to targeted populations and are a feasible intervention that may be transferable to other states.

Pain severity and prescription opioid misuse among individuals with chronic pain: The moderating role of alcohol use severity

BACKGROUND

Chronic pain is a public health problem associated with opioid misuse. Yet, it is important to understand factors underlying opioid misuse in the context of pain. Alcohol use is one factor to consider given past work documenting use of alcohol to manage pain. However, it is unknown whether alcohol use severity exacerbates the relation between pain and opioid misuse. This study sought to examine relations between pain and prescription opioid misuse and the moderating role of alcohol use severity in two online survey studies of individuals with chronic pain.

METHOD

Individuals with chronic pain (study 1, n = 364; study 2, n = 437) were administered measures of pain, alcohol use, and opioid misuse.

RESULTS

In study 1, there was a significant interaction of pain severity and alcohol use (b = 0.16, p < 0.001). Pain was significantly related to opioid misuse among those with higher (b = 1.50, p < 0.001), but not lower (b=-0.26, p = 0.430) alcohol use. In study 2, there was a significant interaction of pain severity and alcohol use (b = 0.03, p < 0.001). Pain was significantly related to opioid misuse among those with higher (b = 0.74, p < 0.001), but not lower (b = 0.07, p = 0.620) alcohol use.

CONCLUSIONS

In two online samples, there was evidence of a novel interaction of pain severity and alcohol use severity in relation to opioid misuse. Although cross-sectional, results replicated in two studies. Pain severity was related to opioid misuse among those with higher but not lower alcohol use. Those who use alcohol, even below suggested cut-offs, may be more likely to misuse opioids when in pain.

Menopausal Symptoms and Higher Risk Opioid Prescribing in a National Sample of Women Veterans with Chronic Pain

BACKGROUND

The greatest increases in long-term opioid use and opioid-related overdose mortality in recent years have been among women in midlife. Common menopausal symptoms broadly affect health and health care utilization in midlife, but their contribution to chronic pain management during this period is unknown.

OBJECTIVE

To examine relationships between menopausal symptoms and long-term opioid prescription patterns among midlife women with chronic pain.

DESIGN

Cross-sectional analysis of national Veterans Health Administration medical and pharmacy records (2014-2015).

PARTICIPANTS

Women Veterans aged 45-64 with ≥ 1 outpatient visit and chronic pain diagnoses spanning ≥ 90 days.

MAIN MEASURES

Long-term opioids (prescribed oral opioids for ≥ 90 days), high-dose long-term opioids (> 50 mg average morphine equivalent daily dose), and long-term opioids co-prescribed with central nervous system depressants (benzodiazepine and non-benzodiazepine sedative-hypnotics, gabapentin/pregabalin, muscle relaxants). Multivariable logistic regression models were used to examine associations between outcomes and menopausal symptoms (menopausal symptom-related diagnoses (i.e., "symptomatic menopausal states") on ≥ 2 encounters and/or menopausal hormone therapy, adjusting for race, age, body mass index, and mental health and substance use disorder diagnoses.

KEY RESULTS

In this national sample of 104,984 midlife women Veterans with chronic pain (mean age 54.5, SD 5.4 years), 17% had evidence of menopausal symptoms, 51% were prescribed long-term opioids, 13% were prescribed high-dose long-term opioids, and 35% were co-prescribed long-term opioids and central nervous system depressants. In multivariable analyses, women with menopausal symptoms had increased odds of long-term opioids (OR 1.21, 95% CI 1.18-1.26), high-dose long-term opioids (OR 1.08, 95% CI 1.02-1.13), and long-term opioids co-prescribed with central nervous system depressants (sedative-hypnotics OR 1.25, 95% CI 1.22-1.30; gabapentin/pregabalin OR 1.23, 95% CI 1.20-1.27; muscle relaxants OR 1.24, 95% CI 1.20-1.28).

CONCLUSIONS

Among midlife women Veterans with chronic pain, evidence of menopausal symptoms was associated with potentially risky long-term opioid prescription patterns, independent of known risk factors.

History of regular nonmedical sedative and/or alcohol use differentiates substance-use patterns and consequences among chronic heroin users

BACKGROUND

Concurrent use of sedating substances (e.g. alcohol or benzodiazepines) with opioids is associated with increased negative consequences of opioid use; however, few studies have attempted to differentiate effects of using sedating substances on heroin-use outcomes. This study examines differences between heroin users who use alcohol or misuse sedatives regularly and those who do not.

METHODS

Substance-use data were collected from 367 non-treatment seeking, chronic heroin-using, 18-to-55 year-old participants. We created 4 groups based on self-reported lifetime history of regular (at least weekly) substance use: heroin only (n = 95), heroin and sedatives (n = 21), heroin and alcohol (n = 151), and heroin, sedative, and alcohol (n = 100). Chi-square analyses and ANOVAs with Bonferroni post hoc tests were used to explore differences between these groups.

RESULTS

Heroin users who denied lifetime alcohol or nonmedical sedative use regularly endorsed fewer consequences associated with any substance they had used. Total adverse consequences of heroin use (e.g. health problems) were significantly higher among those who misused sedatives regularly, irrespective of alcohol use history (F(3,361) = 10.21; p < .001). Regular alcohol use did not independently impact heroin consequences but was associated with increased use of other substances.

CONCLUSIONS

Although polysubstance use is normative among heroin users, the risks depend on the substances used. Regular sedative use is associated with increased heroin consequences whereas regular alcohol use is not. This study refines the investigation of polysubstance use and highlights subgroup differences depending on types of substances used regularly. This knowledge is critical for understanding substance-use motivations and creating avenues for harm reduction.

A gender-based analysis of nonmedical prescription opioid use among people who use illicit drugs

BACKGROUND

Research investigating the unique impacts associated with engaging in nonmedical prescription opioid use (NMPOU) among males and females who also use illicit drugs is needed.

METHODS

Data were collected between 2013 and 2017 from two linked prospective cohort studies in Vancouver: the At-Risk Youth Study and Vancouver Injection Drug Users Study. Generalized estimating equations were used to identify factors associated with engaging in NMPOU among females and males separately.

RESULTS

Among 1459 participants, 534 were female (37%). Similar proportions of females (46%) and males (48%) engaged in NMPOU at their first visit during the study period. In multivariable analyses, factors associated with NMPOU among both males and females included heroin use, overdose, drug dealing, and difficulty accessing health and social services. Among females, those who engaged in NMPOU were more likely to report Caucasian or white ethnicity, cocaine use, crystal methamphetamine use, and sex work; among males, those who engaged in NMPOU were older, reported crack use and engaged in binge drug use (all p < 0.05).

CONCLUSION

The prevalence of NMPOU was similar among males and females who use illicit drugs in Vancouver, and NMPOU was independently associated with markers of vulnerability among both genders. Findings highlight the need for a comprehensive public health approach to address NMPOU that integrates overdose prevention and reversal services, employment opportunities, and better access to services for both women and men.

Pharmacists' perceived responsibility for patient care when there is a risk of misadventure: a qualitative study

OBJECTIVE

To investigate how community pharmacists view their responsibility for patient care in a scenario involving opioid use with significant risk of toxicity or misadventure.

METHODS

A case scenario was developed based on an Australian coronial inquiry involving a patient suffering fatal toxicity following misuse of opioids. Community pharmacists working in Brisbane, Queensland, were invited to take part in face-to-face semi-structured interviews at their place of work. Participants were asked how they would respond to the scenario in practice and their perceived responsibilities.

KEY FINDINGS

Twenty-one pharmacists were interviewed. Participants identified similar actions in response to the case, and potential barriers and enablers. Participants differed with regard to how they described their perceived scope of practice and degree of responsibility in response to the case. Most participants described their scope of practice in terms of medication management with a focus on patient outcomes. Some participants described a narrower scope of practice that focused on either medicine supply or legal aspects. Participants who described a medication management focus differed in their views regarding their responsibility for patient outcomes in the case.

CONCLUSION

Pharmacists in this study varied in terms of their perceived scope of practice and responsibility to patient outcomes in response to a case involving a patient at risk of opioid-related harm. Further work on pharmacist responsibility may reduce this variability.

Opioid-Related Deaths in Eastern Ontario from 2011 to 2016

There has been a growing opioid crisis in the United States and Canada. The aim of this study was to analyze trends in opioid-related deaths from the Eastern Ontario Regional Forensic Pathology Unit so that prevention strategies for these deaths can be developed. The analyses included examining the opioids involved and demographic characteristics of the individuals in these deaths so that possible risk factors for opioid-related deaths could be identified. A retrospective cross-sectional analysis of the full autopsy and toxicology data between 2011 and 2016 was conducted. Trends regarding the opioids involved in the death, all opioids reported in the toxicology reports and certain nonopioid drugs reported in the toxicology reports were examined. The distribution of opioid-related death by age-group and manner of death was also conducted. Two hundred seventy-four opioid-related deaths met the inclusion criteria and were examined. The majority of individuals overdosing were male. The most frequent age range for opioid-related deaths was 45 to 54 years with increasing deaths among individuals aged 55 years and older over the period studied. Fentanyl was responsible for most deaths overall when single or multiple opioids were involved. However, hydromorphone involvement was the only opioid to have a statistically significant increase over the time period. Analysis of nonopioid-related drugs revealed extensive use of antidepressants, benzodiazepines, and their metabolites. Accident was the most common manner of death throughout all age groups except for those aged 65 years or older, where suicide was most common.

Rates of Physician Coprescribing of Opioids and Benzodiazepines After the Release of the Centers for Disease Control and Prevention Guidelines in 2016

IMPORTANCE

The Centers for Disease Control and Prevention guidelines in 2016 recommended avoiding concurrent use of opioids and benzodiazepines.

OBJECTIVE

To determine whether the release of the guidelines was associated with changes in coprescription of opioids and benzodiazepines.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used claims data obtained from a US national database of medical and pharmacy claims for 3 598 322 adult commercially insured patients and 1 299 142 Medicare Advantage (MA) beneficiaries with no recent history of cancer, sickle cell disease, or hospice care who ever used prescribed opioids during the study period, January 1, 2014, through March 31, 2018.

EXPOSURES

Overlapping opioid and benzodiazepine prescriptions filled.

MAIN OUTCOMES AND MEASURES

The extent (proportion of person-months with any overlapping days of prescription of opioids and benzodiazepines) and intensity (proportion of days with opioids prescribed where benzodiazepines were also available) of coprescription.

RESULTS

Of 4 897 464 patients (with 13.4 million person-months of opioid use), the total number of unique commercially insured individuals was 3 598 322 (1 974 731 women [54.9%]), and the total number of unique MA beneficiaries was 1 299 142 (770 256 women [59.3%]). Among 128 576 participants experiencing chronic pain episodes, more than one-half of person-months of long-term opioid use occurred in women (52.7% of person-months among those with commercial insurance and 62.4% of person-months among MA beneficiaries). The median (interquartile range) age of the participants was 51 (41-58) years for patients in the commercial insurance group and 70 (61-77) years for those in the MA group. The mean (SE) extent of coprescription was 23.0% (0.18%) for the commercial insurance group and 25.7% (0.18%) for the MA group. The extent of coprescription decreased in the targeted guideline population-individuals with long-term opioid use-after the guideline release (postguideline slope, -0.95 percentages point per year [95% CI, -1.44 to -0.46 percentage points per year] for the commercial insurance group and -1.06 percentage points per year [95% CI, -1.49 to -0.63 percentage points per year] for the MA group). Nontargeted short-term episodes of opioid use were associated with no change or small declines in trend (for the MA group, postguideline slope of 0.47 percentage point per year [95% CI, 0.35-0.59 percentage point per year]; for the commercial insurance group, postguideline slope of -0.05 percentage point per year [95% CI, -0.12 to 0.02 percentage point per year]). High coprescribing intensity was seen, with 79.3% (95% CI, 78.9%-79.6%) of opioid prescription days in the commercial insurance group and 83.9% (95% CI, 83.7%-84.2%) in the MA group overlapping with benzodiazepines. There was no change in the intensity of coprescribing. Intensity of coprescription was higher when the same clinician prescribed opioids and benzodiazepines.

CONCLUSION AND RELEVANCE

This study observed a reduction in the extent but not intensity of coprescribing of benzodiazepines for patients with long-term opioid use.

Patterns of opioid use (codeine, morphine or meperidine) in the Canadian population over time: analysis of the Longitudinal National Population Health Survey 1994-2011

OBJECTIVE

This study aimed to investigate cohort effects in selected opioids use and determine whether cohort differences were associated with changes in risk factors for use over time.

DESIGN

This study presents secondary analyses of a longitudinal survey panel of the general population that collected data biannually.

SETTING

Data from the Canadian Longitudinal National Population Health Survey 1994-2011.

POPULATION

This study included 12 542 participants from the following birth cohorts: post-World War I (born 1915-1924), pre-World War II (born 1925-1934), World War II (born 1935-1944), Older Baby Boom (born 1945-1954), Younger Baby Boom (born 1955-1964), Older Generation X (born 1965-1974) and Younger Generation X (born 1975-1984).

MAIN OUTCOME

Responses to a single question asking about the use of codeine, morphine or meperidine in the past month (yes/no) were examined.

RESULTS

Over and above age and period effects, there were significant cohort differences in selected opioids use: each succeeding recent cohort had greater use than their predecessors (eg, Gen Xers had greater use than younger baby boomers). Selected opioids use increased significantly from 1994 to 2002, plateauing between 2002 and 2006 and then declining until 2011. After accounting for cohort and period effects, there was a decline in use of these opioids with increasing age. Although pain was significantly associated with greater selected opioids use (OR=3.63, 95% CI 3.39 to 3.94), pain did not explain cohort differences. Cohort and period effects were no longer significant after adjusting for the number of chronic conditions. Cohort differences in selected opioids use mirrored cohort differences in multimorbidity. Use of these opioids was significantly associated with taking antidepressants or tranquillisers (OR=2.52, 95% CI 2.27 to 2.81 and OR=1.60, 95% CI 1.46 to 1.75, respectively).

CONCLUSIONS

The findings underscore the need to consider multimorbidity including possible psychological disorders and associated medications when prescribing opioids (codeine, morphine, meperidine), particularly for recent birth cohorts. Continued efforts to monitor prescription patterns and develop specific opioid use guidelines for multimorbidity appear warranted.

Interactions of benzodiazepines with heroin: Respiratory depression, temperature effects, and behavior

Benzodiazepines are important therapeutic drugs, but they are often abused and co-abused with opioids. Clinical evidence suggests that benzodiazepines can inhibit respiration, and when combined with the respiratory-depressive effects of opioids, may increase likelihood of death. In this study we used oxygen sensors coupled with high-speed amperometry and multi-site thermorecording to examine how intravenous (iv) midazolam, a potent benzodiazepine, modulates the brain hypoxic and temperature effects of iv heroin in freely-moving rats. Oxygen levels and brain temperature were assessed with high temporal resolution in the nucleus accumbens (NAc), an important structure in the motivational-reinforcement circuit. When administered alone, midazolam (2 mg/kg) modestly decreased NAc temperature but had no evident effects on oxygen levels in this structure. In contrast, heroin (0.4 mg/kg) induced a strong decrease in NAc oxygen that was followed by a weaker, rebound-like oxygen increase. Midazolam pretreatment did not affect heroin-induced brain hypoxia but potentiated the initial hypothermia induced by heroin. However, co-administration of these drugs potentiated the heroin-induced oxygen decrease and enhanced heroin-induced brain hypothermia. Co-administration of heroin and midazolam also resulted in enhanced locomotor inhibition and loss of motor control. This effect caused some rats to collapse, resulting in nose and mouth occlusion, which caused a secondary hypoxic phase. These results could have important implications for human drug users, as the combined use of benzodiazepines with potent opioids not only results in sustained brain hypoxia but creates conditions of loss of motor control which could result in asphyxia and death. This article is part of the Special Issue entitled 'New Vistas in Opioid Pharmacology'.

"One guy goes to jail, two people are ready to take his spot": Perspectives on drug-induced homicide laws among incarcerated individuals

BACKGROUND

As overdose deaths have increased in the United States, some lawmakers have explored punitive, "supply-side" interventions aimed at reducing the supply of fentanyl. While a rationale of seeking to protect people who use drugs is often given to justify harsh sentences for fentanyl distribution, there is no research to our knowledge on perceptions of the effect of drug-induced homicide laws among people who use drugs.

METHODS

We conducted semi-structured, qualitative interviews with 40 people with opioid use disorder (OUD) who were enrolled in a medication for addiction treatment (MAT) program in a unified jail and prison system in Rhode Island on attitudes surrounding increased sentences for distribution of fentanyl, including recently enacted drug-induced homicide laws. Codes were developed using a generalized, inductive method and interviews analyzed in NVivo 12 after being coded by two coders.

RESULTS

Most participants stated that drug-induced homicide laws would not be an effective strategy to stem the overdose crisis. We identified key themes, including discussions surrounding the autonomy of people who use drugs, widespread fentanyl prevalence as a barrier to implementation of drug-induced homicide laws, discussions of mass incarceration as ineffective for addressing substance use disorders, feelings that further criminalization could lead to violence, criminalization as a justification for interpersonal loss, and intention as meaningful to categorizing an act as homicide.

CONCLUSIONS

Findings highlight the importance of centering the experiences of people with OUD in creating policies surrounding the overdose epidemic, potential unintended health consequences of drug-induced homicides laws such as deterrence from calling 911 and increased violence, and how drug-induced homicide laws may undermine advances made in expanding access to OUD treatment for people who are criminal justice-involved.

Design, Implementation, and Evaluation of an Integrative Pain Management Program in a Primary Care Safety-Net Clinic

OBJECTIVE

To design, implement, and evaluate a comprehensive Integrative Pain Management Program (IPMP) for patients with chronic pain in a safety-net primary care clinic.

DESIGN

We used a quality improvement "Plan Do Study Act" (PDSA) framework to design, refine, and evaluate an integrative chronic pain program.

SETTING

An urban federally qualified health center located in a community with high rates of chronic pain, substance use, and opioid overdose.

SUBJECTS

Eligible participants included individuals with pain for greater than 3 months who were prescribed opioid therapy.

OUTCOME MEASURES

We designed IPMP using a PDSA framework that promotes continuous evaluation and adaptation of the program to meet the needs of the clinical system. We assessed feasibility and acceptability with program referrals and attendance and evaluated program satisfaction.

RESULTS

The IPMP delivered a 12-week group-based intervention that involved group support, education on pain etiology and treatments, movement-based interventions, mindfulness-based therapies, acupuncture, and massage therapy. One hundred forty-six patients were referred to IPMP; 58 individuals participated in one of the first three cohorts of the program. Sixty-two percent of participants attended at least half of the sessions. Staff and participants reported high levels of satisfaction with IPMP and demand for longitudinal services.

CONCLUSIONS

An IPMP delivered within a safety-net primary care clinic could be implemented in a way feasible and acceptable to staff and participants with the support of the local health care system. The application of a PDSA cycle allowed for rigorous implementation and evaluation of a multimodal pain program. Quality improvement frameworks are a strategy to improve and expand the delivery of high-quality patient-centered integrative pain treatments.

Prescription opioid misuse among middle-aged and older adults in the United States, 2015-2016

Adults ≥50 years of age have high rates of prescription opioid use. The purpose of this study is to estimate the prevalence and correlates of prescription opioid misuse among middle-aged and older adults in the United States who use prescription opioids. Data from adults age ≥ 50 from the two most recent cohorts (2015 and 2016) of the National Survey of Drug Use and Health were examined (N = 17,608). Characteristics of past-year prescription opioid misusers, including demographics, substance use, depression, chronic disease, and emergency department (ED) use, were compared to adults who used prescription opioids as prescribed in the past year and non-users. We used multivariable logistic regression to determine correlates of prescription opioid misuse among adults who used prescription opioids. Among the entire sample, 61.4% reported no past-year prescription opioid use, 36.0% reported past-year prescription opioid use without misuse, and 2.5% reported past-year prescription opioid misuse. Among past-year prescription opioid users, 6.6% reported misuse. Past-year misuse was higher among males, adults age 50-64, misusers of prescription sedatives, stimulants, and tranquilizers, users of other substances (i.e., tobacco, marijuana, cocaine), and those with alcohol use disorder. Past-year misuse was lower among adults with 2 or more chronic diseases. Past-year prescription misuse of sedatives (AOR 4.08 [95% CI 2.05-8.12]), stimulants (AOR 3.88 [95% CI 2.00-7.53]), and tranquilizers (AOR 10.02 [95% CI 6.48-15.50]) were all associated with past-year opioid misuse. Characteristics of opioid misusers determined in this study-particularly misuse of other substances-may help determine middle-aged and older adults at risk for prescription opioid misuse.

The United States opioid epidemic

The United States opioid epidemic is a nationwide public health crisis. Initially driven by increased consumption and availability of pharmaceutical opioids, an increasing number of opioid overdoses are now related to heroin and illicitly manufactured fentanyl and fentanyl analogs. Addressing this epidemic requires addressing the stigma associated with opioid use disorders and its treatment, improving access to efficacious treatment options, specifically methadone and buprenorphine, and reducing opioid overdose fatalities with distribution of the opioid antagonist and overdose reversal agent naloxone.

Increased overdose mortality during the first week of the month: Revisiting the "check effect" through a spatial lens

BACKGROUND

The timing of social service benefit issuance is thought to be associated with increased drug overdose fatalities. However, the extent to which this excess mortality is concentrated in communities with higher levels of benefit receipt has not been studied. We sought to examine if benefit receipt at the neighborhood level was associated with spatiotemporal patterns of overdose fatalities.

METHODS

We conducted a retrospective review of all accidental overdose deaths recorded in Rhode Island from 2014 to 2016 (n = 838). Overdose incident locations were geocoded to the census block group level. Clusters of census block groups with excess overdose mortality at the beginning of a month were identified using spatial scan methods. Logistic regression models were fit to identify characteristics associated with the inclusion of a census block group within a cluster.

RESULTS

Increased rates of overdose fatalities at the beginning of a month were observed relative to the end of a preceding month (Ratio: 1.17; 95% CI: 1.04, 1.38). The proportions of residents receiving cash public assistance or Supplemental Security Income were not associated with excess mortality at the beginning of a month; however, the proportion of residents living in unaffordable housing was (OR: 1.42; 95% CI: 1.05, 1.91).

CONCLUSION

Despite previous research on benefit check issuance and overdose, welfare receipt was not associated with excess overdose mortality at the beginning of a month at the neighborhood level. Future research on housing cost burden and its influence on overdose death risk at the individual level is needed.

The Heroin Epidemic in America: A Surgeon's Perspective

Background: The United States is currently experiencing a heroin epidemic. Recent reports have demonstrated a three-fold increase in heroin use among Americans since 2007 with a shift in demographics to more women and white Americans. Furthermore, there has been a correlation between the recent opioid epidemic and an increase in heroin abuse. Much has been written about epidemiology and prevention of heroin abuse, but little has been dedicated to the surgical implications, complications, and resource utilization. Discussion: This article focuses on the surgical problems encountered from heroin abuse and how to manage them in a constant effort to improve morbidity and mortality for these heroin abusers.

The Association Between Ethnic Identity and Non-Medical Prescription Drug Use Among A Sample of College Students: Does a Sense of Ethnic Belonging Matter?

BACKGROUND

National data demonstrate significant differences in non-medical prescription drug (NMPD) use, with Whites seeming to be more likely to use compared to non-Whites. College students also appear to be at an increased risk for NMPD use.

OBJECTIVES

This study examines NMPD use using a component of social identity theory. We propose that a stronger sense of ethnic identity may reduce the likelihood of NMPD use among college students due to ethnic identity's ties to self-esteem and self-efficacy. We also propose that the protective power of ethnic identity may vary according to one's race.

METHODS

Data for this study were collected from a survey of undergraduate students at a Midwestern university (N = 530). Poisson regression analyses were used to test the relationship between ethnic identity and NMPD use. Of our sample, 135 participants (25.5%) indicated NMPD use over the past year. This percentage is high compared to findings from national college data.

RESULTS

Results indicate that a stronger sense of ethnic identity reduced the frequency of NMPD use among young adults. The findings also reveal that the relationship between ethnic identity and NMPD use is moderated by race. Ethnic identity was found to be a protective factor for non-White participants only.

CONCLUSIONS

This study suggests that ethnic belonging may act as a protective factor against NMPD use among non-White young adults. These findings build upon our understanding of the relationship between ethnic identity and substance use. We conclude with a discussion of directions for future research and intervention programs.

Adolescent and Parent Management of Controlled Prescription Medications

Background: Most adolescents who misuse controlled prescription medications acquire them from home settings. However, little is known regarding household management (storage, administration, and disposal) of these medications. Objective: To describe household management of controlled medications. Methods: This was a cross-sectional study with paired data using brief, online, confidential surveys of adolescents and parents via an adolescent medicine clinic associated with a large academic center. Eligible adolescents were 12-18 years with at least one controlled prescription medication in the home. Six core safe management strategies for controlled medications were identified based on current recommendations. Data were collected and analyzed in 2017. Results: Of the 243 adolescent-parent dyads, 78.2% (n = 190) dyads store medication out of sight, 68.7% (n = 167) lock up medications, 78.2% (n = 190) do not store pills besides a school nurse's office or a parent's place of work, 43.6% (n = 106) provide periodic parental monitoring, 64.6% (n = 157) frequently dispose of unused controlled medications (at least every 3-4 months), and 80.2% (n = 195) dispose of controlled medications in a prescription drug take-back program or by flushing. Families with an adolescent prescription for a controlled medication were more likely to use several core management strategies (periodic parental monitoring, frequent disposal, and appropriate disposal location). Families with a household pain reliever were 8.7 times (95% CI 3.3, 23.3) as likely to not keep spare pills in inappropriate locations. Conclusions/Importance: Most families do not practice all recommended safe management strategies for controlled medications. Healthcare professionals should promote safe management to reduce controlled prescription medication misuse.

Practices Surrounding Pain Management Among American Indians and Alaska Natives in Rural Southern California: An Exploratory Study

OBJECTIVES

This exploratory study examined pain management practices among American Indians and Alaska Natives in the service area of a rural tribal clinic in Southern California.

METHODS

Researchers invited 325 individuals to complete an anonymous survey in clinic waiting rooms and tribal gatherings. Analyses of the 295 eligible responses included calculating frequencies and conducting multiple logistic regressions and a Mantel-Haenszel analysis.

RESULTS

Among respondents in this study, being male, younger, and having less education were strong predictors for riskier methods for managing pain.

CONCLUSIONS

Understanding the methods individuals use to manage pain in a rural setting constitute a stepping-stone to develop strategies for reducing and preventing misuse and abuse of prescription medications and other drugs in rural American Indian and Alaska Native communities.

Receipt of Overlapping Opioid and Benzodiazepine Prescriptions Among Veterans Dually Enrolled in Medicare Part D and the Department of Veterans Affairs: A Cross-sectional Study

BACKGROUND

Overlapping use of opioids and benzodiazepines is associated with increased risk for overdose. Veterans receiving medications concurrently from the U.S. Department of Veterans Affairs (VA) and Medicare may be at higher risk for such overlap.

OBJECTIVE

To assess the association between dual use of VA and Medicare drug benefits and receipt of overlapping opioid and benzodiazepine prescriptions.

DESIGN

Cross-sectional.

SETTING

VA and Medicare.

PARTICIPANTS

All veterans enrolled in VA and Medicare Part D who filled at least 2 opioid prescriptions in 2013 (n = 368 891).

MEASUREMENTS

Outcomes were the proportion of patients with a Pharmacy Quality Alliance (PQA) measure of opioid-benzodiazepine overlap (≥2 filled prescriptions for benzodiazepines with ≥30 days of overlap with opioids) and the proportion of patients with high-dose opioid-benzodiazepine overlap (≥30 days of overlap with a daily opioid dose >120 morphine milligram equivalents). Augmented inverse probability weighting regression was used to compare these measures by prescription drug source: VA only, Medicare only, or VA and Medicare (dual use).

RESULTS

Of 368 891 eligible veterans, 18.3% received prescriptions from the VA only, 30.3% from Medicare only, and 51.4% from both VA and Medicare. The proportion with PQA opioid-benzodiazepine overlap was larger for the dual-use group than the VA-only group (23.1% vs. 17.3%; adjusted risk ratio [aRR], 1.27 [95% CI, 1.24 to 1.30]) and Medicare-only group (23.1% vs. 16.5%; aRR, 1.12 [CI, 1.10 to 1.14]). The proportion with high-dose overlap was also larger for the dual-use group than the VA-only group (4.7% vs. 2.3%; aRR, 2.23 [CI, 2.10 to 2.36]) and Medicare-only group (4.7% vs. 2.9%; aRR, 1.06 [CI, 1.02 to 1.11]).

LIMITATION

Data are from 2013 and cannot capture medications purchased without insurance; unmeasured confounding may remain in this cross-sectional study.

CONCLUSION

Among a national cohort of veterans dually enrolled in VA and Medicare, receiving prescriptions from both sources was associated with greater risk for receiving potentially unsafe overlapping prescriptions for opioids and benzodiazepines.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs.

Overdose and adverse drug event experiences among adult patients in the emergency department

INTRODUCTION

Overdose is a leading cause of injury and death in the United States. Emergency Department (ED) patients have an elevated prevalence of substance use. This study describes overdose/adverse drug event experiences among adult ED patients to inform strategies to address overdose risk.

METHODS

Patients seeking care at a large ED in the city of Flint, Michigan participated in a computerized self-assessment during 2011-2013 (n=4571). Overdose was assessed with a broad definition and included occurrences that could be considered adverse drug events. Among those with this type of experience, additional items assessed symptoms, outcomes, and intent.

RESULTS

12% reported an overdose history. Of participants' most serious overdoses, 74% were without clear intent for self-harm, although this was true of only 61% of overdoses involving opiates or sedatives, and 52% had symptoms present that indicated that it was life-threatening. Binge drinking on a monthly basis (ORs=1.4) was associated with a medically serious overdose compared to never having an overdose. Compared to no drug use in the last year, use of one drug was associated with an OR of 1.8, two drugs was associated with an OR of 5.8, three drugs was associated with an OR of 8.4, and four or more drugs was associated with an OR of 25.1 of having had a medically serious overdose (all p<0.05).

CONCLUSIONS

Most overdose experiences among ED patients were without clear intent of self-harm. The ED may be an appropriate setting for efforts to reduce overdose risk, especially among polysubstance users.