Prescription Opioid Misuse, Abuse, and Treatment in the United States: An Update

Central blockade of orexin type 1 receptors reduces naloxone induced activation of locus coeruleus neurons in morphine dependent rats

Orexin neuropeptides are implicated in the expression of morphine dependence. Locus coeruleus (LC) nucleus is an important brain area involving in the development of withdrawal signs of morphine and contains high expression of orexin type 1 receptors (OX1Rs). Despite extensive considerations, effects of immediate inhibition of OX1Rs by a single dose administration of SB-334867 prior to the naloxone-induced activation of LC neurons remains unknown. Therefore, we examined the direct effects of OX1Rs acute blockade on the neuronal activity of the morphine-dependent rats which underwent naloxone administration. Adult male rats underwent subcutaneous administration of 10 mg/kg morphine (two times/day) for a ten-day period. On the last day of experiment, intra-cerebroventricular administration of 10 μg/μl antagonist of OX1Rs, SB-334867, was performed just before intra-peritoneal injection of 2 mg/kg naloxone. Thereafter, in vivo extracellular single unit recording was employed to evaluate the electrical activity of LC neuronal cells. The outcomes demonstrated that morphine tolerance developed following ten-day of injection. Then, naloxone administration causes hyperactivity of LC neuronal cells, whereas a single dose administration of SB-334867 prior to naloxone prevented the enhanced activity of neurons upon morphine withdrawal. Our findings indicate that increased response of LC neuronal cells to applied naloxone could be prevented by the acute inhibition of the OX1Rs just before the naloxone treatment.

The 5α-reductase inhibitor finasteride reduces opioid self-administration in animal models of opioid use disorder

Opioid use disorder (OUD) has become a leading cause of death in the United States, yet current therapeutic strategies remain highly inadequate. To identify potential treatments for OUD, we screened a targeted selection of over 100 drugs using a recently developed opioid self-administration assay in zebrafish. This paradigm showed that finasteride, a steroidogenesis inhibitor approved for the treatment of benign prostatic hyperplasia and androgenetic alopecia, reduced self-administration of multiple opioids without affecting locomotion or feeding behavior. These findings were confirmed in rats; furthermore, finasteride reduced the physical signs associated with opioid withdrawal. In rat models of neuropathic pain, finasteride did not alter the antinociceptive effect of opioids and reduced withdrawal-induced hyperalgesia. Steroidomic analyses of the brains of fish treated with finasteride revealed a significant increase in dehydroepiandrosterone sulfate (DHEAS). Treatment with precursors of DHEAS reduced opioid self-administration in zebrafish in a fashion akin to the effects of finasteride. These results highlight the importance of steroidogenic pathways as a rich source of therapeutic targets for OUD and point to the potential of finasteride as a new treatment option for this disorder.

Trends in hydrocodone combination product exposures reported to California Poison Control System (CPCS) following DEA rescheduling

CONTEXT

On October 6, 2014, the United States Drug Enforcement Administration (DEA) implemented a regulatory change for hydrocodone combination products (HCPs), moving them from Schedule III to II, in an effort to decrease drug overdoses. Existing research suggests this regulatory action reduced HCP prescribing and dispensing; however, there is limited research assessing its possible effects on overdoses and accidental exposures.

OBJECTIVE

To analyze the changes in opioid exposures reported to the California Poison Control System (CPCS) before and after DEA rescheduling of HCPs.

METHODS

We collected monthly exposure data reported to CPCS from 2012 to 2019 and conducted interrupted time series analyses to assess changes in exposures after rescheduling for HCPs, tramadol, oxycodone, morphine, codeine, fentanyl, and heroin. Additional analyses were done to assess any changes in exposures resulting in severe outcomes (moderate or major health effects). For HCPs, we also conducted logistic regressions to identify characteristics of exposures resulting in severe outcomes before and after rescheduling.

RESULTS

Overall monthly opioid exposures reported to CPCS decreased after DEA rescheduling of HCPs. These decreases were significant for HCP, tramadol, and morphine (p < 0.001). Exposures significantly increased for heroin and fentanyl (p < 0.001). There were no significant changes in the share of severe outcomes attributed to HCP exposures after rescheduling.

DISCUSSION

The DEA rescheduling of HCPs was associated with a significant decrease in HCP exposures and prescription opioid exposures overall, but was associated with increased fentanyl and heroin exposures. While other initiatives may have contributed to this decrease, our findings suggest that rescheduling may be a useful regulatory strategy to reduce drug exposures.

CONCLUSION

DEA rescheduling of HCPs was associated with a significant reduction in prescription opioid exposures, suggesting that rescheduling high-risk drugs may be an effective strategy to improve public health.

Neonatal Opioid Withdrawal Syndrome (NOWS): A Transgenerational Echo of the Opioid Crisis

The incidence of neonatal opioid withdrawal syndrome (NOWS) has increased substantially in the setting of the opioid epidemic, a major public health problem in the United States. At present, NOWS has commonly used assessment and treatment protocols, but new protocols have questioned old practices. However, because of limited access to opioid use disorder (OUD) treatment and socioeconomic factors, many pregnant (and postpartum) women with OUD do not receive treatment. The pathophysiology of NOWS is not completely understood, although limited research studies have been conducted in humans and animals to better understand its etiology. Moreover, there is evidence that epigenetic and genetic factors play a role in the development of NOWS, but further study is needed. Animal models have suggested that there are deleterious effects of in utero opioid exposure later in life. Clinical research has revealed the harmful long-term sequelae of NOWS, with respect to cognitive function and childhood development. Many psychiatric disorders begin during adolescence, so as infants born with NOWS approach adolescence, additional clinical and molecular studies are warranted to identify biologic and psychosocial risk factors and long-term effects of NOWS. Additionally, access to specialized OUD treatment for pregnant women must be more readily available in the United States, especially in rural areas.

Causes of death among U.S. Veterans with a prior nonfatal opioid overdose

BACKGROUND

For over a decade, there has been a surge in opioid-related morbidity and mortality among Veterans. To better understand the impact of the growing epidemic, it is important to identify the cause-specific mortality rates among Veterans with a prior nonfatal opioid overdose.

METHODS

We followed 8370 Veterans who received medical care for a nonfatal opioid overdose between 2011 through 2015.Mortality records were linked to clinical records from the Veterans Health Administration (VHA). We compared the mortality rates among those with a nonfatal opioid overdose to a 5 % stratified random sample of patients accessing services during the same time period. SMRs were calculated using age-adjusted cause-specific mortality rates for the l U.S. population obtained from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER).

RESULTS

The crude mortality for Veterans with a history of a nonfatal overdose was 370.6 per 10,000 person years. Those with a prior nonfatal overdose had a higher risk of substance-related mortality (aHR [adjusted Hazard Ratio] 5.0), including a higher risk of death from drugs (aHR 6.9) and alcohol (aHR 2.7). Similarly, cause-specific mortalities assessed between Veterans and the U.S. population, SMRs were also highest for deaths associated with substances (114.0).

CONCLUSION

Veterans with a prior nonfatal overdose experienced substantially higher mortality rates compared to other Veterans or the general U.S.

POPULATION

Causes of death related to substance use and mental health were significantly higher than other causes of death, highlighting the importance of integrated treatment and substance use services.

Opioid Management in CKD

Patients with chronic kidney disease (CKD) experience a high pain and symptom burden. Concurrently, opioid prescription and use in patients with CKD continues to increase, leading to concern for opioid-related risks. Nephrologists increasingly face challenging clinical situations requiring further evaluation and treatment of pain, for which opioid use may be indicated. However, nephrologists are not commonly trained in pain management and may find it difficult to compile the necessary information and tools to effectively assess and treat potentially multidimensional pain. In these situations, they may benefit from using an evidence-based stepwise approach proposed in this article. We address current approaches to opioid use for pain management in CKD and offer a stepwise approach to individualized opioid assessment, focusing on kidney-specific concerns. This includes thorough evaluation of the pain experience, opioid use history, and treatment goals. We subsequently discuss considerations when initiating opioid therapy, strategies to reduce opioid-related risks, and recommended best practices for opioid stewardship in CKD. Using this sequential approach to opioid management, nephrologists can thereby gain a broad overview of key patient considerations, the foundation for understanding implications of opioid use, and a patient-tailored plan for opioid therapy.

Cancer pain management in the emergency department: a multicenter prospective observational trial of the Comprehensive Oncologic Emergencies Research Network (CONCERN)

PURPOSE

Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes.

METHODS

We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition.

RESULTS

The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status).

CONCLUSIONS

Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.

The art and science of drug titration

A “one-size-fits-all” approach has been the standard for drug dosing, in particular for agents with a wide therapeutic index. The scientific principles of drug titration, most commonly used for medications with a narrow therapeutic index, are to give the patient adequate and effective treatment, at the lowest dose possible, with the aim of minimizing unnecessary medication use and side effects. The art of drug titration involves the interplay of scientific drug titration principles with the clinical expertise of the healthcare provider, and an individualized, patient-centered partnership between the provider and the patient to review the delicate balance of perceived benefits and risks from both perspectives. Drug titration may occur as up-, down-, or cross-titration depending on whether the goal is to reach or maintain a therapeutic outcome, decrease the risk of adverse effects, or prevent withdrawal/discontinuation syndromes or recurrence of disease. Drug titration introduces additional complexities surrounding the conduct of clinical trials and real-world studies, confounding our understanding of the true effect of medications. In clinical practice, wide variations in titration schedules may exist due to a lack of evidence and consensus on titration approaches that achieve an optimal benefit-harm profile. Further, drug titration may be challenging for patients to follow, resulting in suboptimal adherence and may require increased healthcare-related visits and coordination of care amongst providers. Despite the challenges associated with drug titration, it is a personalized approach to drug dosing that blends science with art, and with supportive real-world outcomes-based evidence, can be effective for optimizing pharmacotherapeutic outcomes and improving drug safety.

Translational value of non-human primates in opioid research

Preclinical opioid research using animal models not only provides mechanistic insights into the modulation of opioid analgesia and its associated side effects, but also validates drug candidates for improved treatment options for opioid use disorder. Non-human primates (NHPs) have served as a surrogate species for humans in opioid research for more than five decades. The translational value of NHP models is supported by the documented species differences between rodents and primates regarding their behavioral and physiological responses to opioid-related ligands and that NHP studies have provided more concordant results with human studies. This review highlights the utilization of NHP models in five aspects of opioid research, i.e., analgesia, abuse liability, respiratory depression, physical dependence, and pruritus. Recent NHP studies have found that (1) mixed mu opioid and nociceptin/orphanin FQ peptide receptor partial agonists appear to be safe, non-addictive analgesics and (2) mu opioid receptor- and mixed opioid receptor subtype-based medications remain the only two classes of drugs that are effective in alleviating opioid-induced adverse effects. Given the recent advances in pharmaceutical sciences and discoveries of novel targets, NHP studies are posed to identify the translational gap and validate therapeutic targets for the treatment of opioid use disorder. Pharmacological studies using NHPs along with multiple outcome measures (e.g., behavior, physiologic function, and neuroimaging) will continue to facilitate the research and development of improved medications to curb the opioid epidemic.

Managing pain in seriously ill patients with substance use disorders

ABSTRACT

Managing pain can be challenging, especially in patients with serious illnesses and a history of substance use disorders. This article discusses the challenges of addressing pain in these patients and offers perspectives regarding their clinical management.

Adolescent Work Values and Drug Use in Adulthood: A Longitudinal Prospective Cohort Study

Background: Personal values have been considered as a predictor of drug use. Methods: We examined the association between work values in adolescence and drug use in adulthood using 23-year longitudinal data from the Youth Development Study. Results: Partial extrinsic and intrinsic work values predicted cannabis use in the past year after adjusting for sociodemographic variables and alcohol and tobacco use at baseline. A part of intrinsic work values was negatively associated with illicit drug use in the past year. Conclusions: The present study suggested that some personal values might influence future drug use. Investigating the association between personal values and subsequent drug use through personal value theory and self-determination theory could help to understand risk and preventive factors in drug use.

Prescription Drug Misuse among African Americans and Afro Caribbeans: Results from the National Survey of American Life

BACKGROUND

The misuse of prescription medications is an understudied topic among the non-Hispanic Black population in the U.S. Even less is known about the prevalence and correlates of misuse among African Americans and Afro-Caribbeans, despite documented differences in their substance use behaviors.

OBJECTIVES

We aimed to examine the prevalence and correlates of lifetime prescription drug misuse among African Americans and Afro Caribbeans using data from the National Survey of American Life.

METHODS

A national household probability sample of non-institutionalized African Americans and Afro Caribbeans from the Collaborative Psychiatric Epidemiology Surveys was used. Pooled and ethnicity-stratified logistic regressions were estimated.

RESULTS

Findings showed no significant differences between African Americans (6.36%) and Afro-Caribbeans (5.71%) in lifetime prescription drug misuse. Several correlates were found to be associated with misuse among only African American or Afro-Caribbean respondents.

CONCLUSIONS

While research has shown prescription drug misuse is an issue among Blacks overall, our results show that the role of ethnicity must not be overlooked, especially when tailoring prevention and intervention programs. Limitations of this study are discussed.

[Therapeutic potentials of safe opioid analgesics targeting nociceptin/orphanin FQ peptide receptor]

After the identification of nociceptin/orphanin FQ (N/OFQ) peptide (NOP) and its cognate receptor, the unique functional profiles of the N/OFQ-NOP receptor system have been uncovered. NOP receptors are distributed in the key regions that regulate pain and reward processing in the central nervous system. In non-human primates (NHPs), activation of the NOP receptor causes antinociception and anti-hypersensitivity via spinal and supraspinal effects. Moreover, activation of the NOP receptor attenuates dopaminergic transmission and potentiates mu-opioid peptide (MOP) receptor-mediated analgesia. Here, we highlight the functional profiles of bifunctional NOP and MOP receptor agonists based on their promising effects for the treatment of pain and drug abuse. Bifunctional NOP/MOP receptor "partial" agonists, such as AT-121, BU08028, and BU10038, exert potent analgesic effects without MOP receptor-related side effects such as abuse liability, respiratory depression, physical dependence, and itching in NHPs. These novel NOP/MOP receptor agonists reduce rewarding and the reinforcing effects of abused drugs. Furthermore, a mixed NOP/opioid receptor "full" agonist, cebranopadol, is undergoing several clinical trials, and the therapeutic advantage of the coactivation of NOP and MOP receptors has also been confirmed in humans. Therefore, this class of drugs that coactivate NOP and MOP receptors proposes a wide therapeutic range with fewer side effects, indicating a greater potential for the development of novel safer opioid analgesics.

Analgesic opioid use disorders in patients with chronic non-cancer pain: A holistic approach for tailored management

Chronic pain is a major public health issue that frequently leads to analgesic opioid prescriptions. These prescriptions could cause addiction issues in high-risk patients with associated comorbidities, especially those of a psychiatric, addictive, and social nature. Pain management in dependent patients is complex and is yet to be established. By combining the views of professionals from various specialties, we conducted an integrative review on this scope. This methodology synthesizes knowledge and results of significant practical studies to provide a narrative overview of the literature. The main results consisted in first proposing definitions that could allow shared vocabulary among health professionals regardless of their specialties. Next, a discussion was conducted around the main strategies for managing prescription opioid dependence, as well as pain in the context of opioid dependence and associated comorbidities. As a conclusion, we proposed to define the contours of holistic management by outlining the main guidelines for creating a multidisciplinary care framework for multi-comorbid patients with chronic pathologies.

A Multidisciplinary Approach to Improve Pain Management and Satisfaction in a Trauma Population

An adult trauma center identified pain management as a potential area for improvement. Pain management is at the height of discussion in medical centers across the United States. The Hospital Consumer Assessment of Healthcare Provider and System (HCAHPS) scores relating to pain management were consistently low (<5th percentile). This project was designed to use a collaborative and systematic approach to pain management to improve HCAHPS pain management scores. This is an evaluation of a quality improvement project using a before-and-after design with historical control. Using HCAHPS data to evaluate patients' pain management perceptions, an integrative three-pronged approach was developed and implemented: (1) development of a trauma nurse leadership program, (2) collaboration with pain management providers, and (3) modifications made to the trauma admission order set. Trauma nurse leaders educated patients and families regarding pain management goals and expectations utilizing a standardized script. HCAHPS survey data obtained before and after the intervention showed a significant improvement in patient satisfaction. HCAHPS scores on the three pain questions prior to intervention in Quarters 2 and 3 (Q2-3) 2017 had a mean of less than the 5th percentile. After intervention, HCAHPS scores on the three pain questions improved to a mean of more than the 60th percentile on Q4 2018. Implementation of a pain management strategy involving a three-pronged approach of a dedicated trauma nurse leadership program, collaboration with a pain management team, and evaluation and modification of a trauma admission order set was associated with an improvement in communication about pain with the trauma patients and HCAHPS pain satisfaction scores.

Medicine misuse: A systematic review and proposed hierarchical terminology

AIMS

Although medicine misuse is a public health issue, it has multiple meanings in the medical literature. This study aimed to characterize, classify and identify the most appropriate definitions of medicine misuse.

METHODS

A systematic review was performed in Medline, ISI Web of Science, SocINDEX, PsycInfo, PsycArticles and Psychological and Behavioral Sciences Collection, using keywords related to "misuse", "appropriateness" and "medicine" between 1 November 2008 and 25 August 2020. Additional searches were conducted in websites of regulatory agencies and public health institutions. Two authors independently selected studies providing both definitions and examples of misuse, while a third resolved disagreements. Definitions were used to propose a hierarchical classification based on initiator, intent, purpose and context of medicine misuse. The study is registered on PROSPERO: CRD42018115789.

RESULTS

Of 3404 identified records, 51 were included. A total of 71 definitions and 74 examples of misuse were retrieved. When the prescriber is initiator and according to intent, potential medicine misuse referred to "intentional or unintentional prescribing not in line with clinical evidence". Based on context, they could prescribe medicines not clinically justified, i.e. overprescribing, or prescribe indicated medicines incorrectly, i.e. misprescribing. Among other groups of definitions, those overlapping with drug abuse or medication use errors were considered out-of-scope.

CONCLUSION

This systematic review provides a comprehensive overview of the terms and definitions used to characterize medicine misuse and could serve as a basis for a terminology that makes clear distinctions between misuse, abuse and errors.

Opioid initiation and injection transition in rural northern New England: A mixed-methods approach

BACKGROUND

In rural northern New England, located in the northeastern United States, the overdose epidemic has accelerated with the introduction of fentanyl. Opioid initiation and transition to opioid injection have been studied in urban settings. Little is known about opioid initiation and transition to injection drug use in rural northern New England.

METHODS

This mixed-methods study characterized opioid use and drug injection in 11 rural counties in Massachusetts, Vermont, and New Hampshire between 2018 and 2019. People who use drugs completed audio computer-assisted self-interview surveys on substance use and risk behaviors (n = 589) and shared personal narratives through in-depth interviews (n = 22). The objective of the current study is to describe initiation of opioid use and drug injection in rural northern New England.

RESULTS

Median age of first injection was 22 years (interquartile range 18-28 years). Key themes from in-depth interviews that led to initiating drug injection included normalization of drug use in families and communities, experiencing trauma, and abrupt discontinuation of an opioid prescription. Other factors that led to a transition to injecting included lower cost, increased effect/ rush, greater availability of heroin/ fentanyl, and faster relief of withdrawal symptoms with injection.

CONCLUSIONS

Trauma, normalization of drug use, over-prescribing of opioids, and abrupt discontinuation challenge people who use drugs in rural northern New England communities. Inadequate opioid tapering may increase transition to non-prescribed drug use. The extent and severity of traumatic experiences described highlights the importance of enhancing trauma-informed care in rural areas.

Sex differences in pregabalin-seeking like behavior in a conditioned place preference paradigm

Substance abuse is a chronic, relapsing disorder characterized by compulsive drug use regardless of negative consequences. Incremental increases in pregabalin abuse have been observed in Saudi Arabia and throughout the world. In previous studies, the potential for pregabalin abuse with escalating doses of the drug (30, 60, 90, and 120 mg/kg) were investigated in male mice. Notably, researchers have argued that women may exhibit a greater tendency to consume drugs without a prescription to alleviate stress and depression. Moreover, female subjects are more prone to impulsivity in drug intake or abuse than their male counterparts. Therefore, in the present study, we compared the potential for pregabalin abuse between male and female mice using a conditioned place preference paradigm. Male and female BALB/c mice were divided into four groups based on the pregabalin dose administered (30, 60, 90, or 120 mg/kg, intraperitoneal). Preference scores were then calculated and compared between male and female mice in each dosage group. Interestingly, preference scores were significantly higher in female mice than in male mice at dosages of 30 and 120 mg/kg. These findings indicate that female mice may be more prone to pregabalin abuse and tolerance than male mice. These results might be helpful to the healthcare providers and policymakers to consider these sex differences in choosing therapeutic plans and consider alternatives to the misused prescription medications.

Attitudes and Knowledge Regarding Pain Management and Addiction in Massachusetts: A Mixed Methods Study on Podiatric Residents

BACKGROUND

The opioid epidemic has hit disastrous levels across the United States. Many attempts have been made to counteract this, including policy changes and modification of provider and patient behavior. The purpose of this study was to understand the current state of podiatric residents' knowledge regarding pain management and addiction.

METHODS

This study used mixed quantitative-qualitative methods. Two focus groups were conducted with two podiatric residency programs to understand current issues and inform the creation of a survey. A 30-question survey was created and peer reviewed to assess general pain management knowledge, levels of confidence in pain management and addiction, and areas for improvement.

RESULTS

Pain management education in podiatry is mainly focused on opioids. These concepts are often taught in a nonstandardized method, which does not often include nonopioid alternatives. Knowledge of risk factors for addiction was lacking, whereas knowledge of behaviors concerning for addiction was more bountiful. Thirty-three surveys were completed of a possible 39. A knowledge score was created from eight survey questions for a total of 10 points, with an average score of 4.61. There was no statistical difference between those with and without a pain management rotation. Nearly all residents felt comfortable managing surgical pain. The residents are "never" or "only occasionally" inquiring about risk factors for addiction. Questions asked also suggest that the residents are not thinking about their role within the opioid epidemic.

CONCLUSIONS

As the opioid epidemic grows, it is imperative to examine the causes and solutions to the problem. Focusing efforts on educating resident physicians is one method to address the issue. The results of this study show that pain management basics need to be reinforced and more time must be spent emphasizing the importance of thorough patient histories and educating patients when prescribing pain medication.

Tapentadol, the new kid on the block in India: Is it time to worry?

BACKGROUND AND OBJECTIVES

Large-scale prospective case series of tapentadol abuse or dependence in India is not available. Hence, we aimed to study the prevalence and profile of tapentadol users in a treatment-seeking population.

MATERIALS AND METHODS

The study had prospective and retrospective arms. We collected 8-month prospective data by face-to-face interviews (n = 70) and 8-year retrospective data from case notes (n = 26) with either tapentadol misuse/abuse or dependence in patients attending a de-addiction center.

RESULTS

The prevalence of tapentadol abuse or dependence was 25% among the pharmaceutical opioid users. Concurrent use of other opioids was seen in >80% of participants of both the arms. Major sources of tapentadol were chemists (without a prescription) (53%) and doctors (prescriptions) (40%). Patients in the tapentadol dependence group had a significantly higher dose, duration, and pharmaceutical opioid use.

CONCLUSION

India needs awareness promotion, training, availability restriction, and provision of treatment for tapentadol abuse or dependence.

Non-Opioid Treatments for Opioid Use Disorder: Rationales and Data to Date

Opioid use disorder (OUD) represents a major public health problem that affects millions of people in the USA and worldwide. The relapsing and recurring aspect of OUD, driven by lasting neurobiological adaptations at different reward centres in the brain, represents a major obstacle towards successful long-term remission from opioid use. Currently, three drugs that modulate the function of the opioidergic receptors, methadone, buprenorphine and naltrexone have been approved by the US Food and Drug Administration (FDA) to treat OUD. In this review, we discuss the limitations and challenges associated with the current maintenance and medication-assisted withdrawal strategies commonly used to treat OUD. We further explore the involvement of glutamatergic, endocannabinoid and orexin signaling systems in the development, maintenance and expression of addiction-like behaviours in animal models of opioid addiction, and as potential and novel targets to expand therapeutic options to treat OUD. Despite a growing preclinical literature highlighting the role of these potential targets in animal models of opioid addiction, clinical and translational studies for novel treatments of OUD remain limited and inconclusive. Further preclinical and clinical investigations are needed to expand the arsenal of primary treatment options and adjuncts to maximise efficacy and prevent relapse.

COVID-19 and People Who Use Drugs - A Commentary

OBJECTIVE

People who use drugs (PWUD) face increased risk of exposure to COVID-19, but also elevated risk associated from injection drug use. We describe factors underlying their increased risk and identify mechanisms for reducing or minimizing rates of COVID-19 transmission and other health outcomes.

METHODS

Our commentary draws upon empirical data, governmental and other reports, and field-based unpublished data from our own studies to inform our conclusion and recommendations.

RESULTS

Co-morbid health conditions (eg, diabetes), structural challenges (eg, homelessness, criminal justice involvement), stigma (eg, social devaluation, discrediting), and syndemic clustering of of overdose, HCV, and HIV among PWUD are exacerbated by COVID-19.

CONCLUSIONS

Beyond the many challenges all people face to remain safe and healthy during the COVID-19 pandemic, PWUD face additional barriers to remaining safe not only from COVID-19 but from negative health outcomes associated with their living environments, socioeconomic positions, and injection drug use. Collaborative efforts among governmental agencies, health providers, SSPs, CBOs, and other agencies providing services to PWUD is essential to the development of programs and services to meet the many needs of PWUD, which have been particularly accentuated during the COVID-19 pandemic.

Assessment of Probable Opioid Use Disorder Using Electronic Health Record Documentation

IMPORTANCE

Electronic health records are a potentially valuable source of information for identifying patients with opioid use disorder (OUD).

OBJECTIVE

To evaluate whether proxy measures from electronic health record data can be used reliably to identify patients with probable OUD based on Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study analyzed individuals within the Geisinger health system who were prescribed opioids between December 31, 2000, and May 31, 2017, using a mixed-methods approach. The cohort was identified from 16 253 patients enrolled in a contract-based, Geisinger-specific medication monitoring program (GMMP) for opioid use, including patients who maintained or violated contract terms, as well as a demographically matched control group of 16 253 patients who were prescribed opioids but not enrolled in the GMMP. Substance use diagnoses and psychiatric comorbidities were assessed using automated electronic health record summaries. A manual medical record review procedure using DSM-5 criteria for OUD was completed for a subset of patients. The analysis was conducted beginning from June 5, 2017, until May 29, 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome was the prevalence of OUD as defined by proxy measures for DSM-5 criteria for OUD as well as the prevalence of comorbidities among patients prescribed opioids within an integrated health system.

RESULTS

Among the 16 253 patients enrolled in the GMMP (9309 women [57%]; mean [SD] age, 52 [14] years), OUD diagnoses as defined by diagnostic codes were present at a much lower rate than expected (291 [2%]), indicating the necessity for alternative diagnostic strategies. The DSM-5 criteria for OUD can be assessed using manual medical record review; a manual review of 200 patients in the GMMP and 200 control patients identifed a larger percentage of patients with probable moderate to severe OUD (GMMP, 145 of 200 [73%]; and control, 27 of 200 [14%]) compared with the prevalence of OUD assessed using diagnostic codes.

CONCLUSIONS AND RELEVANCE

These results suggest that patients with OUD may be identified using information available in the electronic health record, even when diagnostic codes do not reflect this diagnosis. Furthermore, the study demonstrates the utility of coding for DSM-5 criteria from medical records to generate a quantitative DSM-5 score that is associated with OUD severity.

Opioid Use in Athletes: A Systematic Review

CONTEXT

The opioid epidemic has been well-documented in the general population, but the literature pertaining to opioid use and misuse in the athletic population remains limited.

OBJECTIVES

The objectives of this study were to seek answers to the following questions: (1) what are the rates of opioid use and misuse among athletes, (2) do these rates differ compared with the nonathletic population, and (3) are there specific subgroups of the athletic population (eg, based on sport, level of play) who may be at higher risk?

DATA SOURCES

The Embase, MEDLINE, and PubMed were used for the literature search.

STUDY SELECTION

Records were screened in duplicate for studies reporting rates of opioid use among athletes. All study designs were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Data regarding rates of opioid use, medication types, prescription patterns, and predictors of future opioid use were collected. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria for clinical studies and 5 key domains previously identified for survey studies.

RESULTS

A total of 11 studies were eligible for inclusion (N = 226,256 athletes). Studies included survey studies and retrospective observational designs. Opioid use among professional athletes at any given time, as reported in 2 different studies, ranged from 4.4% to 4.7%, while opioid use over a National Football League career was 52%. High school athletes had lifetime opioid use rates of 28% to 46%. Risk factors associated with opioid use included Caucasian race, contact sports (hockey, football, wrestling), postretirement unemployment, and undiagnosed concussion. Use of opioids while playing predicted use of opioids in retirement.

CONCLUSION

Overall, opioid use is prevalent among athletes, and use during a playing career predicts postretirement use. This issue exists even at the high school level, with similar rates to professional athletes. Further higher quality observational studies are needed to better define patterns of opioid use in athletes.

Development of Conformationally Constrained α-RgIA Analogues as Stable Peptide Antagonists of Human α9α10 Nicotinic Acetylcholine Receptors

Non-opioid therapeutics for the treatment of neuropathic pain are urgently needed to address the ongoing opioid crisis. Peptides from cone snail venoms have served as invaluable molecules to target key pain-related receptors but can suffer from unfavorable physicochemical properties, which limit their therapeutic potential. In this work, we developed conformationally constrained α-RgIA analogues with high potency, receptor selectivity, and enhanced human serum stability to target the human α9α10 nicotinic acetylcholine receptor. The key lactam linkage introduced in α-RgIA fixed the favored globular conformation and suppressed disulfide scrambling. The NMR structure of the macrocyclic peptide overlays well with that of α-RgIA4, demonstrating that the cyclization does not perturb the overall conformation of backbone and key side-chain residues. Finally, a molecular docking model was used to rationalize the selective binding between a macrocyclic analogue and the α9α10 nicotinic acetylcholine receptor. These conformationally constrained antagonists are therefore promising candidates for antinociceptive therapeutic intervention.

Pain and Opioid Analgesic Use After Otorhinolaryngologic Surgery

Objective

To quantify pain and opioid use after otorhinolaryngologic surgery. To determine the effect of patient and surgical factors on primary outcomes.

Study Design

Prospective cohort.

Setting

Tertiary academic hospital.

Subjects and Methods

Patients undergoing elective otorhinolaryngologic surgery were prospectively enrolled. Patients completed demographic surveys and psychometric questionnaires assessing attitudes toward pain and baseline anxiety and depression before surgery. After surgery, patients documented peak pain levels (0-100 mm, visual analog scale) and daily prescription and nonprescription analgesic requirements over a 2-week period. Average daily and cumulative pain and opioid use were calculated and compared among patient cohorts stratified by procedure and preoperative factors.

Results

A total of 134 patients were enrolled. Total tonsillectomy was associated with significantly higher pain scores and opioid consumption, as compared to all other procedures. There was moderate correlation between average cumulative pain and opioid use. Older patients required significantly fewer doses of opioids. There was no effect of sex, marital status, or education level on postoperative pain or opioid use. Psychometric instrument scores and chronic pain or analgesic use were not associated with significant differences in pain or opioid requirements. Most patients were prescribed substantially more opioids than they actually required.

Conclusion

Postoperative pain following elective otorhinolaryngologic surgery decreases dramatically within the first week and requires only few days of opioid analgesia, with the exception of tonsillectomy. Almost all patients required fewer than 15 doses of opioids.

Prevalence and Health Characteristics of Prescription Opioid Use, Misuse, and Use Disorders Among U.S. Adolescents

PURPOSE

The prevalence of past-year prescription opioid use (POU), nonmedical POU (NMPOU), and POU disorder (POUD) and their correlates were examined in a national sample of American adolescents (N = 41,579).

METHODS

This study used data from the public-use files of the 2015, 2016, and 2017 National Surveys on Drug Use and Health, which captured substance use and mental health problems among noninstitutionalized individuals. Prevalence and specific types of prescription opioids and other substances used and misused in the past year were examined among adolescents. Logistic regression analyses were conducted to determine correlates (demographics, other substances used, past-year major depressive episode, school enrollment, two-parent household, number of lifetime medical conditions, and survey year) of POU, NMPOU, and POUD.

RESULTS

Multiple substance use was common within the past year. The most frequently used prescription opioids were hydrocodone, codeine, oxycodone, and other opioids among adolescents. Cannabis use disorder and alcohol use disorder were comparatively prevalent among opioid misusers. Several correlates (demographics, other substances used, lifetime medical conditions, major depressive episode, and survey year) of POU, NMPOU, and POUD were found.

CONCLUSIONS

In this national sample, multiple substance use was common among adolescents with past-year POU and NMPOU. Clinical screening for opioid use problems, assessment, and treatment expansion for POUD can focus on persons with substance use, mental health, and/or behavioral problems. Longitudinal studies are needed to better elucidate temporal associations between POU and NMPOU/POUD among adolescents, and more prevention and treatment research on rural residents and minority groups is needed.

Contextual risk among adolescents receiving opioid prescriptions for acute pain in pediatric ambulatory care settings

Many adults with opioid use disorder (OUD) report that their first exposure to opioids was in the course of routine pain treatment in medical care settings. Adolescents receive opioid prescriptions with frequency, but are susceptible to a constellation of unique risks in the context of pain management. This empirical study presents the first cohort of adolescents recruited from ambulatory medical care within 72 h of their receipt of opioids to treat acute pain. The primary aim was to capture a time-sensitive report of the intersection of prescription opioid receipt and contextual risks for opioid misuse related to pain experience, mental health symptoms, and substance use at the adolescent and parental levels. Data were collected from 70 14-19-year-old adolescents and their accompanying parent. Results reflected that 90% of this sample of adolescents reported 2 or more risks and 35% reported 5 or more risks for future opioid misuse. Pain catastrophizing (46%) and alcohol use (40%) and were the most common adolescent-level risk factors; mother history of chronic pain (32%) and parent anxiety (21%) were the most common parent-level risk factors. Past-week parent pain intensity showed the strongest association with adolescent past-week pain intensity; neither was associated with adolescent OUD symptoms. Adolescent pain catastrophizing most reliably predicted OUD symptoms; parent pain interference was also associated. Seventy-one percent of parents reported keeping opioids at home, a relevant risk factor for future misuse. These findings illuminate the intersection between adolescent and parental risks in the context of pediatric opioid prescribing for acute pain management, and provide initial insight into potential points of prevention early in adolescent pain treatment, including avenues by which to inform and enhance prescriber decision-making regarding factors to be weighed in adolescent candidacy for opioid therapy.

Therapeutic potentials of NOP and MOP receptor coactivation for the treatment of pain and opioid abuse

Following the identification of the nociceptin/orphanin FQ (N/OFQ) peptide (NOP) as an endogenous ligand for the NOP receptor, ample evidence has revealed unique functional profiles of the N/OFQ-NOP receptor system. NOP receptors are expressed in key neural substrates involved in pain and reward modulation. In nonhuman primates (NHPs), NOP receptor activation effectively exerts antinociception and anti-hypersensitivity at the spinal and supraspinal levels. Moreover, NOP receptor activation inhibits dopaminergic transmission and synergistically enhances mu-opioid peptide (MOP) receptor-mediated analgesia. In this article, we have discussed the functional profiles of ligands with dual NOP and MOP receptor agonist activities and highlight their optimal functional efficacy for pain relief and drug abuse treatment. Through coactivation of NOP and MOP receptors, bifunctional NOP/MOP receptor "partial" agonists (e.g., AT-121, BU08028, and BU10038) reveal a wider therapeutic window with fewer side effects. These newly developed ligands potently induce antinociception without MOP receptor agonist-associated side effects such as abuse potential, respiratory depression, itching sensation, and physical dependence. In addition, in both rodent and NHP models, bifunctional NOP/MOP receptor agonists can attenuate reward processing and/or the reinforcing effects of opioids and other abused drugs. While a mixed NOP/opioid receptor "full" agonist cebranopadol is undergoing clinical trials, bifunctional NOP/MOP "partial" agonists exhibit promising therapeutic profiles in translational NHP models for the treatment of pain and opioid abuse. This class of drugs demonstrates the therapeutic advantage of NOP and MOP receptor coactivation, indicating a greater potential for future development.

Responses among substance abuse treatment providers to the opioid epidemic in the USA: Variations in buprenorphine and methadone treatment by geography, operational, and payment characteristics, 2007-16

Objective

To identify the geographic, organisational, and payment correlates of buprenorphine and methadone treatment among substance abuse treatment (SAT) providers.

Methods

Secondary analyses of the National Survey of Substance Abuse Treatment Services (NSSATS) from 2007–16 were conducted. We provide bivariate descriptive statistics regarding substance abuse treatment services which offered buprenorphine and methadone treatment from 2007–16. Using multiple logistic regression, we regressed geographic, organisational, and payment correlates on buprenorphine and methadone treatment.

Results

Buprenorphine is increasingly offered at SAT facilities though uptake remains comparatively low outside of the northeast. SAT facilities run by tribal governments or Indian Health Service which offer buprenorphine remain low compared to privately operated SAT facilities (AOR = 0.528). The odds of offering buprenorphine among facilities offering free or no charge treatment (AOR = 0.838) or a sliding fee scale (AOR = 0.464) was lower. SAT facilities accepting Medicaid payments showed higher odds of offering methadone treatment (AOR = 2.035).

Conclusions

Greater attention towards the disparities in provision of opioid agonist therapies is warranted, especially towards the reasons why uptake has been moderate among civilian providers. Additionally, the care needs of Native Americans facing opioid-related use disorders bears further scrutiny.

Therapy without a prescription: buprenorphine/naloxone diversion and the therapeutic assemblage in Taiwan

Buprenorphine/naloxone (B/N) therapy is a prescription pharmacotherapy for opioid dependence. For certain health service providers, when B/N escapes supervision and diverts into the hands of people for whom it is unintended, it can pose serious risks even if it may still have therapeutic benefits. The line between therapy and diversion is thus a problematic one. By qualitatively analysing archival review and in-depth interviews, this study uses the concept of a therapeutic assemblage to understand the relationships among government, knowledge, and professionals that surround the regulation of B/N in Taiwan. The therapeutic assemblage is characterised by the partitioning of administration, the loose regulation of prescription, the exclusion of addiction treatment from National Health Insurance (NHI), and the materiality and technicality of therapies. These elements contribute to the therapeutic assemblage's different territorial modes as reflected in the substance schedules that allow for diversion. This is the first grounded work in Asia that empirically examines and theoretically explains the diversion of B/N from an assemblage perspective. It suggests establishing new associations by incorporating addiction treatment into NHI. Lastly, it addresses the analytic purchase of the assemblage approach in unveiling and problematising unintended outcomes of an intervention.

Patterns of Prescription Opioid Use in Women With Endometriosis: Evaluating Prolonged Use, Daily Dose, and Concomitant Use With Benzodiazepines

OBJECTIVE

To examine opioid use, opioid prescribing patterns, and timing of the first opioid prescription in endometriosis patients compared with matched women in the control group without endometriosis.

METHODS

We conducted a retrospective analysis of the Clinformatics Datamart database. Women diagnosed with endometriosis from January 2006 through December 2016 and aged 18-49 years were compared with women in the control group matched on age, region, race, insurance payer, and plan type. Key outcomes included: filled prescription for an opioid, multiple opioid prescriptions, number of days' supply, daily dose (morphine milligram equivalents), and concomitant opioid and benzodiazepine prescriptions. Cohorts were descriptively analyzed using t- and χ statistics and multivariable regression analyses yielded adjusted relative risk (RR) ratios and 95% CI.

RESULTS

The study sample included 53,847 endometriosis patients and 107,694 patients in the control group. The mean age was 38 years, 62.4% of patients were white, and 51.6% lived in the South. Women in the endometriosis case group, compared with women in the control group, were more likely to fill an opioid prescription (42,705 [79.3%] women in the case group vs 26,106 [24.2%] women in the control group; adjusted RR ratio 2.91; 2.87-2.94), had higher likelihood of filling prescriptions with a dose of 50 morphine milligram equivalents or more (24,544 [45.6%] vs 10,463 [9.7%]; adjusted RR ratio 4.07; 3.98-4.16) or 100 morphine milligram equivalents or more (8,013 [14.9%] vs 3,582 [3.3%]; adjusted RR ratio 3.56; 3.43-3.70). Women in the case group were more likely to have concomitant opioid and benzodiazepine prescriptions (5,453 [10.1%] vs 3,711 [3.5%]; adjusted RR ratio 1.95; 1.88-2.03) and to have used these drugs concurrently for at least 30 days (1,596 [3.0%] vs 1,265 [1.2%]; adjusted RR ratio 1.43; 1.34-1.52) or at least 90 days (875 [1.6%] vs 777 [0.7%]; adjusted RR ratio 1.27; 1.17-1.37). Similar results were obtained after excluding opioid prescriptions received during a 30-day postsurgery window.

CONCLUSION

Women with endometriosis had higher probabilities of prolonged use of opioids and concomitant use with benzodiazepines compared with women without this condition.

FUNDING SOURCE

This study was funded by AbbVie, Inc.

The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review

(Reprinted with permission from Am J Psychiatry 2017;174:738-747).

Risk factors for opioid use after total shoulder arthroplasty

HYPOTHESIS

The purpose was to assess opioid use before and after anatomic and reverse total shoulder arthroplasty (TSA) and determine patient factors associated with prolonged postoperative opioid use.

METHODS

Patients undergoing primary TSA (anatomic or reverse) were identified within the Humana database from 2007 to 2015. Patients were categorized as opioid-naive patients who did not fill a prescription prior to surgery or those who filled opioid prescriptions within 3 months preoperatively (OU); the OU cohort was subdivided into those filling opioid prescriptions within 1 month preoperatively and those filling opioid prescriptions between 1 and 3 months preoperatively. The incidence of opioid use was evaluated preoperatively and longitudinally tracked for each cohort. Multivariate analysis was used to identify factors associated with opioid use at 12 months after surgery, with statistical significance defined as P < .05.

RESULTS

Overall, 12,038 patients (5180 in OU cohort, 43%) underwent primary TSA during the study period. Opioid use declined after the first postoperative month; however, the incidence of opioid use was significantly higher in the OU cohort than in the opioid-naive cohort at 1 year (31.4% vs. 3.1%, P < .0001). Subgroup analysis revealed a similar decline in postoperative opioid use for anatomic and reverse TSA (P < .0001 for both). Multivariate analysis identified chronic preoperative opioid use (ie, filling an opioid prescription between 1 and 3 months prior to surgery) as the strongest risk factor for opioid use at 12 months after anatomic and reverse TSA (P < .0001).

CONCLUSION

More than 40% of patients undergoing TSA received opioid medications within 3 months before surgery. Preoperative opioid use, age younger than 65 years, and fibromyalgia were independent risk factors for opioid use 1 year following anatomic and reverse TSA. Chronic preoperative opioid use conferred the highest risk of prolonged postoperative opioid use.

Negative Affect-Related Factors Have the Strongest Association with Prescription Opioid Misuse in a Cross-Sectional Cohort of Patients with Chronic Pain

OBJECTIVE

Increased opioid prescription to relieve pain among patients with chronic pain is associated with increased risk for misuse, potentially leading to substance use disorders and overdose death. We aimed to characterize the relative importance and identify the most significant of several potential risk factors for the severity of self-reported prescribed opioid misuse behaviors.

METHODS

A sample of 1,193 patients (mean age ± SD = 50.72 ± 14.97 years, 64.04% female) with various chronic pain conditions completed a multidimensional registry assessing four pain severity measures and 14 physical, mental, and social health status factors using the National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS). A validated PROMIS measure of medication misuse was completed by 692 patients who endorsed currently taking opioid medication. Patients taking opioid medications were compared across all measures with those who do not take opioid medications. Subsequently, a data-driven regression analysis was used to determine which measures best explained variability in severity of misuse. We hypothesized that negative affect-related factors, namely anxiety, anger, and/or depression, would be key predictors of misuse severity due to their crucial role in chronic pain and substance use disorders.

RESULTS

Patients taking opioid medications had significantly greater impairment across most measures. Above and beyond demographic variables, the only and most significant predictors of prescribed opioid misuse severity were as follows: anxiety (β = 0.15, P = 0.01), anger (β = 0.13, P = 0.02), Pain Intensity-worst (β = 0.09, P = 0.02), and depression (β = 0.13, P = 0.04).

CONCLUSIONS

Findings suggest that anxiety, anger, and depression are key factors associated with prescribed opioid misuse tendencies in patients with chronic pain and that they are potential targets for therapeutic intervention.

Risk Factors for Opioid Use After Patellofemoral Stabilization Surgery: A Population-Based Study of 1,316 Cases

BACKGROUND

Orthopaedic surgeons remain the third-highest group of opioid prescribers among physicians in the United States, accounting for 8% of all opioid prescriptions. The purpose of this study was to identify risk factors for opioid consumption and opioid prescription refills after patellofemoral stabilization surgery. We hypothesized that preoperative opioid use and younger age would be independent risk factors for postoperative opioid use.

METHODS

Patients undergoing primary patellar stabilization surgery between 2007-2017 in the Humana Inc. administrative claims database were identified using Current Procedural Terminology (CPT) codes for patellofemoral stabilization procedures (CPT-27420, 27422, 27427,27418). Patients were categorized into opioid naive (N-OU) and those who filled opioid prescriptions within 3 months prior to surgery (OU). Patients in the OU cohort were further categorized into those who filled prescriptions at 1-3 months before surgery (C-OU) and those who filled opioid prescriptions only in the month preceding surgery (A-OU). Descriptive statistics and multivariate analyses were performed to identify risk factors for postoperative opioid use at 3 and 12 months using the open-source R software (www.r-project.org) housed within PearlDiver.

RESULTS

A total of 1,316 eligible patients were included. One year postoperatively, there was a greater risk of opioid consumption in the OU cohort (OU vs N-OU: 22.2% vs 4.1%; Relative Risk [RR]: 1.233; 95% CI: 1.172- 1.298; P< 0.0001). C-OU (OR: 5.74; 95% CI: 3.75- 8.9; P< 0.0001), obesity (OR: 1.76; 95% CI: 1.14- 2.69; P = 0.0099), and preoperative diagnosis of depression or anxiety (OR: 1.83; 95% CI: 1.01- 3.25; P = 0.0435) were independent risk factors for opioid use at 12 months postoperatively. Younger age (age <30) was associated witha lower risk of opioid use at 3 months (OR: 0.3, 95% CI: 0.21- 0.44; P< 0.0001) and 12 months (OR: 0.29; 95% CI: 0.17- 0.46; P< 0.0001) postoperatively.

CONCLUSIONS

Preoperative opioid utilization significantly increased opioid prescription filling following patellofemoral stabilization surgery. Patient-specific variables including obesity and preoperatively diagnosed depression or anxiety also increased the risk of postoperative opioid utilization. Given the relatively young age and high activity level of patients undergoing patellofemoral stabilization surgery, heightened awareness of patient-specific factors must be considered when selecting appropriate pain management regimens postoperatively.Level of Evidence: III.

The Trends in Opioid Use in Castile and Leon, Spain: A Population-Based Registry Analysis of Dispensations in 2015 to 2018

Opioids are driving-impairing medicines (DIM). To assess the evolution and trends of opioid analgesics use between 2015 and 2018 in Castile and Leon (Spain), a population-based registry study was conceived. The length of opioid use and its concomitant use with other DIMs were studied. Analyses were done considering age and gender distributions. Adjusted consumption for licensed drivers is also presented. Of the 5 million dispensations recorded between 2015 and 2018, opioid analgesics were dispensed to 11.44% of the general population and 8.72% of vehicle drivers. Increases among daily users (2.6 times higher) and chronic users (1.5% higher) were noted, supporting the overall increase in opioid use (1.5%). The use of multiple drugs including other DIMs was a common finding (mean ± SD, 2.54 ± 0.01). Acute use (5.26%) and chronic use (3.20%) were also frequent. Formulations combining opioid analgesics with nonopioid analgesics were preferred. The use of opioids increased in Spain between 2015 and 2018. Concomitant use with other DIMS especially affects women and the elderly. Frequent use of opioid analgesics with other DIMs is a serious problem for drivers and increases the risk of accidents. Promoting safe driving should be a main objective of health authorities, to be achieved by developing and implementing educational activities for healthcare professionals and patients.

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.

Psychiatric comorbidity and co-occurring opioid misuse: Depression mediates the relationship between post-traumatic stress disorder and opioid misuse in community pharmacy settings

AbstractsBackground: Individuals who misuse opioids frequently have comorbid psychiatric issues, including post-traumatic stress disorder (PTSD) and depression. However, little is known about the mechanisms by which these disorders are associated with opioid misuse and specifically in community pharmacy settings. The current study examined whether depression mediated the relationship between PTSD and opioid misuse in patients filling opioid prescriptions. Methods: We administered a health survey in four community pharmacies among patients filling opioid medications in southwestern Pennsylvania. Univariate statistics were used to assess relationships among demographic and clinical characteristics of PTSD, depression, and opioid misuse behaviors. We then examined whether depression mediated the relationship between PTSD and opioid misuse using ordinary least squares path analysis with bootstrapping. Results: A total of 333 participants completed the health survey. Opioid misuse was reported among 15.9% of all participants, 33.3% among those with a positive PTSD screen, and 29.3% of those who screened positive for depression. Depression significantly mediated the relationship between PTSD and opioid misuse. Specifically, there was a statistically significant indirect effect (ab) of PTSD on opioid misuse through a pathway mediated by depression (ab = .06, SE_ab = .02, 95% CI = .02-.10). The direct effect (c') of PTSD on opioid misuse was also significant (c' = .12, SE_c' = .05, P = .01, 95% CI = .03-.22), suggesting partial mediation. Conclusions: Results suggest an indirect pathway by which clinical intervention may help ameliorate outcomes in patients with PTSD. Further, there is an increased need for screening, assessment, and intervention protocols for this patient population in which community pharmacy is a novel setting to expand future efforts within the patient population.

Current status of opioid addiction treatment and related preclinical research

Opioid use disorders (OUDs) are diseases of the brain with behavioral, psychological, neurobiological, and medical manifestations. Vulnerability to OUDs can be affected by factors such as genetic background, environment, stress, and prolonged exposure to μ-opioid agonists for analgesia. Two standard-of-care maintenance medications, methadone and buprenorphine-naloxone, have a long-term positive influence on health of persons with opioid addiction. Buprenorphine and another medication, naltrexone, have also been approved for administration as monthly depot injections. However, neither medication is used as widely as needed, due largely to stigma, insufficient medical education or training, inadequate resources, and inadequate access to treatment. Ongoing directions in the field include (i) personalized approaches leveraging genetic factors for prediction of OUD vulnerability and prognosis, or for targeted pharmacotherapy, and (ii) development of novel analgesic medicines with new neurobiological targets with reduced abuse potential, reduced toxicity, and improved effectiveness, especially for chronic pain states other than cancer pain.

A Latent Spatial Factor Approach for Synthesizing Opioid-Associated Deaths and Treatment Admissions in Ohio Counties

BACKGROUND

Opioid misuse is a major public health issue in the United States and in particular the state of Ohio. However, the burden of the epidemic is challenging to quantify as public health surveillance measures capture different aspects of the problem. Here, we synthesize county-level death and treatment counts to compare the relative burden across counties and assess associations with social environmental covariates.

METHODS

We construct a generalized spatial factor model to jointly model death and treatment rates for each county. For each outcome, we specify a spatial rates parameterization for a Poisson regression model with spatially varying factor loadings. We use a conditional autoregressive model to account for spatial dependence within a Bayesian framework.

RESULTS

The estimated spatial factor was highest in the southern and southwestern counties of the state, representing a higher burden of the opioid epidemic. We found that relatively high rates of treatment contributed to the factor in the southern part of the state, whereas relatively higher rates of death contributed in the southwest. The estimated factor was also positively associated with the proportion of residents 18-64 years of age on disability and negatively associated with the proportion of residents reporting white race.

CONCLUSIONS

We synthesized the information in the opioid-associated death and treatment counts through a spatial factor model to estimate a latent factor representing the consensus between the two surveillance measures. We believe this framework provides a coherent approach to describe the epidemic while leveraging information from multiple surveillance measures.

Evidence for Misspecification of a Nationally Used Quality Measure for Substance Use Treatment

OBJECTIVES

The National Committee for Quality Assurance's (NCQA) measure "Initiation and Engagement of Alcohol and Other Drug Dependence Treatment" captures the proportion of substance use patients with (1) treatment initiation within 14 days and (2) treatment engagement within 30 days thereafter. The definition of treatment considers only counseling but not medication-assisted treatment (MAT), although MAT is supported by current guidelines. Our research question is whether this omission results in meaningful measurement error.

STUDY DESIGN AND METHODS

We analyze claims data for members of commercial health plans to investigate whether including MAT would meaningfully change the measure rate and health plan rankings.

RESULTS

Including MAT increased both the initiation and engagement rates. The initiation and engagement rates increased 2.4% (38.9-39.8%) and 9.9% (12.9-14%), respectively. These differences imply that 19% of health plans would change their ranking by at least one quintile for the initiation measure and 27% for the engagement measure.

CONCLUSIONS

The current specifications result in erroneous conclusions about the quality of care provided by different health plans. Our results suggest that aligning the measure specifications with guideline recommendations, as recently proposed by NCQA, would result in more accurate information.

Provider-patient communication about prescription drug abuse: A qualitative analysis of the perspective of prescribers

Background: Provider-patient communication underpins many initiatives aimed at reducing the public health burden associated with prescription drug abuse in the United States. The purpose of this qualitative analysis was to examine the characteristics of provider-patient communication about prescription drug abuse from the perspective of prescribers. Methods: From 2014 to 2015, 10 semi-structured interviews were conducted with a purposive sample of prescribers from multiple professions and medical fields in Central and South Central Appalachia. The interviews were conducted using a guide informed by Social Cognitive Theory and community theory research, audio-recorded, and transcribed verbatim. Thematic analysis, facilitated by NVivo 10 software, was used to generate themes. Results: Prescribers described 3 primary communication patterns with patients related to prescription drug abuse-informative, counteractive, and supportive. Prescribers also reported multiple factors-personal (e.g., education, experiences, and feelings of tension) and environmental (e.g., relationship with a patient, clinical resources, and policies on controlled prescription drugs)-that affect provider-patient communication and, by association, delivery of patient care related to prescription drug abuse. Conclusions: The findings suggest that provider-patient communication about prescription drug abuse is multidimensional and dynamic, characterized by multiple communication patterns and contributory factors. They have implications for (1) research aimed at advancing theoretical understanding of prescriber prescription drug abuse communication behaviors with patients and (2) interventions aimed at strengthening prescriber prescription drug abuse communication behaviors with patients.

Opioid Epidemic in the United States: Empirical Trends, and A Literature Review of Social Determinants and Epidemiological, Pain Management, and Treatment Patterns

OBJECTIVES

Dramatic increases in opioid and drug overdose mortality have occurred in the United States (US) over the past two decades. To address this national public health crisis and identify gaps in the literature, we analyzed recent empirical trends in US drug overdose mortality by key social determinants and conducted a selective review of the recent literature on the magnitude of the opioid crisis facing different racial/ethnic, socioeconomic, and rural-urban segments of the US population.

METHODS

We used the 1999-2017 mortality data from the US National Vital Statistics System to analyze trends in drug overdose mortality by race/ethnicity, age, and geographic area. Log-linear regression was used to model mortality trends. Using various key words and their combinations, we searched PubMed and Google Scholar for select peer-reviewed journal articles and government reports published on the opioid epidemic between 2010 and 2018.

RESULTS

Our original analysis and review indicate marked increases in drug overdose mortality overall and by race/ethnicity and geographic regions, with adolescents and young adults experiencing steep increases in mortality between 1999 and 2017. Our selective search yielded 405 articles, of which 39 publications were selected for detailed review. Suicide mortality from drug overdose among teens aged 12-19 increased consistently between 2009 and 2017, particularly among teen girls. The rise of efficient global supply chains has increased opioid prescription use and undoubtedly contributed to the opioid epidemic. Many other important contributing factors to the epidemic include lack of education and economic opportunities, poor working conditions, and low social capital in disadvantaged communities.

CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS

Our analysis and review indicate substantial disparities in drug overdoses and related mortality, pain management, and treatment outcomes according to social determinants. Increases in drug overdoses and resultant mortality are not only unique to the US, but have also been observed in other industrialized countries. Healthcare systems, community leaders, and policymakers addressing the opioid epidemic should focus on upstream structural factors including education, economic opportunity, social cohesion, racial/ethnic disadvantage, geographic isolation, and life satisfaction.

Does Osteopathic Manipulative Treatment Make a Neuropsychological Difference in Adults With Pain? A Rationale for a New Approach

Cognitive impairment is common in patients with pain. While symptoms of pain are effectively treated with osteopathic manipulative treatment (OMT), the cognitive complaint is vastly ignored. Pain-induced cognitive dysfunction can be severe and is particularly apparent in working memory and attention. There is good reason to expect cognitive responsiveness to OMT. Previous research has reported the effects of OMT on related psychiatric outcomes, including relief from depression and anxiety, suggesting that OMT may produce more cortical benefits than is currently thought. The rationale to link OMT to cognition comes from the tenets of osteopathic medicine: body unity, homeostasis, and the structure-function relationship. The present article provides background evidence to support the hypothetical link between OMT and cognitive benefits and proposes a physiological mechanism of how OMT could exert its effect on cognition. Research strategies are discussed to test the hypotheses that are generated from the proposed theoretical framework.

Prescription drug misuse in adolescents and young adults: an emerging issue as a health problem

INTRODUCTION

In recent years, prescription drug misuse has become a common issue among adolescents and young adults in many countries, with, for example, a lifetime prevalence of 12% among individuals aged 12-17 in 2017 in United States.

PURPOSE OF REVIEW

To summarize recently published studies about prescription drug misuse among adolescent and young adults.

RECENT FINDINGS

Prescription drug misuse has many definitions, one being any medication taken in a way other than prescribed, whether related to dosage or manner of usage. Among adolescents, it has a relationship with illicit drug use, decline in academic performance, future delinquency, and mental problems. Individual predisposing factors include identity crisis and role confusion, and there are also environmental influences. Preventive approaches include the use of monitoring systems. Management involves initial assessment and treatment, which largely focuses on behavioural interventions.

SUMMARY

Further understanding of risk and protective factors, co-occurring issues, and treatment can help prevent and reduce the prevalence of prescription drug misuse. Collaboration among government, clinicians, and patients is urged to combat this growing issue.