The Opioid Epidemic During the COVID-19 Pandemic

Association of Opioid and Concurrent Benzodiazepine, Skeletal Muscle Relaxant, and Gabapentinoid Usage on Healthcare Expenditure and Resource Utilization: A Serial Cross-Sectional Study, 2009 to 2019

BACKGROUND

Healthcare providers may be utilizing central nervous system (CNS) depressants to reduce opioid use due to recent changes in public policy. Combination use of these agents with opioids increases the risk of respiratory depression and death. Healthcare expenditures by individuals using these drug combinations have not been previously quantified. We sought to characterize healthcare costs and expenditures associated with a population reporting concurrent CNS depressants and opioid use compared with nonopioid analgesics in the United States from 2009 to 2019.

METHODS

A serial cross-sectional design was used to compare the healthcare expenditures of adult Medical Expenditure Panel Survey respondents who were prescribed nonopioid analgesics, opioids only, opioids/benzodiazepines (BZD), opioids/BZD/skeletal muscle relaxants (SMR), or opioids/gabapentin (gaba) using pooled data from 2009 to 2019. Expenditure (cost and resource utilization) categories included inpatient, outpatient, office-based, and prescription medicine. Average marginal effects were used to compare survey-weighted annual costs and resource utilizations across the groups as compared to nonopioid analgesic respondents, adjusted for covariates.

RESULTS

A weighted total of 34 241 838 individuals were identified. Most were opioid-only respondents (46.5%), followed by nonopioid analgesic (43.4%), opioid/BZD (5.3%), opioid-gaba (3.5%), and opioid/BZD/SMR respondents (1.3%). In comparison to the study groups with nonopioid analgesics, opioid-gaba users had the highest significant incremental cost difference among the different pairings (+$11 684, P < .001). Opioid-gaba, opioid/BZD, and opioid/BZD/SMR respondents had significantly higher inpatient, emergency department, and prescription drug costs and use compared to nonopioid analgesic respondents. Opioid-only respondents had higher outpatient and office-based costs and visits compared to nonopioid analgesic respondents.

CONCLUSIONS

As healthcare providers seek to utilize fewer opioids for pain management, attention must be paid to ensuring safe and effective use of concurrent CNS depressants to mitigate high healthcare costs and burden.

Perceptions in Orthopedic Surgery on the Use of Cannabis in Treating Pain: A Survey of Musculoskeletal Trauma Patients-Results From the Canadian POSIT Study

OBJECTIVES

To evaluate the patient-reported expectations regarding cannabis for pain following musculoskeletal (MSK) trauma and patients' perceptions and attitudes regarding its use.

METHODS

DESIGN

A cross-sectional retrospective survey-based study.

SETTING

Three orthopaedic clinics in Ontario (Level-1 trauma center, Level-2 trauma center, rehabilitation clinic).

PATIENTS SELECTION CRITERIA

Adult patients presenting to the clinics from January 24, 2018, to March 7, 2018, with traumatic MSK injuries (fractures/dislocations and muscle/tendon/ligament injury) were administered an anonymous questionnaire on cannabis for MSK pain.

OUTCOME MEASURES AND COMPARISONS

Primary outcome measure was the patients' perceived effect of cannabis on MSK pain, reported on a continuous pain scale (0%-100%, 0 being no pain, and 100 unbearable pain). Secondary outcomes included preferences, such as administration route, distribution method, timing, and barriers (lack of knowledge, concerns for side effects/addiction, moral/religious opposition, etc.) regarding cannabis use.

RESULTS

In total, 440 patients were included in this study, 217 (49.3%) of whom were female and 222 (50.5%) were male, with a mean age of 45.6 years (range 18-92 years, standard deviations 15.6). Patients estimated that cannabis could treat 56.5% (95% CI 54.0%-59.0%) of their pain and replace 46.2% (95% CI 42.8%-49.6%) of their current analgesics. Nearly one-third (131/430, 30.5%) reported that they had used medical cannabis and more than one-quarter (123/430, 28.6%) used it in the previous year. Most felt that cannabis may be beneficial to treat pain (304/334, 91.0%) and reduce opioid use (293/331, 88.5%). Not considering using cannabis for their injury (132/350, 37.7%) was the most common reason for not discussing cannabis with physicians. Higher reported pain severity (β = 0.2/point, 95% CI 0.1-0.3, P = 0.005) and previous medical cannabis use were associated with higher perceived pain reduction (β = 11.1, 95% CI 5.4-16.8, P < 0.001).

CONCLUSIONS

One in 3 orthopaedic trauma patients used medical cannabis. Patients considered cannabis could potentially be an effective option for managing traumatic MSK pain and believed that cannabis could reduce opioid usage following acute musculoskeletal trauma. These data will help inform clinicians discussing medical cannabis usage with orthopaedic trauma patients moving forward.

Attitudes and Beliefs Regarding Pain Medicine: Results of a National Palliative Physician Survey

CONTEXT

Pain is a prevalent symptom in patients with serious illness and often requires interventional approaches for adequate treatment. Little is known about referral patterns and collaborative attitudes of palliative physicians regarding pain management specialists.

OBJECTIVES

To evaluate referral rates, co-management strategies, and beliefs of palliative physicians about the value of Pain Medicine specialists in patients with serious illness.

METHODS

A 30-question survey with demographic, referral/practice, and attitudes/belief questions was mailed to 1000 AAHPM physician members. Responses were characterized with descriptive statistics and further analyzed for associations between training experiences, practice environment, and educational activities with collaborative practice patterns and beliefs.

RESULTS

The response rate was 52.6%. Most survey respondents had initial board certification primarily in internal medicine (n = 286, 56%) or family medicine (n = 144, 28%). A minority of respondents had completed a formal ABMS Hospice and Palliative Medicine fellowship (n = 178, 34%). Respondents had been in practice for a median of nine years, (range 1-38 years) primarily in community hospitals (n = 249, 47%) or academic hospitals (n = 202, 38%). The variables best associated with collaborative practices and attitudes was practice in an academic hospital setting and participation in regular joint academic conferences with pain medicine clinicians.

CONCLUSION

This study shows that Palliative Care physicians have highly positive attitudes toward Pain Medicine specialists, but referrals remain low. Facilitating professional collaboration via joint educational/clinical sessions is one possible solution to drive ongoing interprofessional care in patients with complex pain.

Higher unemployment benefits are associated with reduced drug overdose mortality in the United States before and during the COVID-19 pandemic

OBJECTIVES

Overdose mortality rates in the United States remain critical to population health. Economic , such as unemployment, are noted risk factors for drug overdoses. The COVID-19 pandemic exacerbated economic hardship; as a result, the US government enacted income protection programs in conjunction with existing unemployment insurance (UI) to dampen COVID-19-related economic consequences. We investigate whether UI, operationalized as the weekly benefit allowance (WBA) replacement rate, is negatively associated with drug-related overdoses.

METHODS

Data from the pooled 2014-2020 Detailed Restricted Mortality files for all counties from the Centers for Disease Control and Prevention, restricted to people ≥18 years of age, aggregated at the county-quarter level (n = 89,914). We included any fatal drug, opioid, and stimulant overdose. We modeled the association between WBA replacement rate (e.g., a greater proportion of weekly earnings replaced by UI) on each county-level age-adjusted mortality outcome using separate linear regression models during 2014-2020, pre-COVID (2014-2018), and post-COVID (2019-2020). We conducted sensitivity analyses using multi-level linear regression models.

RESULTS

Results indicated that a more robust WBA replacement rate any drug (Risk Difference [RD]: -0.06, 95 % Confidence Interval [CI]: -0.08, -0.05), opioid (RD: -0.04, 95 % CI: -0.06, -0.03), and stimulant (RD: -0.03, 95 % CI: -0.04, -0.02) across the entire study period (2014-2020). A more robust WBA replacement rate was associated with fewer fatal drug, opioid and stimulant overdoses in the pre-COVID-19 period and on fatal any drug and stimulant overdoses in the COVID-19 period.

CONCLUSIONS

Findings support the notion that income protection policies, such as robust UI, can have a supportive role in preventing fatal drug overdoses, calling for a broader discussion onthe role of the safety net programs to buffer drug-related harms.

Past-Year HIV Testing, Current Antiretroviral Therapy Use, and Participation in Services for People Who Inject Drugs

Evaluating routine HIV testing and treatment and use of services for people who inject drugs (PWID) is critical to curb the ongoing HIV epidemic. We analyzed data from the 2018 National HIV Behavioral Surveillance of PWID aged 18 years or older, recruited using respondent-driven sampling and offered anonymous HIV testing after survey. We performed bivariate and multivariable analyses with log-linked Poisson regression of the generalized linear models to examine the associations between demographics and PWID service use, past-year HIV testing, and current antiretroviral therapy (ART) use. Among 10,311 HIV-negative PWID, 56% reported past-year HIV testing, and of the 553 HIV-positive PWID, 69% reported current ART use. Of the HIV-negative PWID, 64% (2874/4482) in drug treatment and 62% (3386/5440) who used syringe service programs (SSPs) reported past-year HIV testing. Among HIV-positive PWID, 75% (187/248) in drug treatment and 67% (200/298) SSP participants were on ART. In the adjusted multivariable model, past-year HIV testing was associated with drug use treatment (aPR 1.26, 95% CI 1.23-1.31) and SSP participation (aPR 1.19, 95% CI 1.13-1.26) among HIV-negative PWID. Current ART use was associated with drug use treatment (aPR 1.13, 95% CI 1.00-1.28) but the link was not significant probably due to small sample size. Findings support the expansion and improvement of PWID-targeted services, into comprehensive programs, including drug use treatment, SSP, and HIV testing and treatment.

Spatial co-occurrence of firearm homicides and opioid overdose deaths in Chicago by level of COVID-19 mortality, 2017-2021

BACKGROUND

Firearm homicide and opioid overdoses were already leading causes of death in the U.S. before both problems surged during the COVID-19 pandemic. Firearm violence, overdoses, and COVID-19 have all disproportionately harmed communities that are socially and economically marginalized, but the co-occurrence of these problems in the same communities has received little attention. To describe the co-occurrence of firearm homicides and opioid overdose deaths with COVID-19 mortality we used 2017-2021 medical examiner's data from Chicago, IL. Deaths were assigned to zip codes based on decedents' residence. We stratified zip codes into quartiles by COVID-19 mortality rate, then compared firearm homicide and fatal opioid overdose rates by COVID-19 quartile.

FINDINGS

Throughout the study period, firearm homicide and opioid overdose rates were highest in the highest COVID-19 mortality quartile and lowest in the lowest COVID-19 mortality quartile. Increases in firearm homicide and opioid overdose were observed across all COVID-19 mortality quartiles.

CONCLUSIONS

High co-occurrence of these deaths at the community level call for addressing the systemic forces which made them most vulnerable before the pandemic. Such strategies should consider the environments where people reside, not only where fatal injuries occur.

Advances in attenuating opioid-induced respiratory depression: A narrative review

Opioids exert analgesic effects by agonizing opioid receptors and activating signaling pathways coupled to receptors such as G-protein and/or β-arrestin. Concomitant respiratory depression (RD) is a common clinical problem, and improvement of RD is usually achieved with specific antagonists such as naloxone; however, naloxone antagonizes opioid analgesia and may produce more unknown adverse effects. In recent years, researchers have used various methods to isolate opioid receptor-mediated analgesia and RD, with the aim of preserving opioid analgesia while attenuating RD. At present, the focus is mainly on the development of new opioids with weak respiratory inhibition or the use of non-opioid drugs to stimulate breathing. This review reports recent advances in novel opioid agents, such as mixed opioid receptor agonists, peripheral selective opioid receptor agonists, opioid receptor splice variant agonists, biased opioid receptor agonists, and allosteric modulators of opioid receptors, as well as in non-opioid agents, such as AMPA receptor modulators, 5-hydroxytryptamine receptor agonists, phosphodiesterase-4 inhibitors, and nicotinic acetylcholine receptor agonists.

Assessing the Training for Certified Peer Support Specialists Who Provide Mental Health and Substance Use Services

The behavioral health system's peer support workforce must be adequately trained to perform peer support services, but evidence of the adequacy of their training needs to be improved. With survey data from 667 certified peer support specialists (CPSS) from North Carolina, Kentucky, Virginia, and Tennessee, this study used (a) binomial probability test to assess perceptions about the adequacy of the workforce's training, (b) latent profile analysis to identify patterns and predictors of perceptions about the SAMHSA core competencies covered in their training, and (c) thematic analysis to identify additional training needs. Most respondents identified as White (72%), female (73%), and had some college education (83%). Most of the workforce (> 90%) felt prepared to provide services, regardless of their state. Highly and moderately sufficient coverage emerged as two distinct response patterns regarding coverage of the SAMSHA core competencies, with respondents' years of experience, state of residence, education level, race, and sense of preparedness predicting the probability of fitting into either profile. Participants desired additional training in trauma-informed practices, motivational interviewing, and new treatment approaches. Peers' experiences and perspectives were similar across different states. The findings suggest booster training sessions or continuing education opportunities are needed to maintain a robust and well-prepared peer support workforce. States should consider reciprocity agreements to enable the trained workforce to practice across states. A key implication for the training content is the need to incorporate contemporary issues relating to mental health and substance use disorders to better meet behavioral health needs.

Chronic Opioid Treatment Arrests Neurodevelopment and Alters Synaptic Activity in Human Midbrain Organoids

Understanding the impact of long-term opioid exposure on the embryonic brain is critical due to the surging number of pregnant mothers with opioid dependency. However, this has been limited by human brain inaccessibility and cross-species differences in animal models. Here, a human midbrain model is established that uses hiPSC-derived midbrain organoids to assess cell-type-specific responses to acute and chronic fentanyl treatment and fentanyl withdrawal. Single-cell mRNA sequencing of 25,510 cells from organoids in different treatment groups reveals that chronic fentanyl treatment arrests neuronal subtype specification during early midbrain development and alters synaptic activity and neuron projection. In contrast, acute fentanyl treatment increases dopamine release but does not significantly alter gene expression related to cell lineage development. These results provide the first examination of the effects of opioid exposure on human midbrain development at the single-cell level.

Managing an epidemic within a pandemic: orthopedic opioid prescribing trends during COVID-19

INTRODUCTION

In response to the opioid epidemic, a multitude of policy and clinical-guideline based interventions were launched to combat physician overprescribing. However, the sudden rise of the Covid-19 pandemic disrupted all aspects of healthcare delivery. The purpose of this study was to evaluate how opioid prescribing patterns changed during the Covid-19 pandemic within a large multispecialty orthopedic practice.

MATERIALS AND METHODS

A retrospective review of 1,048,559 patient encounters from January 1, 2015 to December 31, 2022 at a single orthopedic practice was performed. Primary outcomes were the percent of encounters with opioids prescribed and total morphine milligram equivalents (MMEs) per opioid prescription. Differences in outcomes were assessed by calendar year. Encounters were then divided into two groups: pre-Covid (1/1/2019-2/29/2020) and Covid (3/1/2020-12/31/2022). Univariate analyses were used to evaluate differences in diagnoses and outcomes between periods. Multivariate analysis was performed to assess changes in outcomes during Covid after controlling for differences in diagnoses. Statistical significance was assessed at p < 0.05.

RESULTS

The percentage of encounters with opioids prescribed decreased from a high of 4.0% in 2015 to a low of 1.6% in 2021 and 2022 (p < 0.001). MMEs per prescription decreased from 283.6 ± 213.2 in 2015 to a low of 138.6 ± 100.4 in 2019 (p < 0.001). After adjusting for diagnoses, no significant differences in either opioid prescribing rates (post-COVID OR = 0.997, p = 0.893) or MMEs (post-COVID β = 2.726, p = 0.206) were observed between the pre- and post-COVID periods.

CONCLUSION

During the Covid-19 pandemic opioid prescribing levels remained below historical averages. While continued efforts are needed to minimize opioid overprescribing, it appears that the significant progress made toward this goal was not lost during the pandemic era.

Certified Community Behavioral Health Clinic Demonstration Impact on Health Care Utilization Among Non-Medicaid Patients with Severe Mental Illnesses

In 2017, the Certified Community Behavioral Health Clinic (CCBHC) demonstration was implemented in New York State to redesign care delivery and financing for behavioral health services. Although CCBHC primarily targeted Medicaid patients, it was hypothesized that the clinic-level benefits of CCBHC were expected to impact even non-Medicaid patients treated in CCBHCs. To test this hypothesis, this study conducted a health insurance claims data analysis of non-Medicaid (ie, commercial and Medicare) patients with severe mental illnesses, comparing a cohort of CCBHC-treated patients with a propensity score-matched comparison cohort of patients treated by non-CCBHC clinics on rates of mental health service utilization, hospitalization, and emergency department (ED) visits. The data suggested CCBHC was associated with more than 10% increase in outpatient mental health service utilization by the patients' second year of CCBHC exposure, accompanied by similarly significant reductions in the rates of all-cause ED visits and non-psychiatric hospitalization. These findings suggest that for behavioral health clinics that serve a sufficiently large population of Medicaid, the impact of innovative clinical redesign attributable to CCBHC is likely to extend to all patients treated by them.

Highlighting Victim Vividness and External Attribution to Influence Policy Support Regarding the Opioid Epidemic: The Mediating Role of Emotions

Recognizing the need for more evidence-based interventions and the potential of well-crafted messages in communicating the opioid epidemic, this study investigates the effectiveness of two messaging strategies (i.e., victim vividness and external attribution) that have the potential to mitigate stigmatization and influence a wide range of public policies concerning the opioid epidemic. Building upon the attribution theory of interpersonal behavior, an experiment with a 2 (victim vividness: high vs. low) × 2 (external attribution: present vs. absent) between-subjects factorial design was conducted among a national sample of U.S. adults (N = 995). The findings show that the messages with greater victim vividness reduced support for victim-oriented punitive policies, whereas the messages that mentioned external attribution increased support for perpetrator-oriented punitive policies. In addition, the two messaging strategies also worked indirectly through various emotions to influence policy support. Discussions on this study's contributions to both theory and practice are provided.

A comparative analysis of opioid-free and opioid-sparing anaesthesia techniques for laparoscopic ovariectomy in healthy dogs

OBJECTIVE

To compare the perioperative analgesic effects of an opioid-free (OFA) and an opioid-sparing (OSA) anaesthetic protocol in dogs undergoing laparoscopic ovariectomy.

STUDY DESIGN

Prospective, randomized, blinded, clinical trial.

ANIMALS

A group of 28 client-owned dogs.

METHODS

Dogs were allocated to one of two groups. The OFA group was administered intramuscular (IM) dexmedetomidine 5 μg kg-1 and ketamine 1 mg kg-1, followed by two intraoperative constant rate infusions (CRIs) of dexmedetomidine (3 μg kg-1 hour-1) and lidocaine (1 mg kg-1 loading dose, 2 mg kg-1 hour-1). The OSA group was administered IM dexmedetomidine 5 μg kg-1, ketamine 1 mg kg-1 and methadone 0.2 mg kg-1, followed by two intraoperative saline CRIs. In both groups, anaesthesia was induced with intravenous (IV) propofol 2 mg kg-1 and diazepam 0.2 mg kg-1 and maintained with isoflurane. Rescue dexmedetomidine (0.5 μg kg-1) was administered IV if there was a 20% increase in cardiovascular variables compared with pre-stimulation values. Ketorolac (0.5 mg kg-1) was administered IV when the surgery ended. Postoperative analgesia was evaluated using the Short Form-Glasgow Composite Measure Pain Scale and methadone (0.2 mg kg-1) was administered IM if the pain score was ≥ 6/24. Statistical analysis included mixed analysis of variance, Chi-square test and Mann-Whitney U test.

RESULTS

There were no significant differences in the intraoperative monitored variables between groups. The OFA group showed a significantly lower intraoperative rescue analgesia requirement (p = 0.016) and lower postoperative pain scores at 3 (p =0.001) and 6 (p < 0.001) hours. No dogs were administered rescue methadone postoperatively.

CONCLUSIONS AND CLINICAL RELEVANCE

Although both groups achieved acceptable postoperative pain scores with no need for further intervention, the analgesic efficacy of the OFA protocol was significantly superior to that of the OSA protocol presented and was associated with a lower intraoperative rescue analgesia requirement and early postoperative pain scores.

Nalmefene Hydrochloride: Potential Implications for Treating Alcohol and Opioid Use Disorder

Nalmefene hydrochloride was first discovered as an opioid antagonist derivative of naltrexone in 1975. It is among the most potent opioid antagonists currently on the market and is differentiated from naloxone and naltrexone by its partial agonist activity at the kappa-opioid receptor which may benefit in the treatment of alcohol use disorder. Oral nalmefene has been approved in the European Union for treatment of alcohol use disorder since 2013. As of 2023, nalmefene is available in the United States as an intranasal spray for reversal of opioid overdose but is not approved for alcohol or opioid use disorder as a maintenance treatment. The substantially longer half-life of nalmefene and 5-fold higher binding affinity to opioid receptors makes it a superior agent over naloxone in the reversal of high potency synthetic opioids like fentanyl and the emerging nitazenes. Nalmefene presents with a comparable side effect profile to other opioid antagonists and should be considered for further development as a maintenance treatment for opioid and other substance use disorders.

Burden of Chronic and Heavy Opioid Use Among Elderly Community Dwellers in the U.S

Introduction

Opioid overprescribing may fuel the opioid epidemic and increase the risk of complications of opioid misuse. This study examined trends and determinants of chronic and heavy opioid use among elderly community dwellers in the U.S.

Methods

Medicare Current Beneficiary Surveys data from 2006 to 2019 were used. Common opioid medications were identified in the prescription medication files (n=47,264). Patients with Chronic users were defined as those receiving 6 or more opioid prescriptions within a year or on medication for 3 or more months, and heavy users were those having an average daily dose of 90 or more morphine milligram equivalents or 3,780 morphine milligram equivalents or more per continuous treatment episode.

Results

One in 6 elderly community dwellers ever used opioids during the study period. Chronic users were more likely to be women than men (68.9% vs 31.1%, p<0.001). Of all survey participants, 4.3% were chronic users, and 2.8% were heavy users. Among ever users, 27.7% were chronic users, and 18.1% were heavy users. The rate of opioid use rose from 12.1% in 2006, peaked at 22.8% in 2013, and decreased to 11.7% in 2019. Chronic use was 5.1%, 10.7%, and 7.6%, respectively. Heavy use was 5.5%, 10.7%, and 7.6%, respectively. However, for chronic and heavy users, there was no significant difference in the median opioid dosage and opioid duration between males and females.

Conclusions

Among elderly Medicare beneficiaries, opioid prescriptions have been decreasing since 2013. However, a substantial number of elderly people were chronic and heavy users, calling for better opioid management among them.

Unmet need for medication for opioid use disorder among persons who inject drugs in 23 U.S. cities

BACKGROUND

Persons who inject drugs (PWID) are at increased risk of HIV and hepatitis C virus (HCV) infections and premature mortality due to drug overdose. Medication for opioid use disorder (MOUD), such as methadone or buprenorphine, reduces injecting behaviors, HIV and HCV transmission, and mortality from opioid overdose. Using data from National HIV Behavioral Surveillance, we evaluated the unmet need for MOUD among PWID in 23 U.S. cities.

METHODS

PWID were recruited by respondent-driven sampling, interviewed, and tested for HIV. This analysis includes PWID who were ≥18 years old and reported injecting drugs and opioid use in the past 12 months. We used Poisson regression to examine factors associated with self-reported unmet need for MOUD and reported adjusted prevalence ratios (aPR) with 95% confidence intervals.

RESULTS

Of 10,879 PWID reporting using opioids, 68.8% were male, 48.2% were ≥45 years of age, 38.8% were non-Hispanic White, 49.6% experienced homelessness, and 28.0% reported an unmet need for MOUD in the past 12 months. PWID who were more likely to report unmet need for MOUD experienced homelessness (aPR 1.26; 95% CI: 1.19-1.34), were incarcerated in the past 12 months (aPR 1.15; 95% CI: 1.08-1.23), injected ≥once a day (aPR 1.42; 95% CI: 1.31-1.55), reported overdose (aPR 1.33; 95% CI: 1.24-1.42), and sharing of syringes (aPR 1.14; 95% CI: 1.06-1.23).

CONCLUSIONS

The expansion of MOUD provision for PWID is critical. Integrating syringe service programs and MOUD provision and linking PWID who experience overdose, incarceration or homelessness to treatment with MOUD could improve its utilization among PWID.

Assessment of Postoperative Pain and Opioid Consumption Following Laryngeal Surgery: A Pilot Study

The epidemic of opioid use in the United States has been declared a national public health crisis due to the rapid increase in drug overdose mortality. Physician overprescribing has been identified as one of many contributing factors, with most patients receiving excess opioid pain medication. Furthermore, there is a significant correlation between prescribed opioid dosage and mortality. Postoperative pain is a well-recognized clinical problem, but little has been done to advance or standardize pain management protocols. The purpose of this study was to determine the expected postoperative pain severity and quantity of opioid analgesic required for adequate pain management after laryngeal surgery.

METHODS

Adult voice center patients who had recently undergone laryngeal surgery were included in this retrospective review. Tylenol #3 had been prescribed for all patients for pain management and they had been instructed to take additional over-the-counter acetaminophen as needed. In the senior author's (RTS) practice, patients are asked routinely to report pain severity and analgesic use during postoperative visits. All patients who had this information available were included in the cohort. Opioid medication consumed, over-the-counter medication consumed, and pain level (scale of 0-10 with 10 being most severe) were analyzed over the first week postoperatively.

RESULTS

There were 43 patients (19 male, 24 female) included in the retrospective cohort (average age = 46.8 ± 18.6, range = 18-82). Procedures performed included vocal fold mass excision (48.8%), type I thyroplasty (27.9%), laser vaporization of vascular lesions (11.6%), laser stenosis resection (9.3%), and VF medialization injection with abdominal fat harvest (7.0%). Overall, voice surgery patients reported mild to moderate pain (2.1-4.7 out of 10). An average of 13.2 ± 2.8 T3 tablets were prescribed for pain management (range = 10-20), and no patient required more T3 tablets than the number provided. Sixteen patients (37.2%) supplemented or substituted their T3 medication for it with OTC acetaminophen. No patients used non-steroidal anti-inflammatory drugs (NSAIDs) for supplemental pain management. Consumption of both T3 pain medication (r = 0.444) and OTC acetaminophen (r = 0.274) was correlated significantly with postoperative pain severity (P < 0.001). When stratified by type of surgical procedure performed, one-way ANOVA (F = 2.749, P = 0.043) and post-hoc Games-Howell test revealed that the patients who underwent type I thyroplasty reported a significantly higher (P = 0.041) pain severity score than patients who underwent vocal fold mass excision (4.7 versus 2.1, respectively). No significant differences in pain severity existed between other procedures (P > 0.05). There were no significant differences between type of procedure performed for number of T3 tablets prescribed, number of T3 tablets taken, or number of OTC tablets taken (P > 0.05). Younger age was correlated significantly with a higher number of OTC tablets consumed (r = -0.316, P = 0.039). Women consumed more OTC pain medications than men.

CONCLUSIONS

Most patients in this study reported mild to moderate postoperative pain. Adequate pain management was achieved using less pain medication tablets than the number prescribed. Type I thyroplasty was associated with more severe pain than other surgeries. Women used more OTC pain medications than men with no significant difference in reported pain level.

The effects of opium consumption on severity of disease on hospitalized COVID-19 patients in East of Iran, a prospective cohort study

There are few theories and little empirical evidence about the bilateral impact of substance use and coronavirus disease 2019 (COVID-19), so a logical and accurate picture of this area is required. We investigated the effects of opium use on severity of disease on hospitalized COVID-19 patients in east of Iran. Demographic and clinical characteristics, vital signs, laboratory tests, mortality rate, type and duration of opium consumption in hospitalized patients who recovered from COVID-19 in the follow-up after 3 months were evaluated. In this study, 60 (20%) participants were the opium user and 251 (80%) were the non-user patients. Based on clinical symptoms, hypertension and systolic blood pressure in opium user were significantly higher than non-user patients (p < 0.05). In the laboratory tests, only the level of urea was higher in the opium positive group (37 [26.5-48.5] vs. 32 [23-43], respectively) and the percent of lymphocytes were lower in the opium positive (17 [8.2-25.8] vs. 18.7 [13.85-26.35], respectively). The initial therapies of both opium positive and negative infected patients showed not any significant changes (p > 0.05). Among the studied groups, one deceased case with COVID-19 was related to a drug user patient. Although, uses of opium reduced the levels of some risk factors, vital signs at admission and initial therapies during hospitalization in COVID-19 patients but it increased lung and heart diseases. Also, the severity of COVID-19 including hospitalization and mortality were associated with opium consumption.

Understanding Regional Patterns of Overdose Deaths Related to Opioids and Psychostimulants

BACKGROUND

As overdose rates increase for multiple substances, policymakers need to identify geographic patterns of substance-specific deaths. In this study, we describe county-level opioid and psychostimulant overdose patterns and how they correlate with county-level social vulnerability measures.

METHODS

A cross-sectional observational study, we used nationwide 2016-2018 restricted access Centers for Disease Prevention and Control county-level mortality files for 1,024 counties. We estimated quartiles of opioid and psychostimulant overdose mortality and provided estimates of their association with county-level Social Vulnerability Index (SVI) percentile.

RESULTS

There was high opioid and psychostimulant overdose mortality in the Middle Atlantic, South Atlantic, East North Central, and Mountain regions. The Central US had the lowest opioid and psychostimulant overdose mortality rates. Counties with higher SVI scores (i.e. higher social vulnerability) were significantly more likely to experience high opioid and high psychostimulant overdose (high-high) mortality. A 10-percentile increase in SVI score was associated with a 3.1 percentage point increase in the likelihood of being a high-high county (p < 0.001) in unadjusted models and a 1.5 percentage point increase (p < 0.05) in models adjusting for region.

CONCLUSION

Our results illustrated the heterogenous geographic distribution of the growing concurrent opioid and psychostimulant overdose crisis. The substantial regional variation we identified highlights the need for local data to guide policymaking and treatment planning. The association of opioid-psychostimulant overdose mortality with social vulnerability demonstrates the critical need in impacted counties for tailored treatment that addresses the complex medical and social needs of people who use both opioids and psychostimulants.

Opioid prescription and risk of atrial fibrillation in younger veterans

BACKGROUND

Opioids may play a part in the development of atrial fibrillation (AF). Understanding the relationship between opioid exposure and AF can help providers better assess the risk and benefits of prescribing opioids.

OBJECTIVE

To assess the incidence of AF as a function of prescribed opioids and opioid type.

DESIGN

We performed unadjusted and adjusted time-updated Cox regressions to assess the association between opioid exposure and incident AF.

PARTICIPANTS

The national study sample was comprised of Veterans enrolled in the Veterans Health Administration (VHA) who served in support of post-9/11 operations.

MAIN MEASURES

The main predictor of interest was prescription opioid exposure, which was treated as a time-dependent variable. The first was any opioid exposure (yes/no). Secondary was opioid type. The outcome, incident AF, was identified through ICD-9-CM diagnostic codes at any primary care visit after the baseline period.

KEY RESULTS

A total of 609,763 veterans (mean age: 34 years and 13.24% female) were included in our study. Median follow-up time was 4.8 years. Within this cohort, 124,395 veterans (20.40%) were prescribed an opioid. A total of 1,455 Veterans (0.24%) were diagnosed with AF. In adjusted time-updated Cox regressions, the risk of incident AF was higher in the veterans prescribed opioids (hazard ratio [HR]: 1.47; 95% confidence interval [CI]: 1.38-1.57). In adjusted time-updated Cox regressions, both immunomodulating and nonimmunomodulating opioid type was associated with increased risk of incident AF (HR: 1.40; 95% CI: 1.25-1.57 and HR: 1.49; 95% CI: 1.39-1.60), compared to no opioid use, respectively.

CONCLUSIONS

Our findings suggest opioid prescription may be a modifiable risk factor for the development of AF.

Effects of the First Year of the COVID-19 Pandemic on Utilization of Emergency Medical Services in Maryland

BACKGROUND

The opioid epidemic in the United States has devastated the lives of individuals and imposed decades-long opportunity costs on the community.

METHODS

We analyzed Emergency Medical Services (EMS) data from the Maryland Department of Health installation of the Electronic Surveillance System for Early Notification of Community-Based Epidemics (ESSENCE) to assess the impact of COVID-19 on EMS call volume and how COVID-19 impacted patients' decisions whether to accept transport to a hospital following an EMS call.

RESULTS

The rate of patients accepting transportation via EMS to a hospital emergency department (ED) declined for both opioid-related and non-opioid-related calls from prepandemic (before April 2020) to mid-pandemic (mid-March 2020 to mid-April 2020). The opioid-related call volume increased more from pre- to mid-pandemic for male patients than for female patients, and this "gender gap" had not returned to prepandemic levels by April 2021.

CONCLUSION

Consistent with reports from other states, the pandemic worsened the opioid crisis in Maryland, impacting some populations more than others while also decreasing the likelihood that individuals experiencing an opioid-related overdose would seek further medical care following an EMS call.

Extended-release Buprenorphine Administered at Discharge in Hospitalized Persons With Opioid Use Disorder: A Case Series

INTRODUCTION

Monthly subcutaneous injectable buprenorphine (XR-Bup) is an option for treatment of opioid use disorder (OUD) that addresses some sublingual buprenorphine adherence barriers and is infrequently offered to hospitalized patients with OUD.

METHODS

A retrospective case series was performed for patients receiving XR-Bup upon discharge from 1 academic medical center. Demographic information, diagnoses, follow-up, and documented factors informing the selection of XR-Bup were extracted from the electronic health record.

RESULTS

In 1 year, 37 hospitalized patients with OUD received XR-Bup at discharge. The average age was 37.6 years, and patients were primarily Medicaid insured with an injection-related infection. The most common documented factors informing the selection of XR-Bup were as follows: previous sublingual buprenorphine adherence barriers, concurrent stimulant use disorder, and patient preference. Sixty-four percent of patients scheduled for follow-up attended appointments, and 55% received a second dose of XR-Bup.

CONCLUSIONS

Subcutaneous injectable buprenorphine is an option for OUD treatment among hospitalized patients providing 30 or more days of buprenorphine coverage in the postdischarge period.

Prescription opioids and economic hardship in France

This paper studies how opioid analgesic sales are empirically related to socioeconomic disparities in France, with a focus on poverty. This analysis is made possible using the OpenHealth database, which provides retail sales data for opioid analgesics available on the French market. We exploit firm-level data for each of the 94 departments in Metropolitan France between 2008 and 2017. We show that increases in the poverty rate are associated with increases in sales: a one percentage point increase in poverty is associated with approximately a 5% increase in mild opioid sales. Our analysis further shows that opioid sales are positively related to the share of middle-aged people and individuals with basic education only, while they are negatively related to population density. The granularity and longitudinal nature of these data allow us to control for a large pool of potential confounding factors. Our results suggest that additional interventions should be more intensively addressed toward the most deprived areas. We conclude that a combination of policies aimed at improving economic prospects and strictly monitoring access to opioid medications would be beneficial for reducing opioid-related harm.

Outcomes of Emergency Department Patients With Opioid Use Disorder Utilizing a Virtual Addiction Bridge Clinic: A Case Series

OBJECTIVES

Within the last decade, there has been a dramatic increase in the rate of emergency department (ED) visits and death from opioid overdose. Those who present to the ED are at high risk for subsequent morbidity and mortality. Despite effective treatment, many patients do not get rapidly connected to outpatient care. The aim of this investigation was to describe outpatient treatment engagement after ED discharge among patients with opioid use disorder (OUD) enrolled in a virtual Addiction Bridge Clinic (ABC).

METHODS

This was a retrospective case series describing an ED-initiated referral for rapid telehealth follow-up among patients with OUD. The primary outcome was addiction treatment engagement among those who completed the initial virtual ABC visit (engaged in ABC) vs. those who did not complete an ABC visit (Not engaged in ABC) at 1 week, 1 month, and 3 and 6 months timepoint intervals after the initial ED presentation.

RESULTS

Of the N = 201 patients referred to the ABC between March and December 2021, a majority were Black (71%) and male (77%). Of the 201 referrals, 85 (42%) completed an initial ABC telehealth visit. Subsequent treatment engagement was 26% at 1 week, 26% at 1 month, 22% at 3 months, and 18% at 6 months after the index ED visit.

CONCLUSIONS

A telehealth-enabled virtual addiction bridge clinic is one potential approach to reduce barriers to rapid treatment access. Strategies are needed to improve subsequent addiction treatment engagement after a virtual addiction bridge clinic visit.

The impact of syringe decriminalization within the Pennsylvania harm reduction community

INTRODUCTION

Syringe decriminalization is a harm reduction approach to decrease deaths and disease related to drug use. The purpose of this study was to develop an understanding of the impact of syringe decriminalization on the harm reduction community in Pennsylvania.

METHODS

Semi-structured interviews were conducted with ten participants identified as harm reduction experts.

ANALYSIS

Narrative content analysis to the point of thematic saturation was used to generate themes around harm reduction and syringe decriminalization in Pennsylvania, specifically the meaning of harm reduction, the importance of harm reduction, and the opinions on syringe decriminalization.

RESULTS

The following themes reflect the meaning of harm reduction: human compassion; meeting people where they are at; minimizing the risk; and shifting power to the person. The themes of being personally impacted, human compassion, innate imperfection, and respecting human autonomy reflect why participants care about harm reduction. All ten participants support syringe decriminalization in Pennsylvania citing the following rationales: improved health outcomes; decreased costs to society; less involvement of the criminal justice system; and increased engagement into treatment.

CONCLUSIONS

Harm reduction is a pioneering approach to drug use that empowers individuals to make positive impacts in their lives. Harm reduction experts in Pennsylvania support syringe decriminalization as a cost-effective way to increase the engagement and improve health outcomes of people who use drugs.

Understanding the use of telemedicine across different opioid use disorder treatment models: A scoping review

INTRODUCTION

The COVID-19 pandemic has instigated the development of telemedicine-mediated provision of medications for opioid use disorder such as buprenorphine and methadone, referred to as TMOUD in this study. As services start to return to pre-pandemic norms, there is a debate around the role of TMOUD as addition to or replacement of the conventional cascade of care for people with opioid use disorder (PWOUD). This scoping review is designed to characterize existing TMOUD services and provide insights to enable a more nuanced discussion on the role of telemedicine in the care of PWOUD.

METHODS

The literature search was conducted in OVID Medline, CINAHL, and PsycINFO, from inception up to and including April 2023, using the Joanna Briggs Institute methodology for scoping reviews. The review considered any study design that detailed sufficient descriptive information on a given TMOUD service. A data extraction form was developed to collect and categorize a range of descriptive characteristics of each discrete TMOUD model identified from the obtained articles.

RESULTS

A total of 45 articles met the inclusion criteria, and from this, 40 discrete TMOUD services were identified. In total, 33 services were US-based, three from Canada, and one each from India, Ireland, the UK, and Norway. Through a detailed analysis of TMOUD service characteristics, four models of care were identified. These were TMOUD to facilitate inclusion health, to facilitate transitions in care, to meet complex healthcare needs, and to maintain opioid use disorder (OUD) service resilience.

CONCLUSIONS

Characterizing TMOUD according to its functional benefits to PWOUD and OUD services will help support evidence-based policy and practice. Additionally, particular attention is given to how digital exclusion of PWOUD can be mitigated against.

Leveraging Policy Changes Made in Response to COVID-19 to Advance Telehealth and Novel Treatment Approaches for People Who Use Opioids: Qualitative Perspectives From Two Rural North Carolina Counties

Background

The COVID-19 pandemic has been a catalyst for telehealth services for people who use opioids; however, the data show dramatic increases in opioid overdose deaths and ongoing lack of treatment options in North Carolina, particularly among rural residents.

Methods

We conducted a listening session and qualitative interviews with 10 health care professionals, administrators, and community partners providing services for individuals who use opioids in Granville and Vance counties. Data were analyzed with an applied thematic approach.

Results

Participants described several benefits of rapid expansion of telehealth services during the pandemic. Continued improvements in access to high-speed internet will be critical to maintain progress in rural areas. Participants advocated for integrated, co-located ser-vices and improved referral processes to minimize cost and burden of attending multiple appointments across sites. Integrated services could include medication for opioid use disorder (MOUD), mental/behavioral health support, primary medical care, and harm reduction services. Participants supported novel community-based strategies, such as mobile clinics, and described a need for after-hours and crisis services for opioid recovery in the region.

Limitations

The study was exploratory in nature and elicited the perspectives of providers serving two rural counties in North Carolina, which may not be generalizable to broader populations. We did not include the perspectives of people who use opioids in this study but will do so in upcoming research.

Conclusions

Participants were strong proponents of the benefits of telehealth and identified strategies for continuing recent progress in rural access to opioid treatment through novel integrated and community-based approaches.

Disease-related stigma among people who inject drugs in Toronto amidst the COVID-19 pandemic

Background

Stigma overwhelmingly affects people who inject drugs. The COVID-19 pandemic posed unique challenges for people who inject drugs, who are already stigmatized as being "dangerous and spreading disease." The present study explored ways in which stigma was experienced by a sample of people who inject drugs in Toronto, Canada following COVID-related public health precaution measures.

Methods

Qualitative interviews were conducted with people who inject drugs (n = 24) recruited from supervised consumption sites in Toronto, Canada. The semi-structured interview guide focused on the impact of COVID-19 on participants' health and social well-being. Interviews took place six-months after initial COVID-19 precautions (September-October 2020). We used thematic analysis to examine findings, with stigma being an emergent theme.

Results

Participants described heightened acts of stigma after COVID-19 restrictions were implemented, including feeling treated as "diseased" and the cause of COVID-19's spread. They reported being less likely to receive emergency care during events such as overdoses. Participants perceived increased disease-related stigma evident through actions of stigma, including amplified dehumanization by the public, others avoiding all contact with them, and more discrimination by police and hospital systems.

Conclusion

Participants provided specific examples of how stigmatizing behaviors harmed them after COVID-19 precautions began. It is plausible that stigma contributed to the dramatic increase in fatal overdoses, difficulty accessing housing, and further difficulty accessing needed healthcare in our setting. Integrating evidence-based harm reduction approaches in areas where stigma is evident might offset harms stemming from disease-related stigma and mitigate these harms during future public health emergencies.

Predictors of opioid overdose during the COVID-19 pandemic: The role of relapse, treatment access and nonprescribed buprenorphine/naloxone

INTRODUCTION

Emerging data indicate a disproportionate increase in overdose deaths since the onset of COVID-19. Speculation about causes for the increase center on rising drug use, illicit drug supply changes, and reduced treatment access. Possible overdose mitigation factors include reduced federal MOUD prescribing restrictions, naloxone distribution programs, and increased use of telehealth. Similarly, nonprescribed buprenorphine (NPB) use, increasingly described as a harm reduction strategy in the absence of treatment, may have moderated overdose risk. This study explored factors associated with pandemic-related overdose in people who use opioids (PWUO) in New Jersey.

METHODS

We surveyed 342 PWUO from March to May 2021. Approximately 50 % of our sample was treated at some time since the COVID-19 emergency declaration in March 2020. The risk and protective factors associated with overdose were identified using Pearson's chi square test and ANOVA and tested in a series of multivariable logistic regression models for the full sample and the subsample of PWUO treated during the pandemic.

RESULTS

Forty-eight percent of respondents increased their drug use during the pandemic, including 32 % who relapsed after previous abstinence. Fifteen percent overdosed at least once since March 2020. In the full sample, overdose was associated with Hispanic ethnicity (AOR = 3.51; 95 % CI = 1.22-10.11), pre-pandemic overdose (AOR = 6.75; 95 % CI = 3.03-15.02), lack/loss of medical insurance (AOR = 3.02; 95 % CI = 1.01-9.02), relapse (AOR = 2.94; 95 % CI = 1.36-6.36), and nonprescribed use of buprenorphine/naloxone (AOR = 3.16; 95 % CI = 1.49-6.70). The study found similar trends in the treatment sample, with the exceptions that heroin/fentanyl use also predicted overdose (AOR = 3.43; 95 % CI = 1.20-9.78) and the association of overdose with nonprescribed buprenorphine/naloxone was stronger (AOR = 4.91; 95 % CI = 2.01-12.03). Potential mitigating factors, such as take-home methadone and telehealth, were not significant.

CONCLUSIONS

Relapse during the pandemic was widespread and a significant contributor to overdose. Lack/loss of medical insurance further exacerbated the risk. Despite the growing literature reporting "therapeutic" use of NPB, people using nonprescribed buprenorphine/naloxone in the current study experienced up to five times the risk of overdose as nonusers. This finding suggests that, despite therapeutic intent, PWUO may be using NPB in ways that are ineffectual for addiction management, especially in the context of changing buprenorphine induction protocols in the context of fentanyl.

Geo-spatial risk factor analysis for drug overdose death in South Florida from 2014 to 2019, and the independent contribution of social determinants of health

PURPOSE

The physical environment and social determinants of health have been shown to influence health behaviors including drug use and fatal drug overdose. The current research examines the effects of the built environment, social determinants of health measures and aggregated risk from the built environment at neighborhood-level on drug overdose death locations in Miami-Dade County, Florida.

METHODS

Risk Terrain Modeling (RTM) was used to assess the place features risk factors that significantly increase the risk of drug overdose death spatially in Miami-Dade County ZIP Code Tabulation Areas, Florida from 2014 to 2019. An aggregated neighborhood risk of fatal drug overdose measure was developed by averaging the risk per grid cell from the RTM within census block groups each year. Six logistic and zero-inflated regression models were built to examine the effects of three indices of incident-specific social determinants of health (IS-SDH) measures and aggregated risk measures separately, and simultaneously on drug overdose death locations each year.

RESULTS

Seven place features including parks, bus stops, restaurants and grocery stores were significantly related to the occurrence of fatal drug overdoses. When examined separately, one or more indices of the IS-SDH were significant covariates of drug overdose locations in some years. When examined simultaneously, the three indices of the IS-SDH and aggregated risk of fatal drug overdose measure could be all significant in certain years.

CONCLUSIONS

The patterns of high-risk areas and place features identified from the RTM related to drug overdose deaths may be used to inform the placement of treatment and prevention resources. A multi-factor approach that combines an aggregated neighborhood risk measure reflecting the risk from the built environment and the incident-specific social determinants of health measures can be used to identify the drug overdose death locations in certain years.

Considerations for the design of overdose education and naloxone distribution interventions: results of a multi-stakeholder workshop

INTRODUCTION

Opioid overdose epidemic is a public health crisis that is impacting communities around the world. Overdose education and naloxone distribution programs equip and train lay people to respond in the event of an overdose. We aimed to understand factors to consider for the design of naloxone distribution programs in point-of-care settings from the point of view of community stakeholders.

METHODS

We hosted a multi-stakeholder co-design workshop to elicit suggestions for a naloxone distribution program. We recruited people with lived experience of opioid overdose, community representatives, and other stakeholders from family practice, emergency medicine, addictions medicine, and public health to participate in a full-day facilitated co-design discussion wherein large and small group discussions were audio-recorded, transcribed and analysed using thematic approaches.

RESULTS

A total of twenty-four participants participated in the multi-stakeholder workshop from five stakeholder groups including geographic and setting diversity. Collaborative dialogue and shared storytelling revealed seven considerations for the design of naloxone distribution programs specific to training needs and the provision of naloxone, these are: recognizing overdose, how much naloxone, impact of stigma, legal risk of responding, position as conventional first aid, friends and family as responders, support to call 911.

CONCLUSION

To create an naloxone distribution program in emergency departments, family practice and substance use treatment services, stigma is a central design consideration for training and naloxone kits. Design choices that reference the iconography, type, and form of materials associated with first aid have the potential to satisfy the need to de-stigmatize overdose response.

Overall and Telehealth Addiction Treatment Utilization by Age, Race, Ethnicity, and Socioeconomic Status in California After COVID-19 Policy Changes

Importance

Addiction treatment rapidly transitioned to a primarily telehealth modality (telephone and video) during the COVID-19 pandemic, raising concerns about disparities in utilization.

Objective

To examine whether there were differences in overall and telehealth addiction treatment utilization after telehealth policy changes during the COVID-19 pandemic by age, race, ethnicity, and socioeconomic status.

Design, Setting, and Participants

This cohort study examined electronic health record and claims data from Kaiser Permanente Northern California for adults (age ≥18 years) with drug use problems before the COVID-19 pandemic (from March 1, 2019, to December 31, 2019) and during the early phase of the COVID-19 pandemic (March 1, 2020, to December 31, 2020; hereafter referred to as COVID-19 onset). Analyses were conducted between March 2021 and March 2023.

Exposure

The expansion of telehealth services during COVID-19 onset.

Main Outcomes and Measures

Generalized estimating equation models were fit to compare addiction treatment utilization during COVID-19 onset with that before the COVID-19 pandemic. Utilization measures included the Healthcare Effectiveness Data and Information Set of treatment initiation and engagement (including inpatient, outpatient, and telehealth encounters or receipt of medication for opioid use disorder [OUD]), 12-week retention (days in treatment), and OUD pharmacotherapy retention. Telehealth treatment initiation and engagement were also examined. Differences in changes in utilization by age group, race, ethnicity, and socioeconomic status (SES) were examined.

Results

Among the 19 648 participants in the pre-COVID-19 cohort (58.5% male; mean [SD] age, 41.0 [17.5] years), 1.6% were American Indian or Alaska Native; 7.5%, Asian or Pacific Islander; 14.3%, Black; 20.8%, Latino or Hispanic; 53.4%, White; and 2.5%, unknown race. Among the 16 959 participants in the COVID-19 onset cohort (56.5% male; mean [SD] age, 38.9 [16.3] years), 1.6% were American Indian or Alaska Native; 7.4%, Asian or Pacific Islander; 14.6%, Black; 22.2%, Latino or Hispanic; 51.0%, White; and 3.2%, unknown race. Odds of overall treatment initiation increased from before the COVID-19 pandemic to COVID-19 onset for all age, race, ethnicity, and SES subgroups except for patients aged 50 years or older; patients aged 18 to 34 years had the greatest increases (adjusted odds ratio [aOR], 1.31; 95% CI, 1.22-1.40). Odds of telehealth treatment initiation increased for all patient subgroups without variation by race, ethnicity, or SES, although increases were greater for patients aged 18 to 34 years (aOR, 7.17; 95% CI, 6.24-8.24). Odds of overall treatment engagement increased (aOR, 1.13; 95% CI, 1.03-1.24) without variation by patient subgroups. Retention increased by 1.4 days (95% CI, 0.6-2.2 days), and OUD pharmacotherapy retention did not change (adjusted mean difference, -5.2 days; 95% CI, -12.7 to 2.4 days).

Conclusions

In this cohort study of insured adults with drug use problems, there were increases in overall and telehealth addiction treatment utilization after telehealth policies changed during the COVID-19 pandemic. There was no evidence that disparities were exacerbated, and younger adults may have particularly benefited from the transition to telehealth.

Public transport access to drug treatment before and during COVID-19: Implications for the opioid epidemic

Public transport disruptions caused by the COVID-19 pandemic had wide-ranging impacts on the ability of individuals to access health care. Individuals with opioid use disorder represent an especially vulnerable population due to the necessity of frequent, supervised doses of opioid agonists. Focused on Toronto, a major Canadian city suffering from the opioid epidemic, this analysis uses novel realistic routing methodologies to quantify how travel times to individuals\220 nearest clinics changed due to public transport disruptions from 2019 to 2020. Individuals seeking opioid agonist treatment face very constrained windows of access due to the need to manage work and other essential activities. We find that thousands of households in the most materially and socially deprived neighbourhoods crossed 30 and 20-minute travel time thresholds to their nearest clinic. As even small changes to travel times can lead to missed appointments and heighten the chances of overdose and death, understanding the distribution of those most impacted can help inform future policy measures to ensure adequate access to care.

Modeling Opioid Abuse: A Case Study of the Opioid Crisis in New England

For the past two decades, the USA has been embroiled in a growing prescription drug epidemic. The ripples of this epidemic have been especially apparent in the state of Maine, which has fought hard to mitigate the damage caused by addiction to pharmaceutical and illicit opioids. In this study, we construct a mathematical model of the opioid epidemic incorporating novel features important to better understanding opioid abuse dynamics. These features include demographic differences in population susceptibility, general transmission expressions, and combined consideration of pharmaceutical opioid and heroin abuse. We demonstrate the usefulness of this model by calibrating it with data for the state of Maine. Model calibration is accompanied by sensitivity and uncertainty analysis to quantify potential error in parameter estimates and forecasts. The model is analyzed to determine the mechanisms most influential to the number of opioid abusers and to find effective ways of controlling opioid abuse prevalence. We found that the mechanisms most influential to the overall number of abusers in Maine are those involved in illicit pharmaceutical opioid abuse transmission. Consequently, preventative strategies that controlled for illicit transmission were more effective over alternative approaches, such as treatment. These results are presented with the hope of helping to inform public policy as to the most effective means of intervention.

Understanding and countering opioid-induced respiratory depression

Respiratory depression is the proximal cause of death in opioid overdose, yet the mechanisms underlying this potentially fatal outcome are not well understood. The goal of this review is to provide a comprehensive understanding of the pharmacological mechanisms of opioid-induced respiratory depression, which could lead to improved therapeutic options to counter opioid overdose, as well as other detrimental effects of opioids on breathing. The development of tolerance in the respiratory system is also discussed, as are differences in the degree of respiratory depression caused by various opioid agonists. Finally, potential future therapeutic agents aimed at reversing or avoiding opioid-induced respiratory depression through non-opioid receptor targets are in development and could provide certain advantages over naloxone. By providing an overview of mechanisms and effects of opioids in the respiratory network, this review will benefit future research on countering opioid-induced respiratory depression. LINKED ARTICLES: This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.

Kim H, Gratzer D, George TP, Le Foll B, Castle DJ. Marked Increase in Amphetamine-Related Emergency Department Visits and Inpatient Admissions in Toronto, Canada, 2014-2021

BACKGROUND

We report emergency department and inpatient amphetamine-related trends focusing on co-occurring substance use and psychiatric diagnoses at the Centre for Addiction and Mental Health, the largest mental health teaching hospital in Canada.

METHODS

We describe yearly trends in amphetamine-related Centre for Addiction and Mental Health emergency department visits and inpatient admissions out of all emergency department visits and inpatient admissions between 2014 and 2021, along with proportions of concurrent substance-related admissions and mental/psychotic disorders emergency department visits and inpatient admissions among amphetamine-related contacts; joinpoint regression analyses assessed changes in amphetamine-related emergency department visits and inpatient admissions.

RESULTS

Amphetamine-related emergency department visits rose from 1.5% in 2014 to 8.3% in 2021, with a peak of 9.9% in 2020. Amphetamine-related inpatient admissions rose from 2.0% to 8.8% in 2021, with a peak of 8.9% in 2020. Significant increasing trends in the percentage of amphetamine-related emergency department visits happened especially between the second and the fourth quarter of 2014 (quarterly percent change =  + 71.4, P <0.01). Similarly, the percentage of amphetamine-related inpatient admissions increased mostly between the second quarter of 2014 and the third quarter of 2015 (quarterly percent change  =  + 32.6, P <0.01). The proportion of concurrent opioid-related contacts among amphetamine-related emergency department visits and inpatient admission increased markedly between 2014 and 2021; psychotic disorders in amphetamine-related inpatient admissions more than doubled from 2015 to 2021.

DISCUSSION

Prevalence of amphetamine use, mostly from methamphetamine, has been increasing in Toronto as have co-occurring psychiatric disorders and opioid use. Our findings highlight the need for increases in accessible efficacious treatments for complex populations with polysubstance use and co-occurring disorders.

Interrupted Time Series Analysis: Patient Characteristics and Rates of Opioid-Use-Disorder-Related Emergency Department Visits in the Los Angeles County Public Hospital System during COVID-19

The COVID-19 pandemic led to disruptions in care for vulnerable patients, in particular patients with opioid use disorder (OUD). We aimed to examine OUD-related ED visits before and during the COVID-19 pandemic and determine if patient characteristics for OUD-related ED visits changed in the context of the pandemic. We examined all visits to the three public safety net hospital EDs in Los Angeles County from April 2019 to February 2021. We performed interrupted time series analyses examining OUD-related ED visits from Period 1, April 2019 to February 2020, compared with Period 2, April 2020 to February 2021, by race/ethnicity and payor group. We considered OUD-related ED visits as those which included any of the following: discharge diagnosis related to OUD, patients administered buprenorphine or naloxone while in the ED, and visits where a patient was prescribed buprenorphine or naloxone on discharge. There were 5919 OUD-related ED visits in the sample. OUD-related visits increased by 4.43 (2.82–6.03) per 1000 encounters from the pre-COVID period (9.47 per 1000 in February 2020) to the COVID period (13.90 per 1000 in April 2020). This represented an increase of 0.41/1000 by white patients, 0.92/1000 by black patients, and 1.83/1000 by Hispanic patients. We found increases in OUD-related ED visits among patients with Medicaid managed care of 2.23/1000 and in LA County safety net patients by 3.95/1000 ED visits. OUD-related ED visits increased during the first year of the COVID pandemic. These increases were significant among black, white, and Hispanic patients, patients with Medicaid managed care, and LA County Safety net patients. These data suggest public emergency departments served as a stopgap for patients suffering from OUD in Los Angeles County during the pandemic and can be utilized to guide preventative interventions in vulnerable populations.

Comparing COVID-19-related Morbidity and Mortality Between Patients With and Without Substance Use Disorders: A Retrospective Cohort Study

Objectives

People with substance use disorders (SUD) are suggested to have higher risk of hospitalization, intubation, or death from coronavirus disease 2019 (COVID-19), although data are mixed. Little is known about other COVID-19-related complications in this group. We compared morbidity and mortality among individuals with and without SUD who were admitted to an urban safety net hospital with COVID-19 early in the pandemic, contemporaneous to other published studies on this subject.

Methods

We performed a retrospective study of patients ⩾18 years old admitted with COVID-19 from March 16th to April 8th, 2020. SUD included alcohol, opioid, cocaine, amphetamine, and benzodiazepine use disorders and was identified using diagnostic codes, free text clinical documentation, and urine drug screens. The primary outcome was inpatient mortality. Secondary outcomes included clinical complications (eg, secondary infections, venous thromboembolism) and resource utilization (eg, mechanical ventilation, length of stay). We used multivariable regression to assess the relationship between SUD and mortality.

Results

Of 409 patients, the mean age was 56 years and 13.7% had SUD. Those with SUD were more likely to be male, have experienced homelessness, have pulmonary disease or hepatitis C, or use tobacco or cannabis. After multivariable analysis, SUD was not associated with mortality (aOR 1.03; 95% CI, 0.31-3.10). Secondary outcomes were also similar between groups.

Conclusions

Our findings suggest that persons with and without SUD have similar COVID-19-related outcomes. Previously reported increased COVID-19 complications may be from medical comorbidities.

Attenuation of the Positive-Reinforcing Effects of Ultra-Potent Fentanyl Analogs, Along with Those of Fentanyl and Heroin, During Daily Treatment with Methocinnamox in Rhesus Monkeys

Without substantial intervention, the opioid crisis is projected to continue, underscoring the need to develop new treatments for opioid use disorder (OUD). One drug under development is the µ opioid receptor antagonist methocinnamox (MCAM), which appears to offer advantages over currently available medications; however, some questions remain about its potential utility, including its ability to block the effects of ultra-potent fentanyl analogs. The goal of this study was to examine its effectiveness in attenuating the abuse-related effects of the fentanyl analogs carfentanil and 3-methylfentanyl in monkeys responding for food or intravenous infusions under a choice procedure. These drugs were compared with fentanyl, heroin, methamphetamine, and cocaine. Food was preferred over saline, and there was a dose-dependent increase in responding for drug over food with no marked decrease in response rates or number of choice trials completed for any of the six drugs studied. Naltrexone (0.032 mg/kg) antagonized choice of µ opioid receptor agonists, producing rightward shifts in dose-effect curves ranging from 27-fold (carfentanil) to 71-fold (heroin). In contrast, naltrexone was less effective in attenuating choice of methamphetamine or cocaine with curves obtained in the presence of naltrexone shifted <3-fold. Daily treatment with 0.032 mg/kg MCAM also antagonized the effects of opioids, shifting curves 20-fold (fentanyl) to 72-fold (heroin) rightward; MCAM did not significantly change dose-effect curves for methamphetamine or cocaine. Thus, antagonism by MCAM is similar across a variety of µ opioid receptor agonists, including ultra-potent fentanyl analogs, further supporting its potential utility as a treatment for OUD. SIGNIFICANCE STATEMENT: Treatments for opioid use disorder (OUD) should attenuate the effects of a variety of opioids, including emerging threats like the ultra-potent fentanyl analogs. The novel µ opioid receptor antagonist MCAM is being developed to treat OUD because it provides long-lasting blockade of the reinforcing effects of heroin and fentanyl. The current study shows that MCAM attenuates the abuse-related effects of the fentanyl analogs carfentanil and 3-methylfentanyl, further supporting the utility of MCAM as a treatment for OUD.

The effect of cancer exemption in mandatory-access prescription drug monitoring programs among oncologists

To address the opioid epidemic, some states mandate that prescribers review a state-run prescription drug monitoring program (PDMP) database before prescribing opioids. We used Medicare Part D prescriber data from 2013 (baseline) to 2019 to examine the association between state mandatory-access PDMPs, with and without a cancer exemption, and changes in the percent of oncologists' patients with any opioid fill per year, stratified by oncologists' baseline prescribing volume. Among 9746 medical or hematologic oncologists, the proportion of patients prescribed opioids declined after states implemented mandatory-access PDMPs without a cancer exemption overall (-0.49 percentage point, 95% confidence interval = -0.78 to -0.20 percentage point) and among those with above-median baseline prescribing, but not in states with a cancer exemption (-0.16 percentage point, 95% confidence interval = -0.50 to 0.18 percentage point) or with below-median baseline prescribing. Carefully designed mandatory-access PDMPs with cancer exemptions minimize unnecessary reductions in prescription opioid treatments among oncology patients in need of pain management.

Society of Pain and Palliative Care Pharmacists White Paper on the Role of Opioid Stewardship Pharmacists

Opioid stewardship is one essential function of pain and palliative care pharmacists and a critical need in the United States. In recent years, this country has been plagued by two public health emergencies: an opioid crisis and the COVID-19 pandemic, which has exacerbated the opioid epidemic through its economic and psychosocial toll. To develop an opioid stewardship program, a systematic approach is needed. This will be detailed in part here by the Opioid Stewardship Taskforce of the Society of Pain and Palliative Care Pharmacists (SPPCP), focusing on the role of the pharmacist. Many pain and palliative care pharmacists have made significant contributions to the development and daily operation of such programs while also completing other competing clinical tasks, including direct patient care. To ensure dedicated time and attention to critical opioid stewardship efforts, SPPCP recommends and endorses opioid stewardship models employing a full time, opioid stewardship pharmacist in both the inpatient and outpatient setting. Early research suggests that opioid stewardship pharmacists are pivotal to improving opioid metrics and pain care outcomes. However, further research and development in this area of practice is needed and encouraged.

The Role of Physical Exercise in Opioid Substitution Therapy: Mechanisms of Sequential Effects

It is generally accepted that chronic opioid use is associated with structural and functional changes in the human brain that lead to an enhancement of impulsive behavior for immediate satisfaction. Interestingly, in recent years, physical exercise interventions have been used as an adjunctive treatment for patients with opioid use disorders (OUDs). Indeed, exercise has positive effects on both the biological and psychosocial basis of addiction, modifying neural circuits such as the reward, inhibition, and stress systems, and thus causing behavioral changes. This review focuses on the possible mechanisms that contribute to the beneficial effects of exercise on the treatment of OUDs, with emphasis placed on the description of a sequential consolidation of these mechanisms. Exercise is thought to act initially as a factor of internal activation and self-regulation and eventually as a factor of commitment. This approach suggests a sequential (temporal) consolidation of the functions of exercise in favor of gradual disengagement from addiction. Particularly, the sequence in which the exercise-induced mechanisms are consolidated follows the pattern of internal activation-self-regulation-commitment, eventually resulting in stimulation of the endocannabinoid and endogenous opioid systems. Additionally, this is accompanied by modification of molecular and behavioral aspects of opioid addiction. Overall, the neurobiological actions of exercise in combination with certain psychological mechanisms appear to promote its beneficial effects. Given the positive effects of exercise on both physical and mental health, exercise prescription is recommended as a complement to conventional therapy for patients on opioid maintenance treatment.

The Impact of the Florida Law HB21 on Opioid Prescribing Patterns After Spine Surgery

Background

The opioid epidemic represents a major public health issue in the United States and has led to significant morbidity and mortality. On July 1 2018, Florida implemented state-law House Bill 21 (HB21), limiting opioid prescriptions to a 3-day supply for acute pain or 7 days if an exception is documented. The purpose of this study is to evaluate the effects of HB21 on opioid prescribing patterns after spine surgery.

Methods

Patients 18 years and older who underwent spine surgery between January 2017 and January 2021 were eligible for inclusion. Information including demographics, pills, days, and morphine milligram equivalents (MMEs) was obtained via retrospective chart review using the Florida Prescription Drug Monitoring Program and Epic Chart Review. Student's t tests and Fisher's exact tests were used for comparison of continuous variables. Multiple logistic regression was utilized to determine which variables were associated with postoperative opioid prescriptions. p<.05 was considered significant.

Results

We reviewed 114 patients who underwent spine surgery from January 2017 to July 2018 and 264 patients from July 2018 to January 21. There were no significant differences between the groups in age, sex, ethnicity, body mass index, number of levels fused, or preoperative opioid use. The average number of MMEs, pills prescribed and days in the first postoperative prescription decreased significantly after HB21. Multiple logistic regression revealed that the variable most predictive of MMEs and number of pills in the first postoperative prescription was postlaw status (p=.002, p=.50).

Conclusions

Florida law HB21 was successful in decreasing postoperative opioid prescriptions after spine surgery, however, the need for additional progress remains. Legislation should be combined with multimodal pain regimens, as well as patient and provider education in order to further decrease postoperative opioid requirements. Future studies should include a larger number of patients treated by multiple spine surgeons across multiple institutions in order to further evaluate the effects of HB21 on postoperative opioid prescriptions.

The Critical Role of Pharmacists in Treating Older People in the Opioid Crisis

Pharmacy-based Opioid Use Disorder (OUD) treatment has been identified as a central pillar in curbing the spiraling opioid epidemic that claimed more than 100,000 lives in the United States in a one year period for the first time. This epidemic is also partially responsible for the plummeting US life expectancy that began prior to the COVID-19 pandemic and has now claimed more than 500,000 lives since 1999 with more than 70% of the 70,630 overdose deaths in 2019 involved with an opioid. Older people are at increased risk of both OUD and OUD-related complications. Recent studies have demonstrated that people older than 65 years of age were more likely to die of OUD-related complications, and - because of an increased likelihood of polypharmacy - are more likely to experience a drug interaction that magnifies the risk of an opioid-related misadventure.

Pre-Paid Phone Distribution: A Tool for Improving Healthcare Engagement for People with Substance Use Disorder

BACKGROUND

The COVID-19 pandemic drove significant disruptions in access to substance use disorder (SUD) treatment and harm reduction services. Healthcare delivery via telemedicine has increasingly become the norm, rendering access to a phone essential for engagement in care.

METHODS

Adult patients with SUD who lacked phones (n = 181) received a free, pre-paid phone during encounters with inpatient and outpatient SUD programs. We evaluated changes in healthcare engagement including completed in-person and telemedicine outpatient visits and telephone encounters 30 days before and after phone receipt. We used descriptive statistics, where appropriate, and paired t-tests to assess the change in healthcare engagement measures.

RESULTS

Patients were predominantly male (64%) and white (62%) with high rates of homelessness (81%) and opioid use disorder (89%). When comparing 30 days before to 30 days after phone receipt, there was a significant increased change in number of telemedicine visits by 0.3 (95% CL [0.1,0.4], p < 0.001) and telephone encounters by 0.2 (95% CL [0.1,0.3], p = 0.004). There was no statistically significant change in in-person outpatient visits observed.

CONCLUSIONS

Pre-paid phone distribution to patients with SUD was associated with an increased healthcare engagement including telemedicine visits and encounters.

Changes in the Street Prices of Prescription Opioids During the COVID-19 Pandemic

OBJECTIVE

This study analyzed changes in prescription opioid street prices during the COVID-19 pandemic.

METHODS

Crowdsourced prescription opioid street prices were obtained from the Researched Abuse, Diversion and Addiction-Related Surveillance System StreetRx Program. Percentage changes in street price per milligram of different opioids between April and December 2020 compared with the same months in 2019 were calculated by using linear regression.

RESULTS

Street prices of high-potency drugs hydromorphone and oxycodone increased 23% and 12% per milligram, respectively. Prices of low-potency drugs hydrocodone and morphine increased 9% and 12% per milligram, respectively. Changes in prices of medications for opioid use disorder were not statistically significant.

CONCLUSIONS

Decreased access to opioid analgesics during the pandemic combined with contributors to opioid demand may have led to increases in street prices of prescription opioids. Measures taken to increase access to medications for opioid use disorder were not associated with changes in those drugs' street prices.

Opioid Prescriptions Prior to Emergency Department Dental Visits: A Comparison of Dental Health Professional Shortage Areas (DPSAs) and Non-DPSAs Using Electronic Health Records

Although prior research has linked dental conditions and opioid prescribing in the U.S., it is not yet known whether the receipt of opioid prescriptions prior to seeking emergency care for dental conditions differs in geographical areas that are underserved by health care professionals (Dental Professional Shortage Areas, DPSAs) compared to other areas. Using Indiana's state-wide electronic health records from January 1, 2016 to October 31, 2020, we examine if patients from DPSAs presenting at the emergency department (ED) for dental conditions are more likely to have received opioid prescriptions in the 30 days prior to their visit, compared to patients from other areas. A higher rate of opioid receipt among DPSA individuals may indicate an association between lower availability of dental professionals and the use of opioids as a coping strategy. We note that our study design has several limitations (such as a lack of data on prescription use after the ED visit) and does not prove causation. We find that individuals experiencing dental condition ED visits in DPSAs are 16% more likely (than those in non-DPSAs) to have filled an opioid prescription in the 30 days prior to the ED visit, after controlling for age, gender, and race/ethnicity. This result is statistically significant at the 1% level. The baseline rate of opioid filling in the 30 days prior to the ED visit is 12% in DPSAs. These correlational results suggest that unmet dental needs might be substantially connected to opioid prescriptions, although further research is needed to establish whether this relationship is causal.

How Do Colorado Public Libraries Respond to Patron Queries about Opioid Use Disorder? A Secret Shopper Study

Background: Colorado's age-adjusted fatal opioid overdose rate increased over 400% from 2000 to 2020. Public libraries are increasingly valuable community resources for accessing health-related information. We sought to evaluate the availability and types of opioid use disorder (OUD)-related resources offered through Colorado Public Library branches using secret shoppers to collect data. Methods: This was a cross sectional study of 197 Colorado Public Libraries in 2021. Anonymous auditors posed as library patrons asking a brief standardized script about availability of OUD-related resources over the phone. We conducted descriptive analyses of the libraries contacted, the response types of OUD resources provided, and information about naloxone availability. Outcomes were compared between urban/rural and libraries within/outside the Denver Public Library (DPL) system via means comparison tests. Results: Approximately 50% of libraries were classified as urban. Most (81%) of the libraries offered a valid OUD-resource, and over half (51%) provided a referral to a treatment center offering at least one medication for OUD. Over a third (36%) of librarians referenced the statewide naloxone standing order allowing patients to obtain naloxone from a pharmacy without prescription. One in ten libraries provided at least one invalid referral resource. Libraries within the DPL system referenced Colorado's naloxone standing order at higher rates than non-DPL libraries. Conclusions: Public libraries may benefit from the development of a standard for OUD-related resource training/education that can be distributed across the state to create a space for community members to obtain resources related to substance use.

Estimating the impact of the COVID-19 pandemic on rising trends in drug overdose mortality in the United States, 2018-2021

PURPOSE

During the COVID-19 pandemic, social and economic disruption such as social isolation, job and income losses, and increased psychological distress, may have contributed to the increase in drug-overdose mortality. This study aims to measure the impact of the pandemic on monthly trends in drug-overdose mortality in the United States.

METHODS

We used the 2018-2020 final and 2021 provisional monthly deaths from the National Vital Statistics System and monthly population estimates from the Census Bureau to compute monthly mortality rates by age, sex, and race/ethnicity. We use log-linear regression models to estimate monthly percent increases in mortality rates from January 2018 through November 2021.

RESULTS

The age-adjusted drug-overdose mortality rate among individuals aged older than or equal to 15 years increased by 30% between 2019 (70,459 deaths) and 2020 (91,536 deaths). During January 2018-November 2021, the monthly drug-overdose mortality rate increased by 2.05% per month for Blacks, 2.25% for American Indians/Alaska Natives, 1.96% for Hispanics, 1.33% for Asian/Pacific Islanders, and 0.96% for non-Hispanic Whites. Average monthly increases in mortality were most marked among those aged 15-24 and 35-44 years.

CONCLUSIONS

The COVID-19 pandemic had a substantial impact on the rising trends in drug-overdose mortality during the peak months in 2020 and 2021.