Major increases in opioid analgesic abuse in the United States: concerns and strategies

Medically Unexplained Physical Symptoms: What They Are and Why Counseling Psychologists Should Care about Them

Medically unexplained symptoms and syndromes (MUS) affect the health of 20%-30% of patients seen in primary care. Optimally, treatment for these patients requires an interdisciplinary team consisting of both primary care and mental health providers. By developing an expertise in MUS, counseling psychologists can improve the care of patients with MUS who are already in their practice, expand the number of patients they help, and enhance the integration of counseling psychology into the broader medical community. Additionally, counseling psychologists' expertise in culture, attunement to therapeutic processes, and our focus on prioritizing patients' perspectives and quality of life can fill the gap in research on MUS and bringing increased attention to counseling psychologists' unique contributions to health service delivery.

U.S. prescribing trends of fentanyl, opioids, and other pain medications in outpatient and emergency department visits from 2006 to 2015

The United States is currently facing an epidemic of opioid-related deaths, increasingly associated with fentanyl use. Our objective was to characterize rates of fentanyl, general opioid and non-opioid pain medication prescription at a national level in both outpatient and emergency department settings. We used a retrospective cross-sectional research design using data from the 2006-2015 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. Between 2006-2015, 66,987 (17.4%) of 390,538 office-based outpatient visits (nationally-representative of 961 million visits) and 134,953 (45.0%) of 305,570 ED visits (nationally-representative of 130 million visits) listed a pain medication prescription. The proportion of all outpatient visits in which any pain medication was prescribed increased from 15.0% in 2006-2007 to 20.5% in 2014-2015 (p < 0.001). The proportion of all outpatient visits in which any fentanyl product was prescribed remained stable at 0.3% and 0.4% (p = 0.32), but increased among ED visits from 0.5% to 1.1% (p = 0.006). In contrast, the proportion of all outpatient visits in which any opioid product was prescribed increased from 6.6% to 9.7% (p < 0.001), but remained relatively stable among ED visits from 26.2% to 24.4% (p = 0.07). Non-opioid pain medication prescription increased in both settings, from 9.7% to 13.7% (p < 0.001) in the outpatient setting and from 25.6% to 27.6% (p = 0.02) in the ED setting between 2006-2007 and 2014-2015, respectively. To address current opioid crisis, both clinical and public health interventions are needed, such as targeted education outreach on evidence-based opioid prescribing and non-opioid alternatives.

Review of Factors, Methods, and Outcome Definition in Designing Opioid Abuse Predictive Models

Objective

Several opioid risk assessment tools are available to prescribers to evaluate opioid analgesic abuse among chronic patients. The objectives of this study are to 1) identify variables available in the literature to predict opioid abuse; 2) explore and compare methods (population, database, and analysis) used to develop statistical models that predict opioid abuse; and 3) understand how outcomes were defined in each statistical model predicting opioid abuse.

Design

The OVID database was searched for this study. The search was limited to articles written in English and published from January 1990 to April 2016. This search generated 1,409 articles. Only seven studies and nine models met our inclusion-exclusion criteria.

Results

We found nine models and identified 75 distinct variables. Three studies used administrative claims data, and four studies used electronic health record data. The majority, four out of seven articles (six out of nine models), were primarily dependent on the presence or absence of opioid abuse or dependence (ICD-9 diagnosis code) to define opioid abuse. However, two articles used a predefined list of opioid-related aberrant behaviors.

Conclusions

We identified variables used to predict opioid abuse from electronic health records and administrative data. Medication variables are the recurrent variables in the articles reviewed (33 variables). Age and gender are the most consistent demographic variables in predicting opioid abuse. Overall, there is similarity in the sampling method and inclusion/exclusion criteria (age, number of prescriptions, follow-up period, and data analysis methods). Intuitive research to utilize unstructured data may increase opioid abuse models' accuracy.

Factors Influencing Judgments to Consult Prescription Monitoring Programs: A Factorial Survey Experiment

BACKGROUND

Prescription monitoring programs (PMPs) can provide health care professionals with valuable information. However, few studies have explored providers' decision making for accessing PMPs.

AIMS

This study aimed to identify provider characteristics and situational factors most influencing perceived importance of consulting the PMP for patients in a simulated context.

DESIGN

The study used a cross-sectional factorial survey.

SETTINGS

The survey was administered electronically.

PARTICIPANTS/SUBJECTS

Community pharmacists, advanced practice registered nurses (APRNs), and physicians in Iowa.

METHODS

Participants were recruited by mail which included a link to the online survey. The survey consisted of demographic questions, eight randomly generated vignettes, and one ranked item. The vignettes described a hypothetical prescription using eight experimental variables whose levels were randomly varied. Respondents evaluated each vignette for importance to access the PMP. Analyses used linear mixed-effects models in R (Version 3.5.0).

RESULTS

A total of 138 responses were available for multilevel analysis. Women, physicians, and APRNs rated it more important to consult the PMP for a given prescription compared with men and pharmacists. Accessing a PMP was perceived as more important with cash payments, quantity dispensed, suspicion for misuse, hydromorphone and oxycodone prescriptions, and headache. Advancing age, postoperative pain, and anxiety or sleep indications were associated with less importance.

CONCLUSIONS

Age, indication for prescribing, misuse, and payment mode each independently had greater importance to providers in accessing the PMP. This was the first study to isolate the influence of different controlled substances on how important it was to consult the PMP.

Fatality of 33-Year-Old Man Involving Kratom Toxicity

Kratom is an herbal product commonly used for its effects which are similar to opioids and stimulants. Few studies demonstrate the dangers and lethality of Kratom, and most fatalities from Kratom involve other abused substances. In the current case report, a 33-year-old white man with a known history of opioid abuse and mental illnesses was found unresponsive in his basement with no obvious signs of trauma. After resuscitative efforts, he was pronounced dead and taken for autopsy evaluation. Blood from the inferior vena cava was analyzed for common abused substances. The laboratory toxicology work-up revealed positive findings of caffeine, cotinine, and naloxone with low levels of Δ-9 tetrahydrocannabinol. However, a marked level of mitragynine at 1.9 mg/L was observed, the highest reported to date. Given the facts and evidence, the medical examiner certified the cause of death as "mitragynine toxicity" and the manner of death was classified as an "accident."

Synthesizing the Strength of the Evidence of Complementary and Integrative Health Therapies for Pain

Objective

Pain and opioid use are highly prevalent, leading for calls to include nonpharmacological options in pain management, including complementary and integrative health (CIH) therapies. More than 2,000 randomized controlled trials (RCTs) and many systematic reviews have been conducted on CIH therapies, making it difficult to easily understand what type of CIH therapy might be effective for what type of pain. Here we synthesize the strength of the evidence for four types of CIH therapies on pain: acupuncture, therapeutic massage, mindfulness techniques, and tai chi.

Design

We conducted searches of English-language systematic reviews and RCTs in 11 electronic databases and previously published reviews for each type of CIH. To synthesize that large body of literature, we then created an “evidence map,” or a visual display, of the literature size and broad estimates of effectiveness for pain.

Results

Many systematic reviews met our inclusion criteria: acupuncture (86), massage (38), mindfulness techniques (11), and tai chi (21). The evidence for acupuncture was strongest, and largest for headache and chronic pain. Mindfulness, massage, and tai chi have statistically significant positive effects on some types of pain. However, firm conclusions cannot be drawn for many types of pain due to methodological limitations or lack of RCTs.

Conclusions

There is sufficient strength of evidence for acupuncture for various types of pain. Individual studies indicate that tai chi, mindfulness, and massage may be promising for multiple types of chronic pain. Additional sufficiently powered RCTs are warranted to indicate tai chi, mindfulness, and massage for other types of pain.

Considerations of trial design and conduct in behavioral interventions for the management of chronic pain in adults

INTRODUCTION

A growing number and type of nonpharmacological approaches for the management of chronic pain have demonstrated at least modest evidence of efficacy, and for some, there is emerging evidence of their effectiveness in relatively large scale trials. Behavioral approaches are those that generally seek to promote adaptive behavioral change in the service of reducing pain and improving physical and emotional functioning and quality of life. Despite a substantial empirical literature supporting the clinical utility of these approaches, a large number of unanswered questions remain and clinical trials to answer some of these questions are needed. Although considerations for development and enactment of data-analytic plans are generally similar to those in pharmacological trials (eg, intent-to-treat, prespecifying outcomes and time points, and handling of missing data), there may be some important differences to consider when planning and conducting clinical trials examining these behavioral approaches.

OBJECTIVES

The primary objective of this article is to describe some aspects of clinical trials for behavioral approaches for the management of chronic pain that requires special consideration.

METHODS

Important topics discussed include: (1) intervention development, (2) research design considerations (adequate and appropriate control and comparison conditions), (3) appropriate outcomes, (4) recruitment and sampling biases and blinding, (5) intervention fidelity and adherence, and (6) demographic and cultural considerations.

RESULTS AND CONCLUSIONS

A number of methodological recommendations are made in the service of encouraging the conduct of high-quality research comparable with that performed for pharmacological and other medical interventions.

Delta-opioid receptor antagonist naltrindole reduces oxycodone addiction and constipation in mice

Oxycodone, a widely prescribed and very potent oral opioid analgesic agent, is highly addictive and has many side effects, including troublesome constipation. Our studies in mice indicated that pretreatment of naltrindole did not significantly affect the analgesic efficacy of oxycodone but attenuated the tolerance and withdrawal induced by chronic oxycodone administration. Naltrindole also attenuated the oxycodone-induced rewarding and re-instatement behaviors, as shown by the conditioned place preference test. Further, oxycodone-induced decrease in intestinal transit (i.e., constipation) was reduced by naltrindole. However, naltrindole did not block the respiratory depression produced by oxycodone. Taken together, these data suggest that naltrindole can attenuate some major side effects while retaining the analgesic efficacy of oxycodone in mice. Naltrindole and oxycodone may have the potential to be a potent analgesic combination with much lower levels of oxycodone's side effects of addictive liability and constipation.

Effects of Combining a Brief Cognitive Intervention with Transcranial Direct Current Stimulation on Pain Tolerance: A Randomized Controlled Pilot Study

Objective

Cognitive behavioral therapy has been shown to be effective for treating chronic pain, and a growing literature shows the potential analgesic effects of minimally invasive brain stimulation. However, few studies have systematically investigated the potential benefits associated with combining approaches. The goal of this pilot laboratory study was to investigate the combination of a brief cognitive restructuring intervention and transcranial direct current stimulation (tDCS) over the left dorsolateral prefrontal cortex in affecting pain tolerance.

Design

Randomized, double-blind, placebo-controlled laboratory pilot.

Setting

Medical University of South Carolina.

Subjects

A total of 79 healthy adult volunteers.

Methods

Subjects were randomized into one of six groups: 1) anodal tDCS plus a brief cognitive intervention (BCI); 2) anodal tDCS plus pain education; 3) cathodal tDCS plus BCI; 4) cathodal tDCS plus pain education; 5) sham tDCS plus BCI; and 6) sham tDCS plus pain education. Participants underwent thermal pain tolerance testing pre- and postintervention using the Method of Limits.

Results

A significant main effect for time (pre-post intervention) was found, as well as for baseline thermal pain tolerance (covariate) in the model. A significant time × group interaction effect was found on thermal pain tolerance. Each of the five groups that received at least one active intervention outperformed the group receiving sham tDCS and pain education only (i.e., control group), with the exception of the anodal tDCS + education-only group. Cathodal tDCS combined with the BCI produced the largest analgesic effect.

Conclusions

Combining cathodal tDCS with BCI yielded the largest analgesic effect of all the conditions tested. Future research might find stronger interactive effects of combined tDCS and a cognitive intervention with larger doses of each intervention. Because this controlled laboratory pilot employed an acute pain analogue and the cognitive intervention did not authentically represent cognitive behavioral therapy per se, the implications of the findings on chronic pain management remain unclear.

Genomewide Study of Epigenetic Biomarkers of Opioid Dependence in European- American Women

There is currently an epidemic of opioid use, overdose, and dependence in the United States. Although opioid dependence (OD) is more prevalent in men, opioid relapse and fatal opioid overdoses have recently increased at a higher rate among women. Epigenetic mechanisms have been implicated in the etiology of OD, though most studies to date have used candidate gene approaches. We conducted the first epigenome-wide association study (EWAS) of OD in a sample of 220 European-American (EA) women (140 OD cases, 80 opioid-exposed controls). DNA was derived from whole blood samples and EWAS was implemented using the Illumina Infinium HumanMethylationEPIC array. To identify differentially methylated CpG sites, we performed an association analysis adjusting for age, estimates of cell proportions, smoking status, and the first three principal components to correct for population stratification. After correction for multiple testing, association analysis identified three genome-wide significant differentially methylated CpG sites mapping to the PARG, RERE, and CFAP77 genes. These genes are involved in chromatin remodeling, DNA binding, cell survival, and cell projection. Previous genome-wide association studies have identified RERE risk variants in association with psychiatric disorders and educational attainment. DNA methylation age in the peripheral blood did not differ between OD subjects and opioid-exposed controls. Our findings implicate epigenetic mechanisms in OD and, if replicated, identify possible novel peripheral biomarkers of OD that could inform the prevention and treatment of the disorder.

Misuse of prescribed opioids in the United States

PURPOSE

To assess the prevalence and correlates of self-reported misuse of prescribed-opioid medications in the US general population.

METHOD

In 31 068 adult participants of the National Survey on Drug Use and Health (NSDUH) 2015 and 2016 who reported using opioids in the past year, we assessed the prevalence and correlates of self-reported misuse of prescribed opioids, defined as using a larger dose, more frequently, or longer than prescribed. Multivariable logistic-regression models and the machine-learning method of boosted regression were used to identify the correlates of misuse.

RESULTS

On the basis of weighted NSDUH estimates, of more than 89 million US adults who used prescription opioids every year, close to 3.9 million (4.4%) reported misused the prescribed medications. Prescribed-opioid misuse was most strongly associated with co-occurring misuse of opioids without a prescription, misuse of benzodiazepines, other drug-use disorders, history of illegal activity, and psychological distress. Misuse of prescribed opioids was also strongly associated with prescription opioid-use disorder, especially among those who misused more potent opioids or started misusing opioids before the current year.

CONCLUSIONS

Misuse of prescribed opioids is associated with other high-risk behaviors and adverse health outcomes. The findings call for better monitoring of opioid prescription in clinical practice.

Causal inference for evaluating prescription opioid abuse using trend-in-trend design

PURPOSE

One response to the opioid crisis in the United States has been the development of opioid analgesics with properties intended to reduce non-oral use. Previous evaluations of abuse in the community have relied on population averaged interrupted time series Poisson models with utilization offsets. However, competing interventions and secular trends complicate interpretation of time-series analyses. An alternative research design, trend-in-trend, accounts for heterogeneity in per capita opioid dispensing and unmeasured time-varying confounding, which provides a causal evaluation, provided that underlying assumptions are met.

METHODS

Trend-in-trend can be modeled using a logistic regression framework. In logistic regression, exposure was any product-specific outpatient dispensing by three-digit ZIP code and calendar quarter, for 22 opioids. The outcome was any product-specific abuse case ascertained from poison centers and drug treatment programs, covering 94% of the US population, between July 2009 and December 2016. Product-specific odds ratios compared places without dispensing with places with any dispensing; the causal contrast represents the odds of product-specific abuse in the community given exposure.

RESULTS

Dispensing of new and low-volume opioids varied considerably across the country, with no region showing high of all products. Of 22 opioids analyzed, the three with approved labeling as intended to deter abuse ranked near the lowest in both absolute (population-adjusted rates: 1.7, 0.9, and 8.2 per million people per quarter, respectively) and relative measures (trend-in-trend ORs: 1.96, 1.79, 1.69, respectively).

CONCLUSIONS

Postmarketing studies of prescription opioid abuse may benefit by evolving from unadjusted surveillance rates to a causal inference approach.

The in vivo antinociceptive and μ-opioid receptor activating effects of the combination of N-phenyl-2',4'-dimethyl-4,5'-bi-1,3-thiazol-2-amines and naloxone

Morphine is widely used for the treatment of severe pain. This analgesic effect is mediated principally by the activation of μ-opioid receptors (MOR). However, prolonged activation of MOR also results in tolerance, dependence, addiction, constipation, nausea, sedation, and respiratory depression. To address this problem, we sought alternative ways to activate MOR - either by use of novel ligands, or via a novel activation mechanism. To this end, a series of compounds were screened using a sensitive CHO-K1/MOR/Gα15 cell-based FLIPR^® calcium high-throughput screening (HTS) assay, and the bithiazole compound 5a was identified as being able activate MOR in combination with naloxone. Structural modifications of 5a resulted in the discovery of lead compound 5j, which could effectively activate MOR in combination with the MOR antagonist naloxone or naltrexone. In vivo, naloxone in combination with 100 mg/kg of compound 5j elicited antinociception in a mouse tail-flick model with an ED₅₀ of 17.5 ± 4 mg/kg. These results strongly suggest that the mechanism by which the 5j/naloxone combination activates MOR is worthy of further study, as its discovery has the potential to yield an entirely novel class of analgesics.

Potentially Inappropriate Medication Prescriptions for Older Adults with Painful Conditions and Association with Return Emergency Department Visits

OBJECTIVES

To describe the frequency and risk of return visit to the emergency department (ED) by older adults after prescription of any of four potentially inappropriate medication (PIM) classes included in the 2015 Beers Criteria commonly used for the relief of acute pain in the ED.

DESIGN

Retrospective cohort study.

SETTING

Large urban academic ED from January 1, 2013, to December 31, 2015.

PARTICIPANTS

Patients age 65 and older discharged from the ED with an initial pain score of 1 or higher (11 822 visits).

MEASUREMENTS

Prescriptions for PIM classes were collected from the medical record: nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, skeletal muscle relaxants, and opioids. The proportion of patients with ED returns within 9 days were compared by medication class and pain severity (mild, moderate, or severe). Multivariable logistic regression was performed for each pain category to determine adjusted odds ratios (aORs) of ED return.

RESULTS

Of 11 822 included patients, PIMs were prescribed in 3392 (28.7%): 2550 (21.6%) opioids, 826 (7.0%) NSAIDs, 277 (2.3%) benzodiazepines, and 68 (0.6%) nonbenzodiazepine skeletal muscle relaxants. Total 9-day ED returns were 1125 (9.5%): mild 7.0%, moderate 8.3%, and severe pain 11.7%. Opioids were not associated with more frequent ED returns for mild or moderate pain, and they were associated with less frequent ED returns for severe pain (9.2% vs 12.7%; p < .001; aOR 0.69; 95% confidence interval [CI] = 0.54-0.87). Benzodiazepines were associated with more frequent ED returns for patients with moderate pain (15.5% vs 8.2%; p < .01; aOR = 2.01; 95%CI = 1.10-3.70).

CONCLUSIONS

These results are consistent with recommendations to limit benzodiazepine prescriptions for older adults and that among older adults with severe pain, opioid prescribing is associated with less frequent ED visits within 9 days of discharge. However, this study was not designed to evaluate safety, adverse events, or other important patient-centered outcomes. J Am Geriatr Soc 67:719-725, 2019.

Dysregulation of Dopaminergic Regulatory Factors TH, Nurr1, and Pitx3 in the Ventral Tegmental Area Associated with Neuronal Injury Induced by Chronic Morphine Dependence

The ventral tegmental area (VTA), a critical portion of the mesencephalic dopamine system, is thought to be involved in the development and maintenance of addiction. It has been proposed that the dopaminergic regulatory factors TH, Nurr1, and Pitx3 are crucial for determining the survival and maintenance of dopaminergic neurons. Thus, the present study investigated whether abnormalities in these dopaminergic regulatory factors in the VTA were associated with neuronal injury induced by chronic morphine dependence. Rat models with different durations of morphine dependence were established. Thionine staining was used to observe morphological changes in the VTA neurons. Immunohistochemistry and western blot were used to observe changes in the expression of the dopaminergic regulatory proteins TH, Nurr1, and Pitx3. Thionine staining revealed that prolonged morphine dependence resulted in dopaminergic neurons with edema, a lack of Nissl bodies, and pyknosis. Immunohistochemistry showed that the number of TH⁺, Nurr1⁺, and Pitx3⁺ cells, and the number of TH⁺ cells expressing Nurr1 or Pitx3, significantly decreased in the VTA after a long period of morphine dependence. Western blot results were consistent with the immunohistochemistry findings. Chronic morphine exposure resulted in abnormalities in dopaminergic regulatory factors and pathological changes in dopaminergic neurons in the VTA. These results suggest that dysregulation of dopaminergic regulatory factors in the VTA are associated with neuronal injury induced by chronic morphine dependence.

Nonmedical prescription sedative/tranquilizer use in alcohol and opioid use disorders

AIMS

Nonmedical prescription sedative/tranquilizer (e.g., benzodiazepines) use (NMSTU) increases risk of overdose when combined with opioids and/or alcohol. Yet, little is known about NMSTU among those with alcohol and opioid use disorders. We aimed to characterize NMSTU and sedative/tranquilizer use disorder among adults with alcohol use disorder (AUD) and/or opioid use disorder (OUD) in a general population sample.

METHODS

We conducted analyses of 2008-2014 National Survey on Drug Use and Health data; adults with past-year AUD-only (n = 27,416), OUD-only (n = 2142), and co-occurring AUD and OUD (n = 1483) were included (total N = 31,041). Multivariable logistic regression models were utilized to examine correlates of past-month NMSTU and past-year sedative/tranquilizer use disorder. Focal independent variables were polysubstance use (i.e., number of substances used in the previous year) and psychiatric distress.

RESULTS

Among those with AUD-only, 27.1% reported lifetime NMSTU, 7.6% reported past-year NMSTU, 2.7% reported past-month NMSTU, and 0.6% met criteria for past-year sedative/tranquilizer use disorder. Corresponding prevalence rates among those with OUD-only were 69.5%, 43.0%, 22.6%, and 11.3%. Those with co-occurring AUD and OUD displayed the highest rates of NMSTU (e.g., 27.5% with past-month NMSTU) and sedative/tranquilizer use disorder (20.2%). Across groups, more severe polysubstance use and psychiatric distress were associated with increased risk of NMSTU and sedative/tranquilizer use disorder.

CONCLUSIONS

Results of this analysis indicate that >25% of adults with AUD and approximately 70% of those with OUD report lifetime NMSTU. Among these populations, individuals with more polysubstance use and greater psychiatric distress might benefit from targeted interventions to reduce NMSTU.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A prospective study of nonmedical use of prescription opioids during adolescence and subsequent substance use disorder symptoms in early midlife

BACKGROUND

This longitudinal study assesses characteristics associated with adolescents' nonmedical use of prescription opioids (NMUPO) including: frequency, co-ingestion, motives, specific opioid type; sequence of initiation of medical use of prescription opioids and NMUPO in relationship to subsequent substance use disorder (SUD) symptoms.

METHODS

Twenty-one independent national cohorts of U.S. high school seniors (n = 8,373) were surveyed and followed 17 years from adolescence to age 35.

RESULTS

The majority of adolescents who engaged in NMUPO reported occasional/frequent NMUPO, non-pain relief motives for NMUPO, simultaneous co-ingestion involving NMUPO and other drugs, opioid analgesics with high misuse potential, and multiple types of opioid analgesics. Adolescents who reported NMUPO for pain relief, NMUPO involving opioid analgesics with high misuse potential, or multiple prescription opioids had significantly greater odds of SUD symptoms at age 35, relative to those who had no history of NMUPO during adolescence. In addition, medical use of prescription opioids after initiating NMUPO (or NMUPO only) during adolescence was associated with significantly greater odds of subsequent SUD symptoms at age 35 relative to those who reported the medical use of prescription opioids only or had no medical use or NMUPO during adolescence.

CONCLUSIONS

This is the first U.S. national prospective study to examine the relationships between adolescents' NMUPO characteristics and later SUD symptoms in early midlife. Several characteristics (frequency, co-ingestion, motives, opioid type, and medical/NMUPO initiation history) were identified that could be used to screen and detect high-risk youth for indicated interventions to reduce prescription opioid misuse and SUDs.

Combating escalating harms associated with pharmaceutical opioid use in Australia: the POPPY II study protocol

INTRODUCTION

Opioid prescribing has increased 15-fold in Australia in the past two decades, alongside increases in a range of opioid-related harms such as opioid dependence and overdose. However, despite concerns about increasing opioid use, extramedical use and harms, there is a lack of population-level evidence about the drivers of long-term prescribed opioid use, dependence, overdose and other harms.

METHODS AND ANALYSIS

We will form a cohort of all adult residents in New South Wales (NSW), Australia, who initiated prescribed opioids from 2002 using Pharmaceutical Benefits Scheme dispensing records. This cohort will be linked to a wide range of other datasets containing information on sociodemographic and clinical characteristics, health service use and adverse outcomes (eg, opioid dependence and non-fatal and fatal overdose). Analyses will initially examine patterns and predictors of prescribed opioid use and then apply regression and survival analysis to quantify the risks and risk factors of adverse outcomes associated with prescribed opioid use.

ETHICS AND DISSEMINATION

This study has received full ethical approval from the Australian Institute of Health and Welfare Ethics Committee, the NSW Population and Health Services Research Committee and the ACT Health Human Research Ethics Committee. This will be the largest postmarketing surveillance study of prescribed opioids undertaken in Australia, linking exposure and outcomes and examining risk factors for adverse outcomes of prescribed opioids. As such, this work has important translational promise, with direct relevance to regulatory authorities and agencies worldwide. Project findings will be disseminated at scientific conferences and in peer-reviewed journals. We will also conduct targeted dissemination with policy makers, professional bodies and peak bodies in the pain, medicine and addiction fields through stakeholder workshops and advisory groups. Results will be reported in accordance with the REporting of studies Conducted using Observational Routinely collected Data (RECORD) Statement.

Brain systems at the intersection of chronic pain and self-regulation

Chronic pain is a multidimensional experience with cognitive, affective, and somatosensory components that can be modified by expectations and learning. Individual differences in cognitive and affective processing, as well as contextual aspects of the pain experience, render chronic pain an inherently personal experience. Such individual differences are supported by the heterogeneity of brain representations within and across chronic pain pathologies. In this review, we discuss the complexity of brain representations of pain, and, with respect to this complexity, identify common elements of network-level disruptions in chronic pain. Specifically, we identify prefrontal-limbic circuitry and the default mode network as key elements of functional disruption. We then discuss how these disrupted circuits can be targeted through self-regulation and related cognitive strategies to alleviate chronic pain. We conclude with a proposal for how to develop personalized multivariate models of pain representation in the brain and target them with real-time neurofeedback, so that patients can explore and practice self-regulatory techniques with maximal efficiency.

Young, American Indian or Alaskan Native, and born in the USA: at excess risk of starting extra-medical prescription pain reliever use?

BACKGROUND

Prescription pain reliever (PPR) overdoses differentially affect 'American Indian/Alaskan Natives' in the United States (US). Here, studying onset of extra-medical PPR use in 12-24-year-olds, we examine subgroup variations in rates of starting to use prescription pain relievers extra-medically (i.e., to get 'high' or for other reasons outside boundaries of prescriber's intent). Risk differences (RD) are estimated for US-born versus non-US-born young people, stratified by American Indian/Alaskan Natives versus other ethnic self-identities.

METHODS

Between 2002-2009, nationally representative cross-sectional samples of 12-24-year-old non-institutionalized civilians completed interviews for the US National Surveys of Drug Use and Health. Analysis-weighted annual incidence estimates, RD, and confidence intervals (CI) are from the Restricted-use Data Analysis System, an online software tool for US National Surveys of Drug Use and Health.

RESULTS

Each year, an estimated 2.5% of 12-24-year-olds in the US start using PPR extra-medically (95% CI [2.1%-3.0%]). Estimates for the US-born (3.8%; 95% CI [3.7%-3.9%]) are larger (non-US-born: 1.8%; 95% CI [1.5%-2.0%]; RD = 2.0; p < 0.05). US-born American Indian/Alaskan Natives youths have the largest incidence rate (4.8%). Robust RD for US-born can be seen for 'non-Hispanic White' subgroups, and for others (e.g., 'Cuban', 'Dominican').

DISCUSSION

Each year, one in 20 of US-born American Indian/Alaskan Natives starts using PPR extra-medically. Overdose prevention is important, but is no substitute for primary prevention initiatives for all young people. The observed epidemiological patterns can guide targeted prevention initiatives for the identified higher risk subgroups in complement with more universal prevention efforts intended to reduce incidence of first extra-medical PPR use, a crucial rate-limiting step on the path toward more serious drug involvement (i.e., progressing past initial use).

[The use of prescription drugs with dependence potential in Germany : A prospective analysis of prescriptions in the public healthcare system between 2006 and 2010]

BACKGROUND

In Germany, about 1.4 to 2.6 million people are dependent on prescription drugs, mainly benzodiazepine derivatives and opioid analgesics. Despite this large number of affected people, studies on prescription behaviour and drug intake are scarce. There are particularly few empirical findings available with regard to elderly people age 65 and over who are disproportionally affected by prescription drug abuse.

METHODS

The North German Pharmacy Computing Centre (Norddeutsches Apothekenrechenzentrum, NARZ) collects the prescription data of about 11 million citizens and covers over 80% of drug pharmacies in North Germany. Based on the data from NARZ, we evaluate person-related prescriptions of benzodiazepines, Z‑drugs and opioid analgesics. By means of incremental calculations, we determine the prevalence of prescription drug use, the long-term intake, the average daily dose of these medications and present this information as a five-year trend (2006-2010).

RESULTS

In 2006, 10.6% of the members of public healthcare system were prescribed at least one of the medications under study. This proportion hardly changed within the five-year span. The share of patients with benzodiazepine prescription steadily decreased from 2006 (5.5%) to 2010 (5.1%), especially among elderly people. While the prevalence of Z‑drug prescriptions remained the same at about 1%, there was a slight increase in prescriptions of opioid analgesics with 5.4% in 2006 to 5.7% in 2010. The proportion of patients with long-term prescriptions decreased with regard to benzodiazepines (from 17.0 to 12.8%) and Z‑drugs (from 24.3 to 21.2%), but increased for opioid analgesics (from 19.2 to 21.2%).

CONCLUSION

The analytical method used in this study is an innovative epidemiological approach to evaluate person-related register data over the course of several years. Establishing a monitoring system of prescription drugs with potential for dependence may allow for a quicker identification of trends and initiation of appropriate measures.

On the front lines of the opioid epidemic: Rescue by naloxone

Naloxone is a specific, high affinity opioid antagonist that has been used to treat suspected or confirmed overdose for more than 40 years. Naloxone use was initially confined to an emergency room setting, but the dramatic rise in opioid overdose events over the past two decades has, with increasing frequency, shifted naloxone use to first responders including police, emergency medical technicians, and the friends and family of overdose victims. The opioids responsible for overdose events have also evolved, from prescription opioids to heroin and most recently, very high potency synthetic opioids such as fentanyl. In 2016, synthetic opioids were linked to more overdose fatalities than either prescription opioids or heroin. In this review, I will discuss the evolution and use of naloxone products by first responders and the development of additional rescue medications in response to the unprecedented dangers posed by synthetic opioids.

Federal Response to the Opioid Crisis

PURPOSE OF REVIEW

In light of the current crisis in opioid involved overdose deaths, the federal Department of Health and Human Services operating divisions are working together to implement a data-driven, research-based strategy to reduce opioid misuse and its consequences.

RECENT FINDINGS

The strategy has five elements: (1) strengthening public health data collection and reporting; (2) advancing the practice of pain management; (3) improving access to addiction prevention, treatment, and recovery support services; (4) increasing availability of overdose-reversing drugs; and (5) supporting cutting-edge research in treatment of pain, opioid use disorder, and associated conditions. The Department of Health and Human Services has developed a concerted, coordinated evidence-based effort across department divisions to reduce opioid misuse, prevalence of opioid use disorder, and reduce deaths due to opioid use.

Implementing Treatment of Opioid-Use Disorder in Rural Settings: a Focus on HIV and Hepatitis C Prevention and Treatment

PURPOSE OF REVIEW

To describe the epidemiology of opioid-use disorder in the rural United States (U.S.) as it pertains to HIV and hepatitis C transmission and treatment resources.

RECENT FINDINGS

Heroin and fentanyl analogs have surpassed prescription opioids in their availability in rural opioid markets adding to HIV and hepatitis C (HCV) and overdose risks. Only 18% of rural individuals live in towns with inpatient services which are of limited quality and utility. Opioid treatment programs that provide methadone are not located in rural areas and only 3% of the primary care providers have the ability to prescribe buprenorphine. National models and resources have been established but lack implementation in rural areas leading to ongoing HIV and HCV transmission and overdose. Addressing the adverse impact of opioids in the rural U.S. will require a concerted effort to implement effective treatments according to national standards.

Chronic Oxycodone Self-administration Altered Reward-related Genes in the Ventral and Dorsal Striatum of C57BL/6J Mice: An RNA-seq Analysis

Prescription opioid abuse, for example of oxycodone, is a pressing public health issue. This study focuses on how chronic oxycodone self-administration (SA) affects the reward pathways in the mouse brain. In this study, we tested the hypothesis that the expression of reward-related genes in the ventral and dorsal striatum, areas involved in different aspects of opioid addiction models, was altered within 1 h after chronic oxycodone SA, using transcriptome-wide sequencing (RNA-seq). Based on results from earlier human genetic and rodent preclinical studies, we focused on a set of genes that may be associated with the development of addictive diseases and the rewarding effect of drugs of abuse, primarily in the opioid, stress response and classical neurotransmitter systems. We found that 32 transcripts in the ventral striatum, and 7 in the dorsal striatum, were altered significantly in adult mice that had self-administered oxycodone (n = 5) for 14 consecutive days (4 h/day) compared with yoked saline controls (n = 5). The following 5 genes in the ventral striatum showed experiment-wise significant changes: proopiomelanocortin (Pomc) and serotonin 5-HT-2A receptor (Htr2a) were upregulated; serotonin receptor 7 (Htr7), galanin receptor1 (Galr1) and glycine receptor 1 (Glra1) were downregulated. Some genes detected by RNA-seq were confirmed by quantitative polymerase chain reaction (qPCR). Conclusion: A RNA-seq study shows that chronic oxycodone SA alters the expression of several reward-related genes in the dorsal and ventral striatum. These results suggest potential mechanisms underlying neuronal adaptation to chronic oxycodone self-exposure, of relevance to our mechanistic understanding of prescription opioid abuse.

Opioid Misuse as a Predictor of Alcohol Treatment Outcomes in the COMBINE Study: Mediation by Medication Adherence

BACKGROUND

Alcohol is often consumed with opioids and alcohol misuse interferes with treatment for opioid use disorder (OUD). Drug misuse is associated with worse alcohol use disorder (AUD) treatment outcomes, yet no studies have investigated the role of opioid misuse in AUD treatment outcomes.

METHODS

We conducted secondary analyses of the medication conditions of the COMBINE study (n = 1,226), a randomized clinical trial of medications (acamprosate and/or naltrexone) and behavioral interventions (medication management and/or behavioral intervention) for alcohol dependence. We examined associations between baseline opioid misuse and the use of cannabis and other drugs with time to first drinking day, time to first heavy drinking day, and the frequency and intensity of drinking during treatment and 1 year following treatment, based on latent profile analysis. Opioid misuse was defined as use of illicit or prescription opioids without a prescription or not as directed in the previous 6 months, in the absence of OUD. Self-reported cannabis and other drug use were also examined. Seventy individuals (5.7%) met the opioid misuse definition and 542 (44.2%) reported use of cannabis or other drugs without opioid misuse. We also examined medication adherence as a potential mediator.

RESULTS

Baseline opioid misuse significantly predicted the time to first heavy drinking day (OR = 1.38 [95% CI: 1.13, 1.64], p = 0.001) and a higher probability of being in a heavier and more frequent drinking profile at the end of treatment (OR = 2.90 [95% CI: 1.43, 5.90], p = 0.003), and at 1 year following treatment (OR = 2.66 [95% CI: 1.26, 5.59], p = 0.01). Cannabis and other drug use also predicted outcomes. Medication adherence partially mediated the association between opioid misuse, cannabis use, other drug use, and treatment outcomes.

CONCLUSIONS

Opioid misuse and other drug use were associated with poorer AUD treatment outcomes, which was partially mediated by medication adherence. Clinicians and researchers should assess opioid misuse and other drug use in patients undergoing AUD treatment.

The future of the international drug control system and national drug prohibitions

A major impediment to any nation abandoning the policy of drug prohibition has been the fact that international drug treaties to which the majority of United Nations (UN) member states are signatory prohibit the non-medical use of amphetamines, cannabis, cocaine and heroin. The future of these treaties is now uncertain because of decisions by Uruguay, eight US states and Canada to legalize cannabis use. This paper: (1) provides a brief account of the international drug control treaties; (2) outlines the major criticisms of the treaties; (3) analyses critically proposals for treaty reform; and (4) provides a personal view on policies that nation states could adopt to minimize the harms from the use of cannabis, party drugs and hallucinogens, opioids, stimulants and new psychoactive substances. It is argued that: a major risk of cannabis legalization in the United States is promotion of heavy use and increased harm by a weakly regulated industry; some cautious national experiments with the regulation of party drugs and hallucinogens would be informative; a strong case remains for prohibiting the nonmedical use of opioids while mitigating the adverse effects that this policy has on opioid-dependent people; stimulant legalization will probably increase problem use but prohibition is difficult to enforce, highlighting the urgency of finding better ways to reduce demand for these drugs and respond to problem users; and that it is unclear what the best approach is to reducing possible harms that may arise from the use of new psychoactive substances.

High-Risk Prescription Opioid Use Among People Living With HIV

BACKGROUND

Prescription opioid use is greater among people living with HIV (PLWH), yet little is known about the prevalence of specific types of high-risk use among these individuals.

SETTING

We analyzed clinical and demographic data from the HIV Research Network and prescribing data from Medicaid for noncancer patients seeking HIV treatment at 4 urban clinics between 2006 and 2010.

METHODS

HIV Research Network patients were included in the analytic sample if they received at least one incident opioid prescription. We examined 4 measures of high-risk opioid use: (1) high daily dosage; (2) early refills; (3) overlapping prescriptions; and (4) multiple prescribers.

RESULTS

Of 4605 eligible PLWH, 1814 (39.4%) received at least one incident opioid prescription during follow-up. The sample was 61% men and 62% African American with a median age of 44.5 years. High-risk opioid use occurred among 30% of incident opioid users (high daily dosage: 7.9%; early refills: 15.9%; overlapping prescriptions: 16.4%; and multiple prescribers: 19.7%). About half of the cumulative incidence of high-risk use occurred within 1 year of receiving an opioid prescription. After adjusting for study site, high-risk opioid use was greater among patients with injection drug use as an HIV risk factor [adjusted hazard ratio (aHR) = 1.39, 95% confidence interval: 1.11 to 1.74], non-Hispanic whites [aHR = 1.61, (1.21 to 2.14)], patients age 35-45 [aHR = 1.94, (1.33 to 2.80)] and 45-55 [aHR = 1.84, (1.27 to 2.67)], and patients with a diagnosis of chronic pain [aHR = 1.32, (1.03 to 1.70)].

CONCLUSIONS

A large proportion of PLWH received opioid prescriptions, and among these opioid recipients, high-risk opioid use was common. High-risk use patterns often occurred within the first year, suggesting this is a critical time for intervention.

Problematic Use of Prescription Opioids and Medicinal Cannabis Among Patients Suffering from Chronic Pain

Objective

To assess prevalence rates and correlates of problematic use of prescription opioids and medicinal cannabis (MC) among patients receiving treatment for chronic pain.

Design

Cross-sectional study.

Setting

Two leading pain clinics in Israel.

Subjects

Our sample included 888 individuals receiving treatment for chronic pain, of whom 99.4% received treatment with prescription opioids or MC.

Methods

Problematic use of prescription opioids and MC was assessed using DSM-IV criteria, Portenoy’s Criteria (PC), and the Current Opioid Misuse Measure (COMM) questionnaire. Additional sociodemographic and clinical correlates of problematic use were also assessed.

Results

Among individuals treated with prescription opioids, prevalence of problematic use of opioids according to DSM-IV, PC, and COMM was 52.6%, 17.1%, and 28.7%, respectively. Among those treated with MC, prevalence of problematic use of cannabis according to DSM-IV and PC was 21.2% and 10.6%, respectively. Problematic use of opioids and cannabis was more common in individuals using medications for longer periods of time, reporting higher levels of depression and anxiety, and using alcohol or drugs. Problematic use of opioids was associated with higher self-reported levels of pain, and problematic use of cannabis was more common among individuals using larger amounts of MC.

Conclusions

Problematic use of opioids is common among chronic pain patients treated with prescription opioids and is more prevalent than problematic use of cannabis among those receiving MC. Pain patients should be screened for risk factors for problematic use before initiating long-term treatment for pain-control.

Ventilatory-depressant effects of opioids alone and in combination with cannabinoids in rhesus monkeys

Pain is a serious health problem that is commonly treated with opioids, although the doses of opioids needed to treat pain are often similar to those that decrease respiration. Combining opioids with drugs that relieve pain through non-opioid mechanisms can decrease the doses of opioids needed for analgesia, resulting in an improved therapeutic window, but only if the doses of opioids that decrease respiration are not similarly decreased. Using small doses of opioids to treat pain has the potential to reduce the number of overdoses and deaths. This study investigated whether the cannabinoid receptor agonists Δ⁹-tetrahydrocannabinol (Δ⁹-THC) and CP 55,940 modify the ventilatory-depressant effects of morphine and fentanyl in three monkeys. Ventilatory parameters, including minute volume (V_E), were monitored with a head plethysmograph. When given alone, morphine (0.032 - 10 mg/kg) and fentanyl (0.00032 - 0.1 mg/kg) dose dependently decreased V_E. Doses of Δ⁹-THC (1 mg/kg) and CP 55,940 (0.01 mg/kg) that enhance the potency of opioids to produce antinociception modestly decreased ventilation when given alone but did not significantly change morphine or fentanyl dose-effect curves. A larger dose of CP 55,940 (0.032 mg/kg) shifted the fentanyl dose-effect curve downward in two monkeys, without significantly changing the morphine dose-effect curve. In summary, cannabinoid receptor agonists, which increase the potency of opioids to produce antinociception, did not increase their potency to depress ventilation. Thus, the therapeutic window is greater for opioids when they are combined with cannabinoid receptor agonists, indicating a possible advantage for these drug mixtures in treating pain.

Intravenous Low-Dose Ketamine Provides Greater Pain Control Compared to Fentanyl in a Civilian Prehospital Trauma System: A Propensity Matched Analysis

Objective: A few studies report comparable analgesic efficacy between low-dose ketamine and opioids such as morphine or fentanyl; however, limited research has explored the safety and effectiveness of intravenous low-dose ketamine as a primary analgesic in a civilian prehospital setting. The objective of this study is to compare pain control between low-dose ketamine and fentanyl when administered intravenously (IV) for the indication of severe pain. Methods: This was a retrospective, observational review of prehospital adult patients (≥18 years) who presented with severe pain (numeric rating scale, 7-10) and were treated solely with either low-dose ketamine IV or fentanyl IV between January 1, 2014 and December 31, 2016. Propensity matched analysis was performed adjusting for all baseline variables with p ≤ 0.10 and for baseline pain score to match ketamine and fentanyl patients on a one-to-one ratio. The primary outcome was change in pain score from baseline to after treatment and evaluated with a paired t-test. Secondary outcomes were changes in vital signs and Glasgow coma scale (GCS) from baseline to after treatment, as well as incidence of clinically significant adverse events (AEs); AEs were followed from scene arrival through emergency department discharge. Results: Propensity matched analysis produced 79 matched pairs. Ketamine IV patients, receiving a mean (SD) dose of 0.3 (0.1) mg/kg, showed a significantly larger mean decrease in pain after treatment, compared to the fentanyl IV patients (-5.5 (3.1) vs. -2.5 (2.4), p < 0.001). A significantly greater proportion of patients receiving ketamine IV achieved at least a 50% reduction in pain compared to those receiving fentanyl IV (67% vs. 19%, p < 0.001), marking 52 ketamine IV patients as responders to treatment. Vital signs demonstrated a nonsignificant decrease in blood pressure, respiratory rate, heart rate, and GCS. No clinically significant AEs were reported for patients receiving ketamine IV. Conclusion: The significant reduction in pain, significantly high proportion of ketamine responders, and the lack of clinically significant AEs characterizing patients receiving low-dose ketamine IV compared to fentanyl IV, all provide further support for its use as an effective prehospital analgesic. Level of Evidence: Level III, therapeutic.

Risk Factors for Opioid Use Disorders in Adult Postsurgical Patients

The use of opioids in the treatment of chronic pain is one of the most controversial topics in medicine today. Many studies have proposed that the postoperative period is a vulnerable time for patients at risk for developing an opioid use disorder. Many patients are prescribed opioids for management of their postsurgical pain and continue using them for prolonged amounts of time following their surgeries. Some populations are more likely to develop an opioid use disorder following exposure to opioid medications than others. In this review, the authors discuss the patient-level risk factors for the abuse of these drugs in postsurgical patients.

Oral Abuse Potential, Pharmacokinetics, and Safety of Once-Daily, Single-Entity, Extended-Release Hydrocodone (HYD) in Recreational Opioid Users

Objectives. A once-daily, extended-release hydrocodone bitartrate tablet with abuse-deterrent properties (Hysingla ER [HYD]) is available for the treatment of chronic pain in appropriate patients. This study evaluated the oral abuse potential and pharmacokinetics (PK) of HYD intact, chewed, or milled to fine particles in comparison with hydrocodone solution or placebo.

Design. Single-center, double-blind, randomized, five-period, five-treatment crossover study.

Subjects. Healthy adult, nondependent, recreational opioid users.

Methods. Forty subjects received orally administered treatments of hydrocodone 60 mg solution, HYD 60 mg intact, HYD 60 mg chewed, HYD 60 mg milled to fine particles, or placebo, separated by a five- to seven-day washout. Assessments over 36 hours postdose included subjective measures of drug liking and willingness to take drug again (assessed using visual analog scales [VAS]), pupillometry, PK, and safety measures.

Results. Following oral administration, HYD intact, HYD chewed, and HYD fine particles led to significantly lower “at this moment” drug liking compared with hydrocodone solution. HYD intact and chewed were significantly different from hydrocodone solution on overall drug liking, take drug again, and good effects. Pupil constriction, as measured by pupillometry, occurred later with HYD intact and HYD chewed than with hydrocodone solution. Across treatments (hydrocodone solution, HYD fine particles, HYD chewed, and HYD intact, respectively), mean C_max and rate of absorption (C_max/T_max) values decreased, respectively, and median T_max values increased, respectively. Safety was consistent with the known effects of opioid agonists.

Conclusion. HYD demonstrated reduced oral abuse potential compared with hydrocodone solution in healthy adult, nondependent, recreational opioid users.*

Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population

Importance

Opioid-related mortality increased by 15.6% from 2014 to 2015 and increased almost 320% between 2000 and 2015. Recent research finds that the use of all pain medications (opioid and nonopioid collectively) decreases in Medicare Part D and Medicaid populations when states approve medical cannabis laws (MCLs). The association between MCLs and opioid prescriptions is not well understood.

Objective

To examine the association between prescribing patterns for opioids in Medicare Part D and the implementation of state MCLs.

Design, Setting, and Participants

Longitudinal analysis of the daily doses of opioids filled in Medicare Part D for all opioids as a group and for categories of opioids by state and state-level MCLs from 2010 through 2015. Separate models were estimated first for whether the state had implemented any MCL and second for whether a state had implemented either a dispensary-based or a home cultivation only-based MCL.

Main Outcomes and Measures

The primary outcome measure was the total number of daily opioid doses prescribed (in millions) in each US state for all opioids. The secondary analysis examined the association between MCLs separately by opioid class.

Results

From 2010 to 2015 there were 23.08 million daily doses of any opioid dispensed per year in the average state under Medicare Part D. Multiple regression analysis results found that patients filled fewer daily doses of any opioid in states with an MCL. The associations between MCLs and any opioid prescribing were statistically significant when we took the type of MCL into account: states with active dispensaries saw 3.742 million fewer daily doses filled (95% CI, -6.289 to -1.194); states with home cultivation only MCLs saw 1.792 million fewer filled daily doses (95% CI, -3.532 to -0.052). Results varied by type of opioid, with statistically significant estimated negative associations observed for hydrocodone and morphine. Hydrocodone use decreased by 2.320 million daily doses (or 17.4%) filled with dispensary-based MCLs (95% CI, -3.782 to -0.859; P = .002) and decreased by 1.256 million daily doses (or 9.4%) filled with home-cultivation-only-based MCLs (95% CI, -2.319 to -0.193; P = .02). Morphine use decreased by 0.361 million daily doses (or 20.7%) filled with dispensary-based MCLs (95% CI, -0.718 to -0.005; P = .047).

Conclusions and Relevance

Medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population. This finding was particularly strong in states that permit dispensaries, and for reductions in hydrocodone and morphine prescriptions.

Prevalence of borrowing and sharing prescription medicines and associated socio-demographic factors: findings from COBERS health centres in northern Uganda

BACKGROUND

The use of prescription medications without the involvement of medical professionals is a growing public health concern. Therefore this study was conducted to determine the prevalence of borrowing and sharing prescription medicines and associated socio-demographic factors among community members who had sought health care from COBERS health centres.

METHODS

We conducted analytical cross - sectional study among former patients who sought treatment during the two months period prior to data collection in nine COBERS health centres. We used cluster proportional-to-size sampling method to get the numbers of research participants to be selected for interview from each COBERS site and logistic regression model was used to assess the associations.

RESULTS

The prevalence of borrowing prescription medication was found to be 35.9% (95% CI 33.5-38.2%) and sharing prescription medication was 32.7% (95% CI 30.4-34.9%). The Socio-demographic factors associated with borrowing prescription medicines were: age group ≤19 years (AOR = 2.64, 95%CI 1.47-4.74, p-value = 0.001); age group 20-29 years (AOR = 2.78, 95%CI 1.71-4.50, p-value≤0.001); age group 30-39 years (AOR = 1.90, 95%CI 1.18-3.06, p-value = 0.009); age group 40-49 (AOR = 1.83, 95%CI 1.15-2.92, p-value = 0.011); being a female (AOR = 2.01, 1.58-2.55, p-value< 0.001); being a Pentecostal by faith (AOR = 1.69, 95%CI 1.02-2.81, p-value = 0.042) and being Employed Salary Earner (AOR = 0.44, 95%CI 0.25-0.78, p-value = 0.005). The socio-demographic factors associated with sharing prescription medicines were: age group ≥19 years (AOR = 4.17, 95%CI 2.24-7.76, p-value< 0.001); age group 20-29 years (AOR = 3.91, 95%CI 2.46-6.29, p-value< 0.001); age group 30-39 years (AOR = 2.94, 95%CI 2.05-4.21, p-value< 0.001); age group 40-49 years (AOR = 2.22, 95%CI 1.29-3.82, p-value = 0.004); being female (AOR = 2.50, 95%CI 1.70-3.47, p-value< 0.001); being Pentecostal by faith (AOR = 2.15, 95%CI 1.15-4.03, p-value = 0.017); and being engaged in business (AOR = 1.80, 95%CI 1.16-2.80, p-value = 0.009).

CONCLUSION

A high proportion of study participants had borrowed or shared prescription medicines during the two months prior to our study. It is recommended that stakeholders sensitise the community members on the danger of borrowing and sharing prescription medicines to avert the practice.

A Descriptive Examination of Nonmedical Fentanyl Use in the United States: Characteristics of Use, Motives, and Consequences

Little is currently known about nonmedical fentanyl use (NFU; that is, use of illicit or pharmaceutically produced fentanyl without a prescription or in ways other than prescribed) despite increases in prevalence and consequences (e.g., overdose, fatality). Individuals with a lifetime history of NFU ( N = 122) in the United States completed an online survey assessing demographics and factors related to use. Results revealed diversion of prescriptions, unintentional use of illicit fentanyl, and high co-occurrence of mental illness and other illicit substance use among users. Commonly reported motives reflected negative/positive reinforcement (e.g., to relieve stress, to get high) and relieving pain/physical discomfort, regardless of frequency of use. More severe consequences (e.g., increased tolerance, withdrawal) were reported among high frequency users. This descriptive examination of NFU may aid in the identification of individuals at-risk for use, promote an understanding of reasons for use, and guide prevention and intervention developments.

Opioid use and harms associated with a sustained-release tapentadol formulation: a postmarketing study protocol

INTRODUCTION

It has been argued that tapentadol may pharmacologically have lower abuse potential than other pharmaceutical opioids currently available. However, there has been no comprehensive triangulation of data regarding use and harms associated with this formulation. A sustained-release formulation (SRF) of tapentadol (Palexia) was released in Australia in 2011 and listed for public subsidy in 2013. We summarise here the methods of a postmarketing study which will measure postintroduction: (1) population level availability, (2) extramedical use and diversion, (3) attractiveness for extramedical use and (4) associated harms, of tapentadol compared against other pharmaceutical opioids.

METHODS AND ANALYSIS

We evaluated key sources on pharmaceutical use and harms in Australia. This review indicateddata from four sources that disaggregate pharmaceutical opioid formulations and capture tapentadol SRF could be triangulated. These data sources comprised: (1) national pharmaceutical opioid community sales data from 2011 to 2017, (2) national pharmaceutical opioid poisonings reported to Poison Information Centres (PICs) from 2011 to 2017, (3) number of vendors on online marketplaces listing pharmaceutical opioids for sale and (4) data on pharmaceutical opioid extramedical use, attractiveness and harms from interviews with people who regularly inject drugs in Australia.

ETHICS AND DISSEMINATION

Ethics approval is not required for use of pharmaceutical sales data. Ethics approval has been obtained for use of national pharmaceutical opioid poisonings reported to PICs (LNR/16/SCHN/44) and for use of online marketplace data and interview data from people who inject drugs (HC12086). Key findings will be published mid-2018 in a peer-reviewed academic journal, and presented at various conferences and professional meetings.

Pharmacoepidemiologic analyses of opioid use among OEF/OIF/OND veterans

Pharmacoepidemiologic analysis found that OEF/OIF/OND veterans have high rates of opioid use, characterized by moderate dose intensity and long treatment duration.

There is a great deal of concern about opioid use in veterans, particularly those who served in Afghanistan (OEF) and Iraq (OIF and OND). The current study provides a detailed pharmacoepidemiologic analysis of opioid use among OEF/OIF/OND veterans from FY09 to FY12. Data from 3 data repositories from the Veterans Health Administration (VHA) were used to describe demographic, clinical, and medication characteristics associated with opioid use among OEF/OIF/OND veterans and among those with TBI. Logistic regression models were used to identify risks associated with chronic opioid use in FY12. Approximately 23% of all OEF/OIF/OND veterans and 35% of those with TBI received any opioid medications. Most received moderate doses ranging from 26 to 30 mg morphine equivalent dose daily. Median days of opioid use for all OEF/OIF/OND veterans were 30 to 40 days. Factors associated with chronic use in both groups included young age, male sex, white race, being married, and living in rural areas. A diagnosis of PTSD (odds ratio [OR] = 1.22, P < 0.0001), major depressive disorder (OR = 1.14, P < 0.0001), and tobacco use disorder (OR = 1.18, P < 0.0001) were strongly associated with chronic opioid use. Back pain was also strongly associated with chronic use (OR = 2.50, P < 0.0001). As pain severity increased the odds of chronic opioid use also increased: mild pain (OR = 3.76, P < 0.0001), moderate pain (OR = 6.80, P < 0.0001), and severe pain (OR = 8.49, P < 0.0001). Opioid use among OEF/OIF/OND veterans is characterized by moderate doses that are used over relatively long periods of time by a minority of veterans.

Increase in Drug Overdose Deaths Involving Fentanyl-Rhode Island, January 2012-March 2014

Objective

This study identified sociodemographic, substance use, and multiple opioid prescriber and dispenser risk factors among drug overdose decedents in Rhode Island, in response to an increase in overdose deaths (ODs) involving fentanyl.

Methods

This cross-sectional investigation comprised all ODs reviewed by Rhode Island's Office of the State Medical Examiners (OSME) during January 2012 to March 2014. Data for 536 decedents were abstracted from OSME's charts, death certificates, toxicology reports, and Prescription Monitoring Program (PMP) databases. Decedents whose cause of death involved illicit fentanyl (N = 69) were compared with decedents whose causes of death did not involve fentanyl (other drug decedents; N = 467).

Results

Illicit-fentanyl decedents were younger than other drug decedents (P = 0.005). While more other-drug decedents than illicit fentanyl decedents had postmortem toxicological evidence of consuming heroin (31.9% vs 19.8%, P < 0.001) and various pharmaceutical substances (P = 0.002-0.027), third party reports indicated more recent heroin use among illicit fentanyl decedents (62.3% vs 45.6%, P = 0.002). Approximately 35% of decedents filled an opioid prescription within 90 days of death; of these, one-third had a mean daily dosage greater than 100 morphine milligram equivalents (MME/day). Most decedents' opioid prescriptions were filled at one to two dispensers (83.9%) and written by one to two prescribers (75.8%). Notably, 29.2% of illicit fentanyl and 10.5% of other drug decedents filled prescriptions for buprenorphine, which is used to treat opioid use disorders.

Conclusions

Illicit-fentanyl deaths frequently involved other illicit drugs (e.g., cocaine, heroin). The proportion of all decedents acquiring greater than 100 MME/day prescription dosages written and/or filled by few prescribers and dispensers is concerning. To protect patients, prescribers and dispensers should review PMP records and substance abuse history prior to providing opioids.

Alcohol and Opioid Use, Co-Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review

The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.

A clinical and mechanistic study of topical borneol-induced analgesia

Bingpian is a time‐honored herb in traditional Chinese medicine (TCM). It is an almost pure chemical with a chemical composition of (+)‐borneol and has been historically used as a topical analgesic for millennia. However, the clinical efficacy of topical borneol lacks stringent evidence‐based clinical studies and verifiable scientific mechanism. We examined the analgesic efficacy of topical borneol in a randomized, double‐blind, placebo‐controlled clinical study involving 122 patients with postoperative pain. Topical application of borneol led to significantly greater pain relief than placebo did. Using mouse models of pain, we identified the TRPM8 channel as a molecular target of borneol and showed that topical borneol‐induced analgesia was almost exclusively mediated by TRPM8, and involved a downstream glutamatergic mechanism in the spinal cord. Investigation of the actions of topical borneol and menthol revealed mechanistic differences between borneol‐ and menthol‐induced analgesia and indicated that borneol exhibits advantages over menthol as a topical analgesic. Our work demonstrates that borneol, which is currently approved by the US FDA to be used only as a flavoring substance or adjuvant in food, is an effective topical pain reliever in humans and reveals a key part of the molecular mechanism underlying its analgesic effect.

Pharmaceutical opioid overdose deaths and the presence of witnesses

BACKGROUND

In the past two decades, rates of pharmaceutical opioid use and harms resulting from their use (including death) have risen. The present study identified a series of fatal opioid overdoses where there was evidence that witnesses had noted symptoms consistent with overdose, and examined associated contextual factors.

METHODS

A retrospective review was undertaken utilising the Coroners Court of Victoria's Overdose Deaths Register for pharmaceutical opioid overdose deaths between 2011 and 2013. Information on the source of pharmaceutical opioids, co-contributing drugs, history of drug dependence, and mental illness was extracted and coded.

RESULTS

Pharmaceutical opioids were involved in 587 deaths, and within these, 125 cases (21%) were witnessed. The majority of these witnessed deaths (77.6%) occurred at the deceased's residence, with the witness being a partner or unrelated acquaintance who did not realise the significance of what they were witnessing. The most common contributing pharmaceutical opioids were methadone (49.6%), codeine (32.0%), and oxycodone (19.2%), with the source more often prescribed than diverted. Co-contributing drugs were involved in 110 cases, with the most common being benzodiazepines. Evidence of current dependence and mental illness was found in 53.6% of cases.

CONCLUSION

Most pharmaceutical opioid overdose deaths with a witness present occurred in the deceased's home, with symptoms of overdose being noted, but not acted upon. These findings support the trialling of education and/or naloxone to partners and family members of people who use pharmaceutical opioids in order to reduce overdose deaths.

The effect of a potentially tamper-resistant oxycodone formulation on opioid use and harm: main findings of the National Opioid Medications Abuse Deterrence (NOMAD) study

BACKGROUND

Escalation of pharmaceutical opioid use and harm in North America is well-documented, with similar issues emerging in Australia. One response is the development of tamper-resistant formulations of opioids. A potentially tamper-resistant formulation of controlled-release oxycodone was introduced in Australia in April, 2014, rapidly replacing the non-tamper-resistant formulation. Our study is the most systematic and comprehensive examination of the impact of a new opioid formulation to date, assessing the effect of tamper-resistant formulation of controlled-release oxycodone on population-level opioid use and opioid-related harm (ie, overdose, help-seeking, and treatment-seeking); and opioid use, tampering, and preference for the tamper-resistant formulation of controlled-release oxycodone compared with other drugs or formulations among sentinel populations likely to tamper with pharmaceutical opioids.

METHODS

We conducted interrupted time-series analyses of opioid sales data and multiple routinely collected health datasets, followed up a cohort of people who tamper with pharmaceutical opioids before and after the introduction of the tamper-resistant formulation of controlled-release oxycodone, and analysed annual surveys of people who inject drugs. Data were collected from several Australian states: New South Wales, South Australia, and Tasmania. Meta-analyses (weighted Z tests) were conducted to synthesise across data sources providing evidence for a given indicator.

FINDINGS

At the population level, we found reduced sales of higher strengths of controlled-release oxycodone and increased sales of other oxycodone formulations. No significant effect was observed among population-level indicators of opioid overdose, or help or treatment-seeking. Mortality data were not available for inclusion at the time of our study. Meta-analyses across sentinel populations (ie, prospective cohort, surveys of people who inject drugs, and clients of supervised injecting facilities or needle and syringe programmes) indicated reduced controlled-release oxycodone use via tampering (mainly injection), with no evidence of switching to heroin or other drug use.

INTERPRETATION

This formulation of controlled-release oxycodone reduced tampering with pharmaceutical opioids among people who inject drugs, but did not affect population-level opioid use or harm.

FUNDING

Mundipharma Australia, the Australian Government, and the National Health and Medical Research Council.