A Public Health Strategy for the Opioid Crisis

Can the interconnection between public health and social work help address current and future population health challenges? A public health viewpoint

The debate over the function and role of public health in all societies (high, middle, and low-income) still continues today. Public health needs to interact with the social and translational sciences to achieve the best possible scientific evidence and practice aimed at development of effective policies for individual and population health practices. As a field, public health is most suited for development of transdisciplinary education, research and practice—improving population health would entail embedding with a variety of other disciplines including social work. Public health and social work in many ways share the same beginnings as well as their role in advocacy for social and health equity. For this reason, the transdisciplinary profession of public health social work is well placed to develop and build the inter-professional and cross-sectoral collaboration that is needed to address the many health challenges of the 21st century, based on theories, knowledge and interventions from both public health and social work. Furthermore, the profession can help in attempting to close the health inequalities gap, address social isolation, family violence and homelessness, advance long and productive lives, create social responses to the changing environment, reduce economic inequality, harness technology for social good, and work toward the achievement of justice and equality of opportunity.

Preventing Overdose Using Information and Data from the Environment (PROVIDENT): protocol for a randomized, population-based, community intervention trial

BACKGROUND AND AIMS

In light of the accelerating drug overdose epidemic in North America, new strategies are needed to identify communities most at risk to prioritize geographically the existing public health resources (e.g. street outreach, naloxone distribution efforts). We aimed to develop PROVIDENT (Preventing Overdose using Information and Data from the Environment), a machine learning-based forecasting tool to predict future overdose deaths at the census block group (i.e. neighbourhood) level.

DESIGN

Randomized, population-based, community intervention trial.

SETTING

Rhode Island, USA.

PARTICIPANTS

All people who reside in Rhode Island during the study period may contribute data to either the model or the trial outcomes.

INTERVENTION

Each of the state's 39 municipalities will be randomized to the intervention (PROVIDENT) or comparator condition. An interactive, web-based tool will be developed to visualize the PROVIDENT model predictions. Municipalities assigned to the treatment arm will receive neighbourhood risk predictions from the PROVIDENT model, and state agencies and community-based organizations will direct resources to neighbourhoods identified as high risk. Municipalities assigned to the control arm will continue to receive surveillance information and overdose prevention resources, but they will not receive neighbourhood risk predictions.

MEASUREMENTS

The primary outcome is the municipal-level rate of fatal and non-fatal drug overdoses. Fatal overdoses will be defined as unintentional drug-related death; non-fatal overdoses will be defined as an emergency department visit for a suspected overdose reported through the state's syndromic surveillance system. Intervention efficacy will be assessed using Poisson or negative binomial regression to estimate incidence rate ratios comparing fatal and non-fatal overdose rates in treatment vs. control municipalities.

COMMENTS

The findings will inform the utility of predictive modelling as a tool to improve public health decision-making and inform resource allocation to communities that should be prioritized for prevention, treatment, recovery and overdose rescue services.

Six-month buprenorphine-naloxone treatment is associated with neurocognitive function improvement in opioid dependence

BACKGROUND AND AIM

The number of longitudinal studies on cognitive functions in patients on buprenorphine-based agonist treatment is limited. Our objective was to assess the change in neurocognitive functions over the first 6 months of buprenorphine-naloxone (BNX) treatment for opioid dependence (OD) and compare cognitive functions on BNX and controls.

METHODS

We selected 60 patients with OD aged 18 to 55 years and 20 sex-matched controls; and excluded patients with other substance dependence, human immunodeficiency virus (HIV), head injury, epilepsy, and severe mental illness. We assessed patients thrice: at baseline, 3, and 6 months and Controls once. Cognitive tests included Wisconsin card sorting test (WCST), Iowa gambling task (IGT), trail making tests A and B (TMT-A and B), verbal and visual N-back test (NBT), and standard progressive matrices (SPM). We measured with-in group effect size with Cohen's D (d).

RESULTS

A total of 24 participants completed at least one follow-up; 17 completed both follow-up assessments. All participants were men. At baseline, the patients performed worse than healthy controls in IGT, TMT-A, and B, and visual and verbal NBT. At 3 months, the performance of visual NBT improved significantly (d = 1.2 for NBT1; 1.3 for NBT2). At 6 months, additional performance improvements were seen in WCST ("perseverative error" d = 1.2), IGT ("net total score" d = 1.2), TMT-A (d = 1.1), and verbal NBT ("omission error" d = 1.7). Except for visual-NBT, results did not differ between patients and controls at both follow-ups.

CONCLUSION

Cognitive flexibility, decision making, attention, working memory, and psychomotor speed showed improvements over 6 months of a stable dose of BNX.

Use of Project ECHO to promote evidence based care for justice involved adults with opioid use disorder

Background: People with opioid use disorders (OUDs) are at heightened risk for involvement with the criminal justice system. Growing evidence supports the safety and effectiveness of providing empirically supported treatments for OUD, such as medications for OUD (M-OUD), to people with criminal justice involvement including during incarceration or upon reentry into the community. However, several barriers limit availability and accessibility of these treatment options for people with OUDs, including a shortage of healthcare and justice professionals trained in how to implement them. This study evaluated a novel education program, the Indiana Jail OUD Treatment ECHO, designed to disseminate specialty knowledge and improve attitudes about providing M-OUD in justice settings. Methods: Through didactic presentations and case-based learning (10 bimonthly, 90-min sessions), a multidisciplinary panel of specialists interacted with a diverse group of community-based participants from healthcare, criminal justice, law enforcement, and related fields. Participants completed standardized surveys about OUD knowledge and attitudes about delivering M-OUD in correctional settings. Thematic analysis of case presentations was conducted. Results: Among 43 participants with pre- and post-series evaluation data, knowledge about OUD increased and treatment was viewed as more practical after the ECHO series compared to before. Cases presented during the program typically involved complicated medical and psychiatric comorbidities, and recommendations addressed several themes including harm reduction, post-release supports, and integration of M-OUD and non-pharmacological interventions. Conclusions: Evaluation of future iterations of this innovative program should address attendance and provider behavior change as well as patient and community outcomes associated with ECHO participation.

Impact of Medicaid Expansion on Reported Incidents of Child Neglect and Physical Abuse

INTRODUCTION

The U.S. Affordable Care Act Medicaid expansion, which allowed states to expand Medicaid coverage to low-income adults beginning in 2014, has reduced the risk factors for child neglect and physical abuse, including parental financial insecurity, substance use, and untreated mental illness. This study examines the associations between Medicaid expansion and the rates of overall, first-time, and repeat reports of child neglect and physical abuse incidents per 100,000 children aged 0-5, 6-12, and 13-17 years.

METHODS

The 2008-2018 National Child Abuse and Neglect Data System was analyzed using an extension of the difference-in-differences approach that accounts for staggered policy implementation across time. Owing to evidence of nonparallel preperiod trends in the 6 states that expanded Medicaid from 2015 to 2017, the main analyses included 20 states that newly expanded Medicaid in 2014 and 18 states that did not expand Medicaid from 2008 to 2018. Analyses were conducted in 2020-2021.

RESULTS

Medicaid expansion states were associated with reductions of 13.4% (95% CI= -24.2, -9.6), 14.8% (95% CI= -26.4, -1.4), and 16.0% (-27.6, -2.6) in the average rate of child neglect reports per 100,000 children aged 0-5, 6-12, and 13-17 years, per state-year, relative to control states. Expansion was associated with a 17.3% (95% CI= -28.9, -3.8) reduction in the rate of first-time neglect reports among children aged 0-5 years and with 16.6% (95% CI= -29.3, -1.6) and 18.7% (95% CI= -32.5, -2.1) reductions in the rates of repeat neglect reports among children aged 6-12 and 13-17 years, respectively. There were no statistically significant associations between Medicaid expansion and the rates of physical abuse among children in any age group.

CONCLUSIONS

Insurance expansions for low-income adults may reduce child neglect.

Drug Legalization, Elite Support, and Government Effectiveness in Latin America

In Latin America, the legalization of drugs—where it occurred—has been driven mainly by elites, although much attention has been placed on public opinion. Considering that efforts toward legalization have been top-down, analysis should concentrate on opinions of the governing elites. To undertake such an analysis, we draw on data from surveys conducted in 18 Latin American parliaments (2012–2018), and we examine elite perspectives on the legalization of all drugs. Results from a Bayesian hierarchical logistic analysis show that in countries where the government is less effective, and where public health problems persist, legislators are less likely to support legalization. We argue that this is due to a lack of trust by MPs in legalization as a solution to trafficking. Wherever those concerned with drug trafficking see the current government as problematic, they will be less likely to support so challenging and complex a policy as drug legalization.

Impact of an overdose reversal program in the context of a safe consumption site in Northern Mexico

Background

Drug overdoses are prevalent in low- and middle-income countries but are scarcely reported in the literature. We report on an opioid overdose reversal and naloxone distribution program that was instituted at the first safe consumption site in Latin America.

Methods

A cross-sectional analysis of witnessed drug overdoses and naloxone distribution between 1 June 2019 and 31 May 2021 in Mexicali, Mexico. Case report forms were entered in an electronic database. Trends in overdose and naloxone distribution were described. Comparisons were made before and after the COVID-19 pandemic was declared in the city. Maps were created to represent the geographic distribution of overdose in the city.

Results

During the study period 1,534 doses of naloxone were distributed throughout the community. In addition, there were 464 overdoses reported during this period, of which 4 were fatal. There was a 30% increase in reported overdoses from the period before the COVID-19 pandemic to the period after the pandemic was declared (p = 0.03). Most common substance reported included heroin (93%), sedatives (21%), methamphetamine (16%) and fentanyl (14%). Naloxone was given in 96% of cases (median 1 dose, IQR 1-2 doses) and emergency services were called in 20% of cases.

Conclusions

An opioid overdose reversal program in Mexicali, Mexico was able to distribute naloxone and register drug overdoses between 2019 and 2021 as a harm reduction strategy. This adds to the growing body of literature on the impact of community-based programs on preventing fatal overdoses and the potential for implementation in low-resource settings.

Studying how state health services delivery policies can mitigate the effects of disasters on drug addiction treatment and overdose: Protocol for a mixed-methods study

BACKGROUND

The United States is experiencing a drug addiction and overdose crisis, made worse by the COVID-19 pandemic. Relative to other types of health services, addiction treatment and overdose prevention services are particularly vulnerable to disaster-related disruptions for multiple reasons including fragmentation from the general medical system and stigma, which may lead decisionmakers and providers to de-prioritize these services during disasters. In response to the COVID-19 pandemic, U.S. states implemented multiple policies designed to mitigate disruptions to addiction treatment and overdose prevention services, for example policies expanding access to addiction treatment delivered via telehealth and policies designed to support continuity of naloxone distribution programs. There is limited evidence on the effects of these policies on addiction treatment and overdose. This evidence is needed to inform state policy design in future disasters, as well as to inform decisions regarding whether to sustain these policies post-pandemic.

METHODS

The overall study uses a concurrent-embedded design. Aims 1-2 use difference-in-differences analyses of large-scale observational databases to examine how state policies designed to mitigate the effects of the COVID-19 pandemic on health services delivery influenced addiction treatment delivery and overdose during the pandemic. Aim 3 uses a qualitative embedded multiple case study approach, in which we characterize local implementation of the state policies of interest; most public health disaster policies are enacted at the state level but implemented at the local level by healthcare systems and local public health authorities.

DISCUSSION

Triangulation of results across methods will yield robust understanding of whether and how state disaster-response policies influenced drug addiction treatment and overdose during the COVID-19 pandemic. Results will inform policy enactment and implementation in future public health disasters. Results will also inform decisions about whether to sustain COVID-19 pandemic-related changes to policies governing delivery addiction and overdose prevention services long-term.

Emergency department-initiated buprenorphine protocols: A national evaluation

OBJECTIVE

Emergency department-initiated buprenorphine (BUP) for opioid use disorder is an evidence-based practice, but limited data exist on BUP initiation practices in real-world settings. We sought to characterize protocols for BUP initiation among a geographically diverse sample of emergency departments (EDs).

METHODS

In December 2020, we reviewed prestudy clinical BUP initiation protocols from all EDs participating in CTN0099 Emergency Department-INitiated bupreNOrphine VAlidaTION (ED-INNOVATION). We abstracted information on processes for identification of treatment-eligible patients, BUP administration, and discharge care.

RESULTS

All participating ED-INNOVATION sites across 22 states submitted protocols; 31 protocols were analyzed. Identification of treatment-eligible patients: Most EDs 22 (71%) relied on clinician judgment to determine appropriateness of BUP treatment with only 7 (23%) requiring decision support tools or diagnosis checklists. Before BUP initiation, 27 (87%) protocols required a documented Clinical Opiate Withdrawal Scale (COWS) score; 4 (13%) required a clinical diagnosis of withdrawal with optional COWS score. Twenty-seven (87%) recommended a minimum COWS score of 8 for ED-initiated BUP. BUP administration: Initial BUP dose ranged from 2-16 mg (mode = 4). For continued withdrawal symptoms, 27 (87%) protocols recommended an interval of 30-60 minutes between first and second BUP dose. Total BUP dose in the ED ranged from 8 to 32 mg. Discharge care: Twenty-eight (90%) protocols recommended a BUP prescription (mode 16 mg daily) at discharge. Naloxone prescription and/or provision was suggested in 23 (74%) protocols.

CONCLUSIONS

In this geographically diverse sample of EDs, protocols for ED-initiated BUP differed between sites. Future work should evaluate the association between this variation and patient outcomes.

Early innovations in opioid use disorder treatment and harm reduction during the COVID-19 pandemic: a scoping review

BACKGROUND

The COVID-19 pandemic has exerted a significant toll on the lives of people who use opioids (PWUOs). At the same time, more flexible regulations around provision of opioid use disorder (OUD) services have led to new opportunities for facilitating access to services for PWUOs. In the current scoping review, we describe new services and service modifications implemented by treatment and harm reduction programs serving PWUO, and discuss implications for policy and practice.

METHODS

Literature searches were conducted within PubMed, LitCovid, Embase, and PsycInfo for English-language studies published in 2020 that describe a particular program, service, or intervention aimed at facilitating access to OUD treatment and/or harm reduction services during the COVID-19 pandemic. Abstracts were independently screened by two reviewers. Relevant studies were reviewed in full and those that met inclusion criteria underwent final data extraction and synthesis (n = 25). We used a narrative synthesis approach to identify major themes around key service modifications and innovations implemented across programs serving PWUO.

RESULTS

Reviewed OUD treatment and harm reduction services spanned five continents and a range of settings from substance use treatment to street outreach programs. Innovative service modifications to adapt to COVID-19 circumstances primarily involved expanded use of telehealth services (e.g., telemedicine visits for buprenorphine, virtual individual or group therapy sessions, provision of donated or publicly available phones), increased take-home medication allowances for methadone and buprenorphine, expanded uptake of long-acting opioid medications (e.g. extended-release buprenorphine and naltrexone), home delivery of services (e.g. MOUD, naloxone and urine drug screening), outreach and makeshift services for delivering MOUD and naloxone, and provision of a safe supply of opioids.

CONCLUSIONS

The COVID-19 pandemic has posed multiple challenges for PWUOs, while simultaneously accelerating innovations in policies, care models, and technologies to lower thresholds for life-saving treatment and harm reduction services. Such innovations highlight novel patient-centered and feasible approaches to mitigating OUD related harms. Further studies are needed to assess the long-term impact of these approaches and inform policies that improve access to care for PWUOs.

Linking Emergency Medical Services and Emergency Department Data to Improve Overdose Surveillance in North Carolina

INTRODUCTION

Linking emergency medical services (EMS) data to emergency department (ED) data enables assessing the continuum of care and evaluating patient outcomes. We developed novel methods to enhance linkage performance and analysis of EMS and ED data for opioid overdose surveillance in North Carolina.

METHODS

We identified data on all EMS encounters in North Carolina during January 1-November 30, 2017, with documented naloxone administration and transportation to the ED. We linked these data with ED visit data in the North Carolina Disease Event Tracking and Epidemiologic Collection Tool. We manually reviewed a subset of data from 12 counties to create a gold standard that informed developing iterative linkage methods using demographic, time, and destination variables. We calculated the proportion of suspected opioid overdose EMS cases that received International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for opioid overdose in the ED.

RESULTS

We identified 12 088 EMS encounters of patients treated with naloxone and transported to the ED. The 12-county subset included 1781 linkage-eligible EMS encounters, with historical linkage of 65.4% (1165 of 1781) and 1.6% false linkages. Through iterative linkage methods, performance improved to 91.0% (1620 of 1781) with 0.1% false linkages. Among statewide EMS encounters with naloxone administration, the linkage improved from 47.1% to 91.1%. We found diagnosis codes for opioid overdose in the ED among 27.2% of statewide linked records.

PRACTICE IMPLICATIONS

Through an iterative linkage approach, EMS-ED data linkage performance improved greatly while reducing the number of false linkages. Improved EMS-ED data linkage quality can enhance surveillance activities, inform emergency response practices, and improve quality of care through evaluating initial patient presentations, field interventions, and ultimate diagnoses.

Barriers to effective care: Specialty drug treatment in Philadelphia

INTRODUCTION

In Philadelphia, the poorest big city in the United States, an estimated 60,000 people misuse opioids and more than 3500 have died of overdose in the past three years. In 2019, fentanyl was detected in 76% of drug-related deaths and 94% of opioid-involved deaths. While much attention has been directed at the public face of the city's drug problem, more than 75% of drug deaths in 2017 took place in a private residence.

METHOD

Based on qualitative research to understand the vulnerabilities of this hidden population of drug users, we interviewed kin of 35 people who had died of opioid overdose in 2017 to learn whether their loved one had interacted with any social services or harm-reduction interventions.

RESULTS

In our demographically and geographically representative sample of decedents, we found that while most had received treatment at least once, many faced barriers to getting treatment when they needed it, including barriers related to stigma, structural racism, gender inequities, bureaucracy, insurance requirements, and cost.

CONCLUSION

We argue that these barriers place an undue burden on people with substance use disorder and their kin during particularly fraught moments of heightened vulnerability. The failure of state and federal policies, practices, and infrastructure to address these barriers, and the failure to require that evidence-based care be provided during treatment have deleterious effects on people affected by the opioid epidemic in the United States.

Hospital Care for Opioid use in Illinois, 2016-2019

This study analyzes trends in hospital emergency room visits and admissions for patients with opioid diagnoses seen at 214 hospitals in Illinois over 42 months. Visits were coded hierarchically for opioid overdose, dependence, abuse, or use. Visit rates per 100,000 were stratified by zip code level of poverty. Regression estimates of the likelihood of inpatient admission and death are presented. There were 239,069 visits accounting for almost $5 billion in total charges and over 710,000 inpatient hospital days with less than a 1% death rate. The Illinois opioid epidemic is concentrated in the poorest areas of the Chicago metropolitan area. There was a sharp gradient in visits rates and deaths rates by poverty level area and more than a fivefold difference in hospital deaths. Effective state policy responses should expand to include decriminalization and proven harm reduction strategies such as medically assisted treatment, access to safe syringes, take home naloxone, and supervised safe consumption facilities.

Introduction to the Special Issue: Opioids and the Workplace - Risk Factors and Solutions

The workplace has been a neglected element in the national response to the opioid crisis. This ignores that workplace safety and health and drug policies have become important factors in opioid use disorder among workers. This results from physical or emotional pain related to workplace injuries, illnesses, and stress, and through punitive workplace drug policies, failure to address stigma, and inadequate access to treatment and recovery resources. This comprehensive New Solutions special issue encompasses timely cutting-edge research, commentaries, activism, and calls for action on primary prevention in the workplace and intervention research. It also addresses the convergence of the COVID-19 and the opioid crises, high-risk occupations and industries, health inequalities, employer and union programs, peer advocacy and member assistance programs, worker training, health parity for addiction treatment and recovery services, protection of first responders and site clean-up workers, working conditions of substance use treatment workers, and calls for necessary funding.

Polysubstance Use Among Patients Treated With Buprenorphine From a National Urine Drug Test Database

IMPORTANCE

Polysubstance use is a concern for patients treated for opioid use disorder (OUD). While buprenorphine can curtail harmful opioid use, co-occurring use of nonprescribed substances, such as cocaine, methamphetamine, and other opioids, may negatively affect treatment outcomes.

OBJECTIVE

To characterize factors associated with urine drug positivity for nonprescribed substances among patients prescribed buprenorphine.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included patients who had been prescribed buprenorphine and who provided urine specimens for urine drug testing (UDT), as ordered by clinicians in primary care or behavioral health or at substance use disorder treatment centers, from 2013 to 2019. Specimens were analyzed by liquid chromatography-tandem mass spectrometry to assess positivity for several commonly used substances.

EXPOSURES

Buprenorphine prescription.

MAIN OUTCOMES AND MEASURES

Positivity for buprenorphine and several nonprescribed substances. Unadjusted trends in positivity for each nonprescribed substance were compared between specimens that did and did not test positive for buprenorphine. Multivariable logistic regression was used to examine factors associated with positivity; factors included patient age, sex, setting of care, payer, collection year, and census division.

RESULTS

The study included first UDT specimens from 150 000 patients, of whom 82 107 (54.74%) were men and 77 300 (51.53%) were aged 18 to 34 years. Across all specimens, 128 240 (85.49%) were positive for buprenorphine, and 71 373 (47.58%) were positive for 1 or more nonprescribed substances. From 2013 to 2019, positivity rates increased for most substances (eg, fentanyl: from 131 of 21 412 [0.61%] to 1464 of 13 597 [10.77%]). Factors associated with positivity varied widely by substance; for example, fentanyl positivity was highest for men (OR, 1.13; 95% CI, 1.06-1.21), patients aged 18 to 24 years (OR for patients ≥55 years, 0.46; 95% CI, 0.39-0.54), patients living in New England (OR, 1.19; 95% CI, 1.07-1.33), and patients with Medicaid (OR, 1.20; 95% CI, 1.11-1.31), whereas oxycodone positivity was greatest for women (OR for men, 0.84; 95% CI, 0.79-0.89), patients older than 55 years (OR, 1.42; 95% CI, 1.22-1.64), patients living in the South Atlantic (OR, 1.45, 95% CI, 1.33-1.58), and patients with private insurance (OR for Medicaid, 0.78; 95% CI, 0.73-0.84). Patients whose specimens were positive for buprenorphine were significantly less likely to be positive for other opioids (eg, fentanyl: OR for buprenorphine-negative samples, 6.71; 95% CI, 6.29-7.16; heroin: OR for buprenorphine-negative samples, 9.93; 95% CI, 9.31-10.59).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, patterns of nonprescribed substance positivity among patients prescribed buprenorphine varied widely. This study highlights the utility of UDT in public health surveillance efforts related to patients treated with buprenorphine for OUD.

Equity-oriented frameworks to inform responses to opioid overdoses: a scoping review

OBJECTIVE

The purpose of this scoping review was to systematically identify and describe literature that uses a health equity-oriented approach for preventing and reducing the harms of stigma or overdose for people who use illicit drugs or misuse prescription opioids.

INCLUSION CRITERIA

To be included, papers had to both: i) use a health equity-oriented approach, defined as a response that addresses health inequities and aims to reduce drug-related harms of stigma or overdose; and ii) include at least one of the following concepts: cultural safety, trauma- and violence-informed care, or harm reduction. We also looked for papers that included an Indigenous-informed perspective in addition to any of the three concepts.

METHODS

An a priori protocol was published and the JBI methodology for conducting scoping reviews was employed. Published and unpublished literature from January 1, 2000, to July 31, 2019, was included. The databases searched included CINAHL (EBSCOhost), MEDLINE (Ovid), Academic Search Premier (EBSCOhost), PsycINFO (EBSCOhost), Sociological Abstracts and Social Services Abstracts (ProQuest), JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO, Aboriginal Health Abstract Database, First Nations Periodical Index, and the National Indigenous Studies Portal. The search for unpublished studies included ProQuest Dissertations and Theses, Google Scholar, and targeted web searches. Screening and data extraction were performed by two reviewers using templates developed by the authors. Data extraction included specific details about the population, concepts, context, and key findings or recommendations relevant to the review objectives.

RESULTS

A total of a total of 1065 articles were identified and screened, with a total of 148 articles included. The majority were published in the previous five years (73%) and were from North America (78%). Most articles only focused on one of the three health equity-oriented approaches, most often harm reduction (n = 79), with only 16 articles including all three. There were 14 articles identified that also included an Indigenous-informed perspective. Almost one-half of the papers were qualitative (n = 65; 44%) and 26 papers included a framework. Of these, seven papers described a framework that included all three approaches, but none included an Indigenous-informed perspective. Recommendations for health equity-oriented approaches are: i) inclusion of people with lived and living experience; ii) multifaceted approaches to reduce stigma and discrimination; iii) recognize and address inequities; iv) drug policy reform and decriminalization; v) ensure harm-reduction principles are applied within comprehensive responses; and vi) proportionate universalism. Gaps in knowledge and areas for future research are discussed.

CONCLUSIONS

We have identified few conceptual frameworks that are both health equity-oriented and incorporate multiple concepts that could enrich responses to the opioid poisoning emergency. More research is required to evaluate the impact of these integrated frameworks for action.

Barriers to Integrated Medication-Assisted Treatment for Rural Patients With Co-occurring Disorders: The Gap in Managing Addiction

OBJECTIVE

Guidelines for treatment of opioid use disorder stipulate for mental health assessment and the option for treatment alongside medication for opioid use disorder (MOUD). Yet efforts to expand MOUD treatment capacity have focused on expanding the workforce of buprenorphine providers. This article aims to describe the processes facilitating and impeding integrated care for rural patients with co-occurring opioid use disorder and mental health conditions.

METHODS

Qualitative interviews were conducted with primary care and specialty providers (N=26) involved in integrated care through the state's hub-and-spoke system and with system-level stakeholders (N=16) responsible for expanding access to MOUD in rural California.

RESULTS

Rural primary care providers struggled to offer adequate mental health resources to patients with co-occurring conditions because of personnel shortages and inadequate availability of telehealth. Efforts to intensify care through referral to county mental health systems and private community providers were thwarted by access barriers. The bifurcated nature of treatment systems resulted in inadequate training in integrated care and the deprioritization of mental health in patient evaluations.

CONCLUSIONS

Significant system-level barriers undermine the implementation of integrated MOUD in rural areas, potentially increasing the suffering of residents with co-occurring conditions and intensifying burnout among providers.

Legacies of the war on drugs: Next of kin of persons who died of opioid overdose and harm reduction interventions in Philadelphia

BACKGROUND

Between the years 2017-2019 in Philadelphia, more than 70% of all deaths from opioid overdose occurred in a private residence. To learn more about home-based opioid use and overdose, researchers conducted qualitative interviews with next of kin of overdose victims to learn their perceptions about the decedent's drug use and their opinions about city-led harm reduction efforts, specifically naloxone administration and collaborative efforts to open an overdose prevention site.

METHODS

In 2019, researchers conducted 35 qualitative interviews with next of kin of persons who died of opioid overdose in Philadelphia in 2017. Data were coded and analyzed using NVivo software.

RESULTS

Data reveal that while persons who use drugs may benefit from enhanced harm reduction interventions that target their family members and caregivers including naloxone education and public health messaging about overdose prevention, these efforts may be up against other realities that Philadelphia families navigate-in particular structural inequalities exacerbated by decades of "War on Drugs" policies.

CONCLUSION

Existing health disparities and structural barriers to care increase vulnerability to overdose and highlight the urgency to collaborate with impacted families and communities to design relevant harm reduction interventions. Without efforts to redress the consequences of war on drug policies, however, harm reduction interventions will not reach their full potential.

A Public Health Approach to Protecting Workers from Opioid Use Disorder and Overdose Related to Occupational Exposure, Injury, and Stress : APHA Policy Statement Number 202012, Issued October 24, 2020

Opioid overdose mortality, in combination with increased deaths from alcohol and suicide, is having a profound impact on American workplaces, compromising occupational health and safety and increasing workers' compensation and health insurance costs, absenteeism, and lost productivity. The President's Council of Economic Advisers estimates that more than 1 million workers are out of the workforce due to the opioid crisis. The impact on workers is equally profound, including job loss, divorce and family disruption, and potentially imprisonment, injury, illness, and death. Pain from occupational injuries and illnesses and stress are important pathways to opioid use disorder. Effective workplace programs that incorporate the public health approach to prevention offer a significant opportunity to prevent and respond to the opioid crisis. To date, the nation's efforts at combating the crisis have not included the necessary policy reforms to transform the workplace from a pathway to opioid misuse to a pathway to prevention, including education of workers, unions, employers, and health care providers and treatment and recovery of affected workers. Several key policy interventions are recommended to address this disconnect, including prevention of workplace injury, illness, and emotional distress; worker education and training; and replacement of stigmatizing, punitive workplace substance use programs with supportive programs. Increasing access to alternative pain treatment and preventing opioid misuse in workers' compensation systems are other key policy recommendations.

The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis

PURPOSE OF REVIEW

This review provides an update on recently published literature on the rise of illicit fentanyls, risks for overdose, combinations with other substances, e.g. stimulants, consequences, and treatment.

RECENT FINDINGS

Overdose due to illicit synthetic opioids (e.g. fentanyl and fentanyl analogs) continues to rise in the US both preceding and during the COVID-19 pandemic. Fentanyl-related overdose is rising in new geographic areas e.g. the western USA. Stimulant-related overdose is also increasing nationwide driven by methamphetamine and cocaine. Polysubstance use, e.g. the use of a stimulant along with an opioid is driving stimulant-related overdose. Other medical consequences of injection drug use are rising including HIV and hepatitis C infections. Medication approaches to treating opioid use disorder remain the standard of care and there are new promising pharmacological approaches to treating methamphetamine use disorder.

SUMMARY

A 'fourth wave' of high mortality involving methamphetamine and cocaine use has been gathering force in the USA. Availability and use of illicit fentanyls are still the major drivers of overdose deaths and the current rise in stimulant-related deaths appears entwined with the ongoing opioid epidemic.

Pharmacists should treat patients who have opioid use disorders, not police them

Pharmacists are caught in the throes of a relentless overdose crisis that has already claimed half a million lives and threatens to claim thousands more. The addiction treatment system is fragmented and inadequate to meet demand. Few physicians provide medications for opioid use disorder (MOUDs), the most effective form of evidence-based treatment, and insufficient treatment options leave patients vulnerable to overdose. Pharmacists routinely interact with patients who have OUD but lack ways to treat them. The primary tools that pharmacists have received to curb the crisis are prescription drug monitoring programs (PDMPs), big data surveillance technologies that they can use to track patients' medication acquisition patterns. Pharmacists like PDMPs because they help them make decisions efficiently. However, PDMPs are enforcement technologies, not health care tools; therefore, pharmacists typically use PDMPs to police patients instead of treating them. Policing patients not only fails to help combat overdose, but can also exacerbate harm. Informed by a decade's worth of interviews with pharmacists before and after PDMP implementation, I argue that pharmacists should be better equipped to help patients with OUD. Specifically, clinical and community pharmacists should mobilize to provide MOUDs through collaborative practice agreements with physicians. Studies show that collaborative practice models are effective at reducing the risk of overdose and saving money and physicians' time. And pharmacists have the clinical competencies necessary to provide MOUDs for patients. Pharmacists must overcome legal, economic, and interprofessional barriers to do so, but giving pharmacists the tools to treat patients will affirm their professional commitment to caring for patients and saving lives.

Tailoring services in opioid treatment programs for patients involved in America's criminal justice system: national associations and variation by state and Medicaid expansion status

Background

Opioid treatment programs (OTPs) are the primary source of medication-assisted treatment (MAT) for many individuals with opioid use disorder, including poor and uninsured patients and those involved in the criminal justice (CJ) system. Substance use treatment services that are tailored to the unique needs of patients often produce better outcomes, but little national research has addressed characteristics associated with whether OTPs offer services specifically tailored to community members involved in the CJ system. Medicaid expansion under the Affordable Care Act has broadly strengthened MAT services, but the role of expansion in supporting MAT services that are specifically tailored towards CJ-involved populations remains unknown. Moreover, it is unknown whether the availability of tailored services varies between Medicaid expansion states.

Methods

We used the 2019 National Survey of Substance Abuse Treatment Services to identify OTPs in the US (n = 1679) and whether they offered services specifically tailored for CJ-involved patients. We used logistic regression to model the association between OTPs offering tailored services and state Medicaid expansion status, adjusted for state-level opioid overdose and community supervision rates.

Results

Nationally, only a quarter of OTPs offered services tailored to CJ populations, and the majority of OTPs (73%) were located in Medicaid expansion states. Compared to OTPs in non-expansion states, OTPs in expansion states demonstrated nearly double the odds of offering tailored services (adjusted odds ratio = 1.90, 95% confidence interval = 1.41–2.57, p < 0.0001). The predicted probability of offering tailored services varied by state; probability estimates for all expansion states were above the national mean, and estimates for all non-expansion states were below the national mean.

Conclusion

Our findings reiterate the role of Medicaid in promoting the adoption of comprehensive OTP services for CJ-involved populations. However, the proportion of OTPs that offered tailored services was relatively low, pointing to the need to continually strengthen Medicaid services and coverage.

Political frames of public health crises: Discussing the opioid epidemic in the US Congress

When and how do politicians talk about public health crises? Using evidence from the opioid crisis in the United States, this paper assembles and analyzes novel data on Congressional statements to explore the conditions under which politicians (1) issue public statements about opioids and (2) frame the opioid crisis as a predominantly public health or law enforcement problem. We examined 3.8 million Congressional floor speeches and 111,000 public statements to identify (1) floor speeches about drug crises in the 97th to 114th Congresses (1981-2017) and (2) public statements about the opioid crisis in the 116th Congress (2019-2020). Moderate ideology, women, greater overdose deaths, and larger white populations are associated with significantly higher frequencies of opioid statements. Using a dictionary-based text analysis approach, we find that ideologically liberal and African American legislators are more likely to use public health framing, while ideologically conservative members are more likely to use law enforcement framing and refer to national borders or foreign countries in opioid statements. Democrats/liberals more often referenced medication treatment for opioids. These findings imply two broader conclusions about the nature of political discourse in public health crises. First, that political extremists are least likely to talk about opioids suggests that increasing partisan polarization may result in less discussion, emphasis, and expertise in public health issues. Second, the tenor of discourse about opioids and other public health crises is likely to change with partisan electoral waves, potentially hindering long term planning of public health capacity.

Refusal to accept emergency medical transport following opioid overdose, and conditions that may promote connections to care

BACKGROUND

Opioid overdose is a leading cause of death in the United States. Emergency medical services (EMS) encounters following overdose may serve as a critical linkage to care for people who use drugs (PWUD). However, many overdose survivors refuse EMS transport to hospitals, where they would presumably receive appropriate follow-up services and referrals. This study aims to (1) identify reasons for refusal of EMS transport after opioid overdose reversal; (2) identify conditions under which overdose survivors might be more likely to accept these services; and (3) describe solutions proposed by both PWUD and EMS providers to improve post-overdose care.

METHODS

The study comprised 20 semi-structured, qualitative in-depth interviews with PWUD, followed by two semi-structured focus groups with eight EMS providers.

RESULTS

PWUD cited intolerable withdrawal symptoms; anticipation of inadequate care upon arrival at the hospital; and stigmatizing treatment by EMS and hospital providers as main reasons for refusal to accept EMS transport. EMS providers corroborated these descriptions and offered solutions such as titration of naloxone to avoid harsh withdrawal symptoms; peer outreach or community paramedicine; and addressing provider burnout. PWUD stated they might accept EMS transport after overdose reversal if they were offered ease for withdrawal symptoms, at either a hospital or non-hospital facility, and treated with respect and empathy.

CONCLUSION

Standard of care by EMS and hospital providers following overdose reversal should include treatment for withdrawal symptoms, including buprenorphine induction; patient-centered communication; and effective linkage to prevention, treatment, and harm reduction services.

Persistent Spinal Pain Syndrome: A Proposal for Failed Back Surgery Syndrome and ICD-11

Objective

For many medical professionals dealing with patients with persistent pain following spine surgery, the term Failed back surgery syndrome (FBSS) as a diagnostic label is inadequate, misleading, and potentially troublesome. It misrepresents causation. Alternative terms have been suggested, but none has replaced FBSS. The International Association for the Study of Pain (IASP) published a revised classification of chronic pain, as part of the new International Classification of Diseases (ICD-11), which has been accepted by the World Health Organization (WHO). This includes the term Chronic pain after spinal surgery (CPSS), which is suggested as a replacement for FBSS.

Methods

This article provides arguments and rationale for a replacement definition. In order to propose a broadly applicable yet more precise and clinically informative term, an international group of experts was established.

Results

14 candidate replacement terms were considered and ranked. The application of agreed criteria reduced this to a shortlist of four. A preferred option—Persistent spinal pain syndrome—was selected by a structured workshop and Delphi process. We provide rationale for using Persistent spinal pain syndrome and a schema for its incorporation into ICD-11. We propose the adoption of this term would strengthen the new ICD-11 classification.

Conclusions

This project is important to those in the fields of pain management, spine surgery, and neuromodulation, as well as patients labeled with FBSS. Through a shift in perspective, it could facilitate the application of the new ICD-11 classification and allow clearer discussion among medical professionals, industry, funding organizations, academia, and the legal profession.

The Impact Of Academic Medical Center Policies Restricting Direct-To-Physician Marketing On Opioid Prescribing

Direct-to-physician opioid marketing by pharmaceutical companies is widespread and may contribute to opioid overprescribing, an important driver of the US opioid crisis. Using a difference-in-differences approach and Medicare Part D prescriber data, we examined the effects of academic medical centers' conflict-of-interest policies that restrict direct-to-physician marketing of all drugs on opioid prescribing by physicians at eighty-five centers in the period 2013-16. We examined restrictions on gifts and meals, speaking and consulting engagements, and industry representatives' access to academic medical centers, as well as rules requiring conflict-of-interest disclosures. Bans on sales representatives were associated with a 4.7 percent reduction in the total volume of opioids prescribed and disclosure requirements with a 2.5 percent reduction, while having all four marketing restriction policies was associated with an 8.8 percent reduction. Policies that restrict direct-to-physician pharmaceutical marketing may curb opioid prescribing, but additional patient-level research is needed to understand how such policies affect the delivery of evidence-based treatment for chronic pain.

Influence of G protein-biased agonists of μ-opioid receptor on addiction-related behaviors

Opioid analgesics remain a gold standard for the treatment of moderate to severe pain. However, their clinical utility is seriously limited by a range of adverse effects. Among them, their high-addictive potential appears as very important, especially in the context of the opioid epidemic. Therefore, the development of safer opioid analgesics with low abuse potential appears as a challenging problem for opioid research. Among the last few decades, different approaches to the discovery of novel opioid drugs have been assessed. One of the most promising is the development of G protein-biased opioid agonists, which can activate only selected intracellular signaling pathways. To date, discoveries of several biased agonists acting via μ-opioid receptor were reported. According to the experimental data, such ligands may be devoid of at least some of the opioid side effects, such as respiratory depression or constipation. Nevertheless, most data regarding the addictive properties of biased μ-opioid receptor agonists are inconsistent. A global problem connected with opioid abuse also requires the search for effective pharmacotherapy for opioid addiction, which is another potential application of biased compounds. This review discusses the state-of-the-art on addictive properties of G protein-biased μ-opioid receptor agonists as well as we analyze whether these compounds can diminish any symptoms of opioid addiction. Finally, we provide a critical view on recent data connected with biased signaling and its implications to in vivo manifestations of addiction.

"People Don't Just Start Shooting Heroin on Their 18th Birthday": A Qualitative Study of Community Stakeholders' Perspectives on Adolescent Opioid Use and Opportunities for Intervention in Baltimore, Maryland

Initiation of non-medical prescription opioid use (NMPO) during early adolescence is tightly linked to heroin and other drug use disorders and related sequelae in later adolescence and young adulthood. Few studies explore stakeholders’ perspectives on the burden and determinants of youth opioid use and barriers and facilitators to engaging youth in opioid use prevention and treatment services in urban settings with longstanding opioid epidemics. In-depth interviews were conducted with 22 stakeholders representing health and social service agencies in Baltimore, Maryland from May 2018- February 2019, to examine their perspectives on the burden and context of adolescent opioid use and identify barriers and facilitators to preventing and responding to adolescent opioid use. Transcripts were analyzed using the constant comparison method to identify themes. Most respondents described a recent uptick in opioid use independently, and in combination with other substances. As compared to heroin, NMPO was perceived to be more frequently used and less stigmatized among youth. Stakeholders perceived the process of transitioning from using NMPO to heroin as more common among White vs. Black youth and was perceived as occurring faster among White vs. Black youth. Some stakeholders believed racial differences in internal stigma against heroin use, and differential health service use among Black youth and White youth may have influenced these differences. Trauma and poverty were noted determinants of youth opioid use. Barriers to service provision included youth cognitive development, stigma and structural factors (e.g., disinvestment, lack of youth-centered and integrated services). Stakeholders perceive prevalent NMPO among Baltimore youth and identify multilevel barriers to delivering prevention, treatment and harm reduction services to this population. These findings encourage further investigation of determinants and consequences of opioid use among diverse racial/ethnic groups of youth in urban settings, and development of multilevel, youth-driven and youth-centered approaches to prevention and treatment.

Integrating human services and criminal justice data with claims data to predict risk of opioid overdose among Medicaid beneficiaries: A machine-learning approach

Health system data incompletely capture the social risk factors for drug overdose. This study aimed to improve the accuracy of a machine-learning algorithm to predict opioid overdose risk by integrating human services and criminal justice data with health claims data to capture the social determinants of overdose risk. This prognostic study included Medicaid beneficiaries (n = 237,259) in Allegheny County, Pennsylvania enrolled between 2015 and 2018, randomly divided into training, testing, and validation samples. We measured 290 potential predictors (239 derived from Medicaid claims data) in 30-day periods, beginning with the first observed Medicaid enrollment date during the study period. Using a gradient boosting machine, we predicted a composite outcome (i.e., fatal or nonfatal opioid overdose constructed using medical examiner and claims data) in the subsequent month. We compared prediction performance between a Medicaid claims only model to one integrating human services and criminal justice data with Medicaid claims (i.e., integrated model) using several metrics (e.g., C-statistic, number needed to evaluate [NNE] to identify one overdose). Beneficiaries were stratified into risk-score decile subgroups. The samples (training = 79,087, testing = 79,086, validation = 79,086) had similar characteristics (age = 38±18 years, female = 56%, white = 48%, having at least one overdose = 1.7% during study period). Using the validation sample, the integrated model slightly improved on the Medicaid claims only model (C-statistic = 0.885; 95%CI = 0.877–0.892 vs. C-statistic = 0.871; 95%CI = 0.863–0.878), with small corresponding improvements in the NNE and positive predictive value. Nine of the top 30 most important predictors in the integrated model were human services and criminal justice variables. Using the integrated model, approximately 70% of individuals with overdoses were members of the top risk decile (overdose rates in the subsequent month = 47/10,000 beneficiaries). Few individuals in the bottom 9 deciles had overdose episodes (0-12/10,000). Machine-learning algorithms integrating claims and social service and criminal justice data modestly improved opioid overdose prediction among Medicaid beneficiaries for a large U.S. county heavily affected by the opioid crisis.

Willingness to Participate in At-Home HIV Testing Among Young Adults Who Use Opioids in Rural Appalachia

New HIV infections associated with injection drug use are of major concern in rural US communities. This study explores acceptability of, consent for, and uptake of free at-home HIV testing among people who use drugs (PWUD) in one of the nation’s epicenters for drug-related harms and HIV vulnerability: Rural Central Appalachia. Eligible participants were 18–35 years old, lived in Appalachian Kentucky, and reported using opioids to get high in the previous 30 days. A majority reported being likely (63.6%, 96/151) to take a free at-home HIV tests and 66.9% (101/151) consented to receive one. Among those who were randomly selected to receive a Home Access HIV-1 test kit (n = 37), 37.8% mailed in blood spots and 21.6% called to receive results. This study provides evidence that PWUD may be willing to take an at-home test, but other barriers may inhibit actual completion.

Medication for Adolescents and Young Adults With Opioid Use Disorder

Opioid-related morbidity and mortality have risen in many settings globally. It is critical that practitioners who work with adolescents and young adults (AYAs) provide timely, evidence-based treatment for opioid use disorder (OUD). Such treatment should include medications for opioid use disorder (MOUD), including buprenorphine, naltrexone, and methadone. Medication treatment is associated with reduced mortality, fewer relapses to opioid use, and enhanced recovery and retention in addiction care, among other positive health outcomes. Unfortunately, the vast majority of AYAs with OUD do not receive medication. The Society for Adolescent Health and Medicine recommends that AYAs be offered MOUD as a critical component of an integrated treatment approach. Barriers to receipt of medications are widespread; many are common to high-, middle-, and low-income countries alike, whereas others differ. Such barriers should be minimized to ensure equitable access to youth-friendly, affirming, and confidential addiction treatment that includes MOUD. Robust education on OUD and medication treatment should be provided to all practitioners who work with AYAs. Strategies to reduce stigma surrounding medication-and stigma experienced by individuals with substance use disorders more generally-should be widely implemented. A broad research agenda is proposed with the goal of expanding the evidence base for the use and delivery of MOUD for AYAs.

Why comparative epidemiological indicators suggest that New Zealand is unlikely to experience a severe opioid epidemic

North America (i.e., the United States and Canada) and select other wealthy Commonwealth countries (e.g., Australia, the UK) have been experiencing marked 'opioid epidemics', consisting of elevated opioid use and related (e.g., mortality and morbidity) harms involving both prescription and, increasingly, illicit opioid substances. Multiple commentators have alerted to the possibility of New Zealand becoming home to a similar opioid crisis. In this article, we briefly examine and compare key system-level epidemiological indicators for New Zealand in regards to this situation and prospect. These data suggest that, comparatively, population-level (medical) opioid use, exposure and supply in New Zealand have been low and moderate, mostly involving restrained and lower-risk (e.g., short-duration, few long-acting/high-potency formulations, restricted settings) medical opioid availability, with limited over-time increases and absent the major oscillations in opioid dispensing observed elsewhere. Similarly, illicit opioids have been rather low in availability and use, and do not form primary substances in illicit drug scenes or markets. Correspondingly, opioid-related mortality in New Zealand has been somewhat increasing over-time albeit at comparably low levels, and principally involves methadone, morphine and codeine, i.e. the main opioids medically prescribed. Synthesizing the evidence, New Zealand has not featured the distinct characteristics or system-level drivers that have facilitated the opioid epidemics as have unfolded in other jurisdictions. It appears that New Zealand may have all along engaged in the more measured opioid use practices that other jurisdictions have attempted to revert to post-hoc (but largely when too late) while experiencing extensive adverse consequences related to opioids. On this basis, New Zealand provides for a worthwhile comparative case study towards more moderate opioid utilization and control entailing relatively limited collateral harms (e.g., opioid mortality) on public health compared to elsewhere. Details and characteristics of New Zealand's approach to and experience with opioids should be further examined for future and other jurisdictions' benefit.

Changes in opioid-related deaths following increased access to opioid substitution treatment

BACKGROUND

Opioid-related mortality is high and increasing in the Western world, and interventions aimed at reducing opioid-related deaths represent an important area of study. In Skåne County, Sweden, a patient choice reform resulted in increased access to opioid substitution treatment (OST). In addition, a gradual shift towards less restrictive terms for exclusion from OST has been implemented. The aim of this study was to assess the impact of these policy changes on opioid-related deaths.

METHODS

Detailed data on opioid-related deaths in Skåne during the 2 years prior to and following the policy change were obtained from forensic records and from health care services. Data on overdose deaths for Skåne and the rest of Sweden were obtained using publicly available national register data. Time periods were used as the predictor for opioid-related deaths in the forensic data. The national level data were used in a natural experiment design in which rates of overdose deaths were compared between Skåne and the rest of Sweden before and after the intervention.

RESULTS

There was no significant difference in the number of deaths in Skåne between the data collection periods (RR: 1.18 95% CI:0.89-1.57, p= 0.251). The proportion of deaths among patients enrolled in OST increased between the two periods (2.61, 1.12-6.10, p= 0.026). There was no change in deaths related to methadone or buprenorphine in relation to deaths due to the other opioids included in the study (0.92, 0.51-1.63, p= 0.764). An analysis of national mortality data showed an annual relative decrease in unintentional drug deaths in Skåne compared to the rest of Sweden following the onset of the reform (0.90, 0.84-0,97, p= 0.004).

CONCLUSIONS

Opioid-related deaths, as assessed using forensic data, has not changed significantly in Skåne following a change to lower-threshold OST. By contrast, national level data indicate that the policy change has been associated with decreased overdose deaths. The discrepancy between these results highlights the need for more research to elucidate this issue. The result that more patients die during ongoing OST following an increase in access to treatment underlines the need for further preventive interventions within the OST treatment setting.

Data Needs in Opioid Systems Modeling: Challenges and Future Directions

INTRODUCTION

The opioid crisis is a pervasive public health threat in the U.S. Simulation modeling approaches that integrate a systems perspective are used to understand the complexity of this crisis and analyze what policy interventions can best address it. However, limitations in currently available data sources can hamper the quantification of these models.

METHODS

To understand and discuss data needs and challenges for opioid systems modeling, a meeting of federal partners, modeling teams, and data experts was held at the U.S. Food and Drug Administration in April 2019. This paper synthesizes the meeting discussions and interprets them in the context of ongoing simulation modeling work.

RESULTS

The current landscape of national-level quantitative data sources of potential use in opioid systems modeling is identified, and significant issues within data sources are discussed. Major recommendations on how to improve data sources are to: maintain close collaboration among modeling teams, enhance data collection to better fit modeling needs, focus on bridging the most crucial information gaps, engage in direct and regular interaction between modelers and data experts, and gain a clearer definition of policymakers' research questions and policy goals.

CONCLUSIONS

This article provides an important step in identifying and discussing data challenges in opioid research generally and opioid systems modeling specifically. It also identifies opportunities for systems modelers and government agencies to improve opioid systems models.

Solving the Opioid Crisis Isn't Just a Public Health Challenge-It's a Bioethics Challenge

Among those who discuss America's opioid crisis, it is popular to claim that we know what we, as a society, ought to do to solve the problem-we simply don't want it badly enough. We don't lack knowledge; we lack the will to act and to fund the right policies. In fact, I've heard two versions of this. Among those who focus on prescription opioids, it is clear that we ought to stop prescribing so many powerful opioid painkillers. And among my public health colleagues focusing on illicit drug use, it is clear that we ought to expand addiction treatment and harm-reduction services. The problem, however, is that the second claim is not obvious (and, indeed, is denied by many Americans), and the first claim probably isn't even true (at least, not in so crude a form). In short, the opioid crisis presents not only a problem of political will but also one of ethics. It will take work to discover or justify our normative claims in this arena.

Unclassified drug overdose deaths in the opioid crisis: emerging patterns of inequity

OBJECTIVE

Examine whether individual, geographic, and economic phenotypes predict missing data on specific drug involvement in overdose deaths, manifesting inequities in overdose mortality data, which is a key data source used in measuring the opioid epidemic.

MATERIALS AND METHODS

We combined national data sources (mortality, demographic, economic, and geographic) from 2014-2016 in a multi-method analysis of missing drug classification in the overdose mortality records (as defined by the use of ICD-10 T50.9 on death certificates). We examined individual disparities in decedent-level multivariate logistic regression models, geographic disparities in spatial analysis (heat maps), and economic disparities in a combination of temporal trend analyses (descriptive statistics) and both decedent- and county-level multivariate logistic regression models.

RESULTS

Our analyses consistently found higher rates of unclassified overdoses in decedents of female gender, White race, non-Hispanic ethnicity, with college education, aged 30-59 and those from poorer counties. Despite the fact that unclassified drug overdose death rates have reduced over time, gaps persist between the richest and poorest counties. There are also striking geographic differences both across and within states.

DISCUSSION

Given the essential role of mortality data in measuring the scale of the opioid epidemic, it is important to understand the individual and community inequities underlying the missing data on specific drug involvements. Knowledge of these inequities could enhance our understanding of the opioid crisis and inform data-driven interventions and policies with more equitable resource allocations.

CONCLUSION

Multiple individual, geographic, and economic disparities underlie unclassified overdose deaths, with important implications for public health informatics and addressing the opioid crisis.

Comparison of Crude Population-Level Indicators of Opioid Use and Related Harm in New Zealand and Ontario (Canada)

North America and select other Commonwealth jurisdictions have been experiencing unprecedented opioid epidemics characterized by excessive and persistently high levels of opioid misuse, morbidity and mortality, and related disease burden. Recent discussions have considered whether New Zealand might undergo or needs to expect a similar ‘opioid crisis’. Towards further informing these considerations, we examine and compare essential, publicly available indicators of opioid utilization and harms (mortality) from New Zealand and the Canadian province of Ontario, due to the fact that both operate public health care systems in similar socio-cultural settings. We find that the two jurisdictions have featured vastly different population levels of opioid exposure, opioid consumption patterns (e.g., high-dose/long-term/high-risk prescribing) known as key predictors of adverse outcomes, and levels of opioid mortality as evidenced by concrete epidemiological indicators and data. Specifically for opioid-related death rates, these were already approximately threefold higher in Ontario compared to New Zealand based on most recent comparison data (e.g., 2012); these differentials have likely further grown more recently given major and distinct changes in population-level opioid exposure and risks, and subsequent opioid-related deaths since then in Ontario. Based on the present data and related evidence, New Zealand does not seem to need to anticipate an opioid mortality epidemic similar to that experienced in North America; however, it would be of interest to establish more comprehensive and timely surveillance of key system-level indicators of opioid use and harms as are standard in North America. As such, this inter-jurisdictional comparison makes for a case study in starkly contrasting scenarios of opioid use and harms, the drivers behind which deserve further systematic examination.

Persistence and Pervasiveness : Early Wave Opioid Overdose Death Rates Associated With Subsequent Overdose Death Rates

OBJECTIVES

Although trends in opioid-related death rates in the United States have been described, the association between state-level opioid overdose death rates in early waves and substance-related overdose death rates in later waves has not been characterized. We examined the relationship between state-level opioid overdose death rates at the beginning of the crisis (1999-2004) and overdose death rates for opioids and other substances in later years.

METHODS

Using 1999-2018 multiple cause of death data from the Centers for Disease Control and Prevention, we first categorized each state by quartile of baseline (1999-2004) opioid overdose death rates. By baseline opioid overdose death rates, we then compared states' annual overdose death rates from any opioid, heroin, synthetic opioids, sedatives, stimulants/methamphetamine, and cocaine from 2005 through 2018. To test the association between baseline opioid overdose death rates and subsequent substance-related overdose death rates for all 6 substances, we estimated unadjusted and adjusted linear models controlling for annual state-level unemployment, median household income, age, sex, and race/ethnicity.

RESULTS

Our results suggest 2 characteristics of the opioid crisis: persistence and pervasiveness. In adjusted analyses, we found that for each additional opioid overdose death per 100 000 population at baseline, states had 23.5 more opioid deaths, 4.4 more heroin deaths, 8.0 more synthetic opioid deaths, 9.2 more sedative deaths, 3.3 more stimulant deaths, and 4.6 more cocaine deaths per 100 000 population from 2005 to 2018.

CONCLUSION

These findings have important implications for continued surveillance to assist policy makers in deciding how to deploy resources to combat not just opioid use disorder but also polysubstance use disorder and broader problems of substance use disorder.

Economic burden of opioid crisis and the role of pharmacist-led interventions

Opioids are often used to treat pain and improve function. Canada and the United States are one of the highest users of opioids per capita worldwide and are experiencing the devastating consequences of the opioid crisis. The objectives of this commentary are 2-fold: first, highlight the economic burden of the opioid crisis in the United States and Canada; second, define the role of pharmacists to address this crisis. A body of literature delineates the cost of this crisis to health care system, lost productivity, and law enforcement. Contemporary data indicate that the economic burden of the opioid crisis was $78.5 billion and $3.5 billion in the United States and Canada, respectively. Community pharmacists are often the first health care providers who identify issues with opioid prescriptions, signs of misuse, abuse, and diversion. Contemporary studies highlight their critical role to address this crisis by ensuring the safe and appropriate use of opioids, which can decrease morbidity, mortality, use of health services and societal resources, and costs. The expanding scope of practice and the amendment of existing regulations and legislations have the potential to maximize the contribution of pharmacists to address this crisis. Pharmacists should be reimbursed for the services they provide to be sustainable.

‘Safer opioid distribution’ as an essential public health intervention for the opioid mortality crisis – Considerations, options and examples towards broad-based implementation

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Canada experiences excessive opioid mortality, mainly from toxic opioid exposure.

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Many interventions have been implemented, but are limited in reach and impact.

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‘Safer opioid distribution’ (SOD) is a crucial preventive measure for overdose.

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SOD needs to be implemented for a large, ‘at-risk’ opioid user population.

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Other community-based public health interventions may guide SOD organization.

Fourth Amendment Protections of Prescription Drug Monitoring Programs: Patient Privacy in the Opioid Crisis

The opioid crisis is one of the largest public health problems in the history of the United States. Prescription drug monitoring programs ("PDMPs")-state databases containing the records of all prescriptions for controlled substances written in the state-have emerged as a means to track opioid prescribing and use. While PDMPs are typically used as a tool for physicians to inform their prescribing practices, many states also permit law enforcement to access PDMPs when investigating controlled substance distribution, often without prior judicial approval. Such law enforcement use of PDMPs raises serious questions of patient privacy. The Fourth Amendment protects individuals from unreasonable searches and seizures where they have a reasonable expectation of privacy and has been interpreted to require law enforcement have probable cause and a search warrant before infringing upon an individual's reasonable expectation of privacy. Several courts have held that patients have no reasonable expectation of privacy, or a severely diminished expectation of privacy, in their prescription drug records held in PDMPs. As support, courts rely on the third-party doctrine because the information is disclosed to physicians and then held by the state; the highly regulated nature of the prescription drug industry; and the statutory framework of the Controlled Substances Act. Such analysis disregards patients' expectation of privacy in their personal health information, the confidentiality in the physician-patient relationship, and the resulting patient incentives not to seek care. Therefore, this Article argues that law enforcement must have probable cause and a search warrant to access PDMPs because the exceptions to the Fourth Amendment's probable cause and warrant requirements do not apply.

Predictive Modeling of Opioid Overdose Using Linked Statewide Medical and Criminal Justice Data

IMPORTANCE

Responding to the opioid crisis requires tools to identify individuals at risk of overdose. Given the expansion of illicit opioid deaths, it is essential to consider risk factors across multiple service systems.

OBJECTIVE

To develop a predictive risk model to identify opioid overdose using linked clinical and criminal justice data.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional sample was created using 2015 data from 4 Maryland databases: all-payer hospital discharges, the prescription drug monitoring program (PDMP), public-sector specialty behavioral treatment, and criminal justice records for property or drug-associated offenses. Maryland adults aged 18 to 80 years with records in any of 4 databases were included, excluding individuals who died in 2015 or had a non-Maryland zip code. Logistic regression models were estimated separately for risk of fatal and nonfatal opioid overdose in 2016. Model performance was assessed using bootstrapping. Data analysis took place from February 2018 to November 2019.

EXPOSURES

Controlled substance prescription fills and hospital, specialty behavioral health, or criminal justice encounters.

MAIN OUTCOMES AND MEASURES

Fatal opioid overdose defined by the state medical examiner and 1 or more nonfatal overdoses treated in Maryland hospitals during 2016.

RESULTS

There were 2 294 707 total individuals in the sample, of whom 42.3% were male (n = 970 019) and 53.0% were younger than 50 years (647 083 [28.2%] aged 18-34 years and 568 160 [24.8%] aged 35-49 years). In 2016, 1204 individuals (0.05%) in the sample experienced fatal opioid overdose and 8430 (0.37%) experienced nonfatal opioid overdose. In adjusted analysis, the factors mostly strongly associated with fatal overdose were male sex (odds ratio [OR], 2.40 [95% CI, 2.08-2.76]), diagnosis of opioid use disorder in a hospital (OR, 2.93 [95% CI, 2.17-3.80]), release from prison in 2015 (OR, 4.23 [95% CI, 2.10-7.11]), and receiving opioid addiction treatment with medication (OR, 2.81 [95% CI, 2.20-3.86]). Similar associations were found for nonfatal overdose. The area under the curve for fatal overdose was 0.82 for a model with hospital variables, 0.86 for a model with both PDMP and hospital variables, and 0.89 for a model that further added behavioral health and criminal justice variables. For nonfatal overdose, the area under the curve using all variables was 0.85.

CONCLUSIONS AND RELEVANCE

In this analysis, fatal and nonfatal opioid overdose could be accurately predicted with linked administrative databases. Hospital encounter data had higher predictive utility than PDMP data. Model performance was meaningfully improved by adding PDMP records. Predictive models using linked databases can be used to target large-scale public health programs.

Opioid-related overdose deaths among African Americans: Implications for research, practice and policy

Opioid-related overdose deaths among African Americans have only recently received national attention despite evidence of increase in death rates among this population spanning the past decade. Numerous authors have highlighted how the 'opioid epidemic' has largely been portrayed as a problem mostly affecting White America. The purpose of this commentary is to provide a synthesis spotlighting the unique structural and cultural considerations involved in research, practice and policy related to opioid use and treatment for opioid use disorders among African Americans. The commentary concludes with considerations for future research and practice intended to reduce deaths among this group.