Prescription opioids, abuse and public health in Canada: is fentanyl the new centre of the opioid crisis?

College students' knowledge about opioids and implications for the opioid crisis

OBJECTIVE

This study assessed undergraduate unhealthy substance use, levels of knowledge about opioid pharmacology, unhealthy use and safety, and students' perceptions about their level of knowledge.

PARTICIPANTS

Participants were undergraduate students at a large, private university in the Northeast.

METHODS

This study employed a cross-sectional study design using an online survey. A convenience sample of undergraduate students (N = 317) described their actual and perceived levels of opioid knowledge and their self-reported substance use.

RESULTS

Objective answers to quiz-style questions about opioids showed knowledge deficits. Participants rated themselves as slightly less knowledgeable than the "average student." Ten percent of students surveyed had used opioids unhealthily at some point in their lifetime. Those reporting unhealthy opioid use had higher subjective and objective opioid knowledge scores.

CONCLUSIONS

University students' subjective and objective knowledge of opioids warrants more effective and engaging substance use education on college campuses.

Design, synthesis, and biological evaluation of C6-difluoromethylenated epoxymorphinan Mu opioid receptor antagonists

The recent widespread abuse of high potency synthetic opioids, such as fentanyl, presents a serious threat to individuals affected by substance use disorder. Synthetic opioids generally exhibit prolonged in vivo circulatory half-lives that can outlast the reversal effects of conventional naloxone-based overdose antidotes leading to a life-threatening relapse of opioid toxicity known as renarcotization. In this manuscript, we present our efforts to combat the threat of renarcotization by attempting to extend the half-life of traditional MOR antagonists through the design of novel, fluorinated 4,5-epoxymorphinans possessing increased lipophilicity. Analogues were prepared via a concise synthetic strategy highlighted by decarboxylative Wittig olefination of the C6 ketone to install a bioisosteric 1,1-difluoromethylene unit. C6-difluoromethylenated compounds successfully maintained in vitro potency against an EC90 challenge of fentanyl and were predicted to have enhanced circulatory half-life compared to the current standard of care, naloxone. Subsequent in vivo studies demonstrated the effective blockade of fentanyl-induced anti-nociception in mice.

The iatrogenic opioid crisis: An example of 'institutional corruption of pharmaceuticals'?

RATIONALE

Prescribed opioids are major contributors to the international public health opioid crisis. Such widespread iatrogenic harms usually result from collective decision failures of healthcare organizations rather than solely of individual organizations or professionals. Findings from a system-wide safety analysis of the iatrogenic opioid crisis that includes roles of pertinent healthcare organizations may help avoid or mitigate similar future iatrogenic consequences. In this retrospective exploratory study, we report such an analysis.

METHODS

The study population encompassed the entire age spectrum and included those in whom opioids prescribed for chronic pain (unrelated to malignancy) were associated with death or morbidity. Root cause analysis, incorporating recent suggestions for improvement, was used to identify possible contributory factors from the literature. Based on their mandated roles and potential influences to prevent or mitigate the iatrogenic crisis, relevant organizations were grouped and stratified from most to least influential.

RESULTS

The analysis identified a chain of multiple interrelated causal factors within and between organizations. The most influential organizations were pharmaceutical, political, and drug regulatory; next: experts and their related societies, and publications. Less influential: accreditation, professional licensing and regulatory, academic and healthcare funding bodies. Collectively, their views and decisions influenced prescribing practices of frontline healthcare professionals and advocacy groups. Financial associations between pharmaceutical and most other organizations/groups were common. Ultimately, patients were adversely affected. There was a complex association with psychosocial variables.

LIMITATIONS

The analysis suggests associations not causality.

CONCLUSION

The iatrogenic crisis has multiple intricately linked roots. The major catalyst: pervasive pharma-linked financial conflicts of interest (CoIs) involving most other healthcare organizations. These extensive financial CoIs were likely triggers for a cascade of erroneous decisions and actions that adversely affected patients. The actions and decisions of pharma ranged from unethical to illegal. The iatrogenic opioid crisis may exemplify 'institutional corruption of pharmaceuticals'.

Opioid use disorder

Opioid use disorder (OUD) is a chronic relapsing disorder that, whilst initially driven by activation of brain reward neurocircuits, increasingly engages anti-reward neurocircuits that drive adverse emotional states and relapse. However, successful recovery is possible with appropriate treatment, although with a persisting propensity to relapse. The individual and public health burdens of OUD are immense; 26.8 million people were estimated to be living with OUD globally in 2016, with >100,000 opioid overdose deaths annually, including >47,000 in the USA in 2017. Well-conducted trials have demonstrated that long-term opioid agonist therapy with methadone and buprenorphine have great efficacy for OUD treatment and can save lives. New forms of the opioid receptor antagonist naltrexone are also being studied. Some frequently used approaches have less scientifically robust evidence but are nevertheless considered important, including community preventive strategies, harm reduction interventions to reduce adverse sequelae from ongoing use and mutual aid groups. Other commonly used approaches, such as detoxification alone, lack scientific evidence. Delivery of effective prevention and treatment responses is often complicated by coexisting comorbidities and inadequate support, as well as by conflicting public and political opinions. Science has a crucial role to play in informing public attitudes and developing fuller evidence to understand OUD and its associated harms, as well as in obtaining the evidence today that will improve the prevention and treatment interventions of tomorrow.

[Quasi-experimental study of an intervention on the pharmacological management of non-oncological chronic pain in Primary Care]

OBJECTIVE

To analyse the impact of a formative / informative intervention on the treatment of non-oncological chronic pain in Primary Care.

DESIGN

Quasi-experimental study before-after, and follow-up of the patient cohort.

LOCATION

64 Primary Care teams/centres (770 physicians).

PARTICIPANTS

Patients≥14 years without an oncological diagnosis on: 1) fentanyl citrate, 2) major opioids and≥2 anxiolytics-hypnotics, 3) long-term major and minor opioids, 4) transdermal lidocaine, out of indication.

INTERVENTION

Dissemination of recommendations for the treatment of non-oncological chronic pain and the reporting of the incidents of their patients to each doctor.

MAIN MEASUREMENTS

Number of incidents in 2 cross sections (June 2017 and June 2018). Number of incidents in June 2017, which were maintained in June 2018 (prospective cohort).

RESULTS

Of the 2,465 incidents detected in 2017, there was a 21.1% reduction after the intervention. The reduction was higher (61.8%, p<.001) in the prospective cohort. In absolute values, the most important reduction was in incidences of lidocaine patches outside of indication (1,032 incidences). The approved indication was found in less than 8% of the treated patients.

CONCLUSIONS

The intervention reduced the number of patients with incidences, and this reduction was higher in the prospective cohort, confirming the efficacy of sending information about patients with incidences to their physicians. The incorporation of new treatments during the follow-up year was significant, so these interventions should be perpetuated over time.

Family Physician Perceptions of Their Role in Managing the Opioid Crisis

PURPOSE

We examined the perspectives of family physicians (FPs) on opioid prescribing and management of chronic pain to better understand the barriers to safer prescribing in primary care and differences in perspectives that may be potential drivers of practice variation.

METHODS

We used an exploratory qualitative study design. Semistructured interviews were conducted in June and July 2017 with 22 FPs in Ontario and coded inductively. Thematic analysis was used to identify themes, and a framework analysis explored the influence of physician demographics on prescribing experience.

RESULTS

Three key themes emerged: the discrepancy between FPs' training and current practice, the tension between the FP's role and patient and system expectations, and the influence of length of time in practice and strength of therapeutic relationships on perspectives on opioid prescribing. There was an overarching sentiment among participants that FPs are unsupported in their efforts to manage chronic pain. More years in practice (≥15 years) seems to influence practice patterns by increasing trust in therapeutic relationships and decreasing reliance on emergent guidelines (vs clinical experience).

CONCLUSION

Number of years in practice influences FPs' response to emergent evidence, requiring initiatives to include strategies tailored to individual beliefs. Initiatives must move beyond dissemination and education to equip FPs with the skills they need to navigate emotionally charged conversations. External pressures and misaligned system and patient expectations place FPs at the center of a challenging situation, which may result in a higher risk of burnout compared with that of their specialist colleagues.

Qualitative exploration of the education and skill needs of community pharmacists in Saskatoon concerning substance use disorder

BACKGROUND

Identifying the skills and educational needs of community pharmacists concerning addiction is critical to improving the services provided for people who suffer from addiction disease (PWSAD).

METHODS

Eleven one-to-one semi-structured interviews were conducted with community pharmacists practising in the Saskatoon Health Region, Canada. The interviews were recorded and transcribed verbatim and verified with the participants. Thematic analysis was employed to analyze the transcripts.

RESULTS

Four major themes were identified: 1) effect of the work setting on pharmacists' encounters with PWSAD, 2) pharmacists' knowledge of key aspects of addiction, 3) level of support within the health care system, and 4) educational and training needs.

CONCLUSION

Participants indicated that a lack of knowledge and training were major hindrances to improving the quality of the services provided to people who suffer from addiction disease. Additional practicum experience at the undergraduate level and interprofessional interactive educational sessions at the continuing educational level were key recommendations emerging from the study.

Correlations between population-levels of prescription opioid dispensing and related deaths in Ontario (Canada), 2005-2016

Canada is experiencing an ongoing opioid-related public health crisis, including persistently rising opioid (e.g., poisoning) mortality. Previous research has documented marked correlations between population-levels of opioid dispensing and deaths. We examined possible correlations between annual population-level dispensing of specific opioid formulations and related poisoning deaths in Ontario (Canada), for the period 2005-2016. Annual coroner statistics-based numbers of poisoning deaths associated with six main opioid formulations (codeine, fentanyl, hydromorphone, methadone, morphine, and oxycodone) for Ontario were converted into annual death rates (per 100,000 population). Annual dispensing data for the opioid formulations under study were based on commercial retail-sales data from a representative, stratified sample of community pharmacies (IMSQuintiles/IQVIA CompuScript), converted into Defined Daily Doses (DDD/1,000 population/day). Possible relationships between the annual death and dispensing rates were assessed by Pearson's correlation coefficient analyses. Death rates increased for almost all, while dispensing rates increased for half of the opioid categories. A significant positive correlation between death and dispensing rates was found for hydromorphone (r = 0.97, 95% CI: 0.88-0.99) and oxycodone (r = 0.90, 95% CI: 0.68-0.97) formulations; a significant negative correlation was found for codeine (r = -0.78, 95% CI: -0.93 to -0.37). No significant correlations were detected for fentanyl, methadone, and morphine related deaths. Strong correlations between levels of dispensing and deaths for select opioid formulations were found. For select others, extrinsic factors - e.g., increasing involvement of non-medical opioid products (e.g., fentanyl) in overdose deaths - likely confounded underlying correlation effects. Opioid dispensing levels continue to influence population-level mortality levels, and need to be addressed by prevention strategies.

Use of rapid fentanyl test strips among young adults who use drugs

BACKGROUND

The overdose epidemic has been exacerbated by a dramatic increase in deaths involving illicitly manufactured fentanyl (IMF). Drug checking is a novel strategy to identify IMF in illicit drugs. We examined the uptake and acceptability of rapid fentanyl test strips among young adults.

METHODS

From May to September 2017, we recruited 93 young adults in Rhode Island who reported injecting drugs or using heroin, cocaine, or illicitly obtained prescription pills in the past 30 days. Participants were asked to test either their urine after drug use (post-consumption) or a drug sample prior to use (pre-consumption) using rapid fentanyl test strips. After a questionnaire and a brief training, participants received ten strips for their personal use and were asked to return for a one-month follow-up visit, which assessed the uptake and acceptability of the rapid strips tests and the behavioral outcomes associated with receipt of a positive test.

RESULTS

Of the 81 (87%) participants who returned for follow-up and who had complete data, the mean age was 27, 45 (56%) were male, and 37 (46%) were non-white. A total of 62 participants (77%) reported using at least one test strip. Of these, 31 (50%) received at least one positive result. A positive result was associated with older age, homelessness, heroin use, injection drug use, ever witnessing an overdose, and concern about overdose or drugs being laced with fentanyl (all p < 0.05). Receiving a positive result was significantly associated with reporting a positive change in overdose risk behavior between baseline and follow-up (p ≤  0.01). Among all participants, 79 (98%) reported confidence in their ability to use the test strips and 77 (95%) wanted to use them in the future.

CONCLUSIONS

Young adults reported high uptake and acceptability of fentanyl test strips to detect IMF in illicit drugs.

Prescription opioid analgesic use in France: Trends and impact on morbidity-mortality

BACKGROUND

While data from USA and Canada demonstrate an opioid overdose epidemic, very little nation-wide European studies have been published on this topical subject.

METHODS

Using a nationally representative sample of the French Claims database (>700,000 patients), the exhaustive nationwide hospital discharge database, and national mortality registry, all patients dispensed at least one prescription opioid (PO) in 2004-2017 were identified, to describe trends in PO analgesic use, shopping behaviour, opioid-related hospitalizations and deaths. Annual prevalence of PO use and shopping behaviour (≥1 day of overlapping prescriptions from ≥2 prescribers, dispensed by ≥3 pharmacies) was estimated.

RESULTS

In 2004-2017, the annual prevalence of weak opioid use codeine, tramadol and opium rose by 150%, 123%, and 244%, respectively (p < 0.05). Strong opioid use increased from 0.54% to 1.1% (+104%, p < 0.05), significantly for oxycodone (+1950%). Strong opioid use in chronic noncancer pain rose by 88% (p < 0.05) and 1180% for oxycodone. Opioid shopping increased from 0.50% to 0.67% (+34%, p < 0.05), associated with higher mortality risk HR = 2.8 [95% confidence interval (CI): 1.2-6.4]. Opioid-related hospitalizations increased from 15 to 40 per 1,000,000 population (+167%, 2000-2017), and opioid-related deaths from 1.3 to 3.2 per 1,000,000 population (+146%, 2000-2015).

CONCLUSIONS

This study provided a first European approach to a nationwide estimation with complete access to several national registries. In 2004-2017 in France, PO use excluding dextropropoxyphene more than doubled. The increase in oxycodone and fentanyl use, and nontrivial increasing trend in opioid-related morbidity-mortality should prompt authorities to closely monitor PO consumption in order to prevent alarming increases in opioid-related morbidity-mortality.

SIGNIFICANCE

In 2004-2017, prescription opioid use in France at least doubled and oxycodone use increased particularly, associated with a nontrivial increase in opioid-related morbidity-mortality. Although giving no indication for an 'opioid epidemic,' these findings call for proper monitoring of opioid use.

At-a-glance - What can social media tell us about the opioid crisis in Canada?

We explored social media as a potential data source for acquiring realtime information on opioid use and perceptions in Canada. Twitter messages were collected through a social media analytics platform between June 15, 2017, and July 13, 2017, and analyzed to identify recurring topics mentioned in the messages. Messages concerning the medical use of opioids as well as commentary on the Canadian government's current response efforts to the opioid crisis were common. The findings of this study may help to inform public health practice and community stakeholders in their efforts to address the opioid crisis.

Youth Mental Health Should Be a Top Priority for Health Care in Canada

In this article we have provided a perspective on the importance and value of youth mental health services for society and argued that advancing youth mental health services should be the number one priority of health services in Canada. Using the age period of 12-25 years for defining youth, we have provided justification for our position based on scientific evidence derived from clinical, epidemiological and neurodevelopmental studies. We have highlighted the early onset of most mental disorders and substance abuse as well as their persistence into later adulthood, the long delays experienced by most help seekers and the consequence of such delays for young people and for society in general. We have also provided a brief review of the current gross inadequacies in access and quality of care available in Canada. We have argued for the need for a different conceptual framework of youth mental disorders as well as for a transformation of the way services are provided in order not only to reduce the unmet needs but also to allow a more meaningful exploration of the nature of such problems presenting in youth and the best way to treat them. We have offered some ideas based on previous work completed in this field as well as current initiatives in Canada and elsewhere. Any transformation of youth mental health services in Canada must take into consideration the significant geographic, cultural and political diversity across the provinces, territories and indigenous peoples across this country.

Intravenous fentanyl use among people who inject drugs in Australia

INTRODUCTION AND AIMS

There is a current epidemic of pharmaceutical opioid (PO) misuse, particularly fentanyl and fentanyl analogues, globally. Fentanyl is a highly potent synthetic opioid with rapid onset and significantly higher risk of overdose compared with other opioids. Contexts and correlates of fentanyl use among people who inject drugs (PWID) in Australia are under-researched.

DESIGN AND METHODS

The Australian Needle Syringe Program Survey is conducted annually. Consenting PWID complete a self-administered questionnaire and provide a capillary dried blood spot for human immunodeficiency virus and hepatitis C virus antibody testing. Bivariate and multivariate logistic regressions determined correlates of recent (last 6 months) fentanyl injection in 2014.

RESULTS

Recent fentanyl injection was reported by 8% (n = 193) of the total sample. Among the 848 PWID who recently injected POs, 23% injected fentanyl. Compared with PO injectors who had not injected fentanyl, those who had injected fentanyl were significantly more likely to identify as Indigenous Australian [adjusted odds ratio (AOR) 1.61; 95% confidence interval (CI) 1.04, 2.51; P = 0.034], inject daily or more frequently (AOR 1.92; 95% CI 1.30, 2.83; P = 0.005), inject in public (AOR 1.43; 95% CI 1.01, 2.02; P = 0.042) and to have overdosed in the past year (AOR 2.16; 95% CI 1.48, 3.13; P < 0.001), but were significantly less likely to receptively share syringes (AOR 0.56; 95% CI 0.36, 0.87; P = 0.010).

DISCUSSION AND CONCLUSIONS

Fentanyl injectors in Australia are significantly more likely to identify as Indigenous, report frequent injection, inject in public and experience overdose. Increased access to harm reduction interventions, including naloxone distribution, wheel filters and supervised injection facilities, are likely to benefit this population.

The 'fentanyl epidemic' in Canada - Some cautionary observations focusing on opioid-related mortality

In Canada, opioid-related overdose mortality has steeply increased in recent years; as a substantial number of opioid-related deaths are related to fentanyl products, this phenomenon has widely been described as the 'fentanyl epidemic', also implying that these deaths are largely caused by clandestinely produced illicit fentanyl products. We examined numbers and rates of opioid- and fentanyl-related deaths in six pan-Canadian provinces with respective (coroner-based) data available from 2010 to 2016. While fentanyl-related deaths are clearly increasing from relatively low levels in all provinces, those increases are strongest in the two Western provinces (e.g., British Columbia, where fentanyl accounts for the majority of opioid deaths in 2016 and Alberta), and, to some extent, Ontario. However, fentanyl-related deaths remain a minority of deaths in Ontario (40%) and the remaining provinces (<25%). Furthermore, it is uncertain what proportion of fentanyl-related deaths is actually related to illicit fentanyl products. We conclude that fentanyl-related overdose deaths have risen - most strongly in the West - due to both a high availability of medical fentanyl products, as well as an influx of illegal fentanyl products. In most provinces, the majority of opioid deaths remain associated with other (non-fentanyl) products. Appropriate (prevention, treatment and policy) interventions need to be targeted at the full range of opioid deaths from different sources. Overall, a realistic framing of the social (e.g., media) discourse about the nature of the 'opioid overdose death crisis' is required, which is not exclusively an 'illicit fentanyl death crisis' even though this may be a socio-politically appealing image.

Will optogenetics be used to treat chronic pain patients?

Chronic pain affects a third of the population and current treatments produce limited relief and severe side effects. An alternative strategy to decrease pain would be to directly modulate somatosensory pathways using optogenetics. Optogenetics involves the use of genetically encoded and optically active proteins, namely opsins, to control neuronal circuits. In preclinical animal models, optical silencing of peripheral nociceptors has been shown to alleviate both inflammatory and neuropathic pain. An opsin-based gene therapy to treat chronic pain patients is not ready yet, but encouraging advances have been made in optical and viral technology. In view of the increasing burden of chronic pain in our aging society, innovative analgesic approaches based on optogenetics are definitely worth exploring.