America's Opioid Epidemic: a Comprehensive Review and Look into the Rising Crisis

Neuropsychological mechanisms of observational learning in human placebo effects

Scientific evidence indicates that placebo effects are psychoneurobiological events involving the contribution of distinct central nervous systems and peripheral physiological mechanisms that influence pain perception and other symptoms. Placebo effects can occur without formal conditioning and direct prior experience because crucial information can be acquired through observational learning. Observation of benefits in another person results in placebo effects of a magnitude like those induced by directly experiencing an analgesic benefit. Understanding the psychological mechanisms of observationally induced placebo effects is a complex and multifaceted endeavor. While previous reviews have highlighted various frameworks and models to understand these phenomena, the underlying biological mechanisms have been overlooked. We summarize critically current understanding of its behavioral and neural mechanisms. Understanding the neural mechanisms of hypoalgesia driven by observation can serve as a foundation for future development of novel theoretical and methodological approaches and ultimately, applications.

rdHSV-CA8 non-opioid analgesic gene therapy decreases somatosensory neuronal excitability by activating Kv7 voltage-gated potassium channels

Chronic pain is common and inadequately treated, making the development of safe and effective analgesics a high priority. Our previous data indicate that carbonic anhydrase-8 (CA8) expression in dorsal root ganglia (DRG) mediates analgesia via inhibition of neuronal ER inositol trisphosphate receptor-1 (ITPR1) via subsequent decrease in ER calcium release and reduction of cytoplasmic free calcium, essential to the regulation of neuronal excitability. This study tested the hypothesis that novel JDNI8 replication-defective herpes simplex-1 viral vectors (rdHSV) carrying a CA8 transgene (vHCA8) reduce primary afferent neuronal excitability. Whole-cell current clamp recordings in small DRG neurons showed that vHCA8 transduction caused prolongation of their afterhyperpolarization (AHP), an essential regulator of neuronal excitability. This AHP prolongation was completely reversed by the specific Kv7 channel inhibitor XE-991. Voltage clamp recordings indicate an effect via Kv7 channels in vHCA8-infected small DRG neurons. These data demonstrate for the first time that vHCA8 produces Kv7 channel activation, which decreases neuronal excitability in nociceptors. This suppression of excitability may translate in vivo as non-opioid dependent behavioral- or clinical analgesia, if proven behaviorally and clinically.

False-Positive Rate for Suspected Drug-Related Deaths Following Full Autopsy

ABSTRACT

The sharp increase in drug-related deaths has tempted medical examiner/coroner offices to perform external examinations with comprehensive toxicology testing instead of performing a standard autopsy. Compounding the problem of an increasing workload has been the decrease in available forensic pathologists. Opting for external examinations on suspected drug-related fatalities, however, is antithetical to current best practices. The purpose of this study was to review case files, autopsy reports, and toxicologic results of all deaths that were autopsied at the authors' facility and decide whether significant disease processes or injuries that would supersede the results of toxicologic testing and external examination findings alone were being missed.

Child Protection System Interactions for Children With Positive Urine Screens for Illicit Drugs

Importance

Young children are ingesting illicit drugs at increased rates, but it is unknown what the associated child protection system (CPS) responses are when a child tests positive.

Objective

To document the child protection system involvement and the characteristics of children who test positive for illicit substances.

Design, Setting, and Participants

This retrospective cross-sectional study linked medical discharge and child protection system administrative data. The setting was Rady Children's Hospital San Diego, a free-standing pediatric hospital in California. Participants included all emergency department and inpatient medical encounters involving children aged 12 years or younger with a positive urine drug test between 2016 and 2021. Statistical analysis was performed from February 2023 to January 2024.

Exposure

Drug type, including amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, fentanyl, opiates, and phencyclidine.

Main Measures and Outcomes

CPS responses associated with the medical encounter including reports, substantiations, case openings, and out-of-home placements.

Results

A total of 511 emergency department and inpatient medical encounters involving children had a positive drug test (262 [51.3%] were female; 309 [60.5%] were age 6 years or younger; fewer than 10 [<3.0%] were American Indian or Alaska Native; 252 [49.3%] were Hispanic [any race], 20 [3.9%] were non-Hispanic Asian, 56 [11.0%] were non-Hispanic Black, 143 [28.0%] were non-Hispanic White, 36 [7.0%] had other or unknown race and ethnicity; 233 [43.6%] had a CPS report prior to the medical encounter). Following the positive screen, 244 (47.7%) were reported to child protection, and 61 (11.9%) were placed out-of-home within 30 days. Mean (SD) quarterly counts of encounters with positive drug tests doubled after the COVID-19 pandemic onset (32.9 [9.8]) compared with prior to the pandemic onset (16.5 [4.7]); for encounters positive for cannabis, mean (SD) quarterly counts were 3 times as high after the pandemic onset than prior (16.6 [4.7] vs 5.7 [2.9]). Encounters for children under age 1 were significantly more likely to have associated child protection reports (relative risk [RR], 2.91 [95% CI, 2.21-3.83]) and child protection case openings (RR, 1.71 [95% CI, 1.07-2.72]) than encounters involving older children.

Conclusions and Relevance

In this cross-sectional study of emergency department and inpatient medical encounters, less than half of children with positive urine drug screens were reported to CPS; out-of-home placements were uncommon. With increased encounters for positive drug tests, it is unclear what services these children and families are receiving.

Longitudinal polysubstance use patterns and non-fatal overdose: A repeated measures latent class analysis

BACKGROUND

Polysubstance use (PSU) is common among people who use opioids (PWUO) and has been associated with drug-related harms. We aimed to identify latent longitudinal PSU classes among a cohort of PWUO and characterize non-fatal overdose risks among different sub-classes over time.

METHODS

We used longitudinal data (2005-2018) from three ongoing prospective cohorts of people who use drugs in Vancouver, Canada. The primary outcome of interest was self-reported non-fatal overdose during the past six months. The primary exposure of interest was longitudinal PSU patterns among PWUO, obtained from repeated measures latent class analysis (RMLCA) of weekly substance use-related outcome indicators. Multivariable generalized estimating equations models were built to assess the association between latent PSU class membership and non-fatal overdose, adjusting for potential sociodemographic, behavioural, and structural confounders.

RESULTS

2627 PWUO were included in the analysis, and 1094 (41.6 %) had experienced at least one non-fatal overdose during the study period. RMLCA revealed five distinct latent longitudinal PSU classes, including low/infrequent use (Class 1; 30 %), primarily opioid and methamphetamine use (Class 2; 22 %), primarily cannabis use (Class 3; 15 %), primarily opioid and crack use (Class 4; 29 %), and frequent PSU (Class 5; 4 %). In comparison with Class 1 (low), membership in all latent PSU classes except Class 3 (cannabis) was associated with increased odds of non-fatal overdose: Class 2 (opioids + meth) vs. Class 1 (Adjusted odds ratios [aOR] = 2.20, 95 % confidence intervals [CI]: 1.51-3.22), Class 4 (opioids + crack) vs. Class 1 (aOR = 1.06, 95 % CI: 0.85-1.33), and Class 5 (frequent) vs. Class 1 (aOR = 2.39, 95 % CI: 1.92-2.97).

CONCLUSION

Our findings highlighted the heterogeneous characteristics of PWUO in terms of patterns of PSU and non-fatal overdose risk. The diverse nature of PWUO and the potential additive or multiplicative impact of using several substances on overdoses should be reflected across the substance use treatment continuum and care provision.

Self-reported Impacts of the COVID-19 Pandemic and Economic Inflation on the Well-being of Low-income U.S. Veterans

The health and well-being of low-income populations may be disproportionately impacted by major public health and economic events. This study examined written self-reported impacts of the Coronavirus Disease-2019 (COVID-19) pandemic and the economic inflationary period on health from a national sample of 854 low-income U.S. veterans. Responses were analyzed using rapid assessment procedures. In response to the COVID-19 pandemic, 59% of participants reported the pandemic had "no effect" on their health, 7% reported increased social isolation, and small proportions of participants reported negative effects on physical and mental health. In response to economic inflation, 43% of participants reported inflation had "no effect" on their health, 11% reported concerns about personal finances, and only small proportions reported other negative psychosocial impacts. Collectively, these findings suggest many low-income veterans are resilient during major events. Further research is needed on long-term health effects of inflation on this population.

HIV-1 and opiates modulate miRNA profiles in extracellular vesicles

Opiate abuse increases the risk of HIV transmission and exacerbates HIV neuropathology by increasing inflammation and modulating immune cell function. Exosomal EVs(xEV) contain miRNAs that may be differentially expressed due to HIV infection or opiate abuse. Here we develop a preliminary exosomal-miRNA biomarker profile of HIV-infected PBMCs in the context of opiate use. PBMCs infected with HIV were treated with increasing dosages of morphine for 72 hours, the culture supernatants were collected, and the exosomes isolated using differential centrifugation. Exosomal miRNAs were extracted, expression levels determined via Nanostring multiplexed microRNA arrays, and analyzed with Webgestalt. The effect of the exosomes on neuronal function was determined by measuring calcium. Preliminary findings show that HIV-1 infection altered the miRNA profile of PBMC-derived EVs concurrently with opiate exposure. MicroRNA, hsa-miR-1246 was up-regulated 12-fold in the presence of morphine, relative to uninfected control. PBMCs infected with HIV-1 MN, an X4-tropic HIV-1 strain and exposed to morphine, displayed a trend which suggests potential synergistic effects between HIV-1 infection and morphine exposure promoting an increase in viral replication. Dose-dependent differences were observed in miRNA expression as a result of opiate exposure. The xEVs derived from PBMCs exposed to morphine or HIV modulated neuronal cell function. SH-SY5Y cells, treated with xEVs derived from ART-treated PBMCs, exhibited increased viability while for SH-SY5Ys exposed to xEVs derived from HIV-1 infected PBMCs viability was decreased compared to the untreated control. Exposing SH-SY5Y to xEVs derived from HIV-infected PBMCs resulted in significant decrease in calcium signaling, relative to treatment with xEVs derived from uninfected PBMCs. Overall, HIV-1 and morphine induced differential miRNA expression in PBMC-derived exosomes, potentially identifying mechanisms of action or novel therapeutic targets involved in opiate use disorder, HIV neuropathology, TNF signaling pathway, NF-κB signaling pathway, autophagy, and apoptosis in context of HIV infection.

Paternal morphine exposure in rats reduces social play in adolescent male progeny without affecting drug-taking behavior in juvenile males or female offspring

The ongoing opioid addiction crisis necessitates the identification of novel risk factors to improve prevention and treatment of opioid use disorder. Parental opioid exposure has recently emerged as a potential regulator of offspring vulnerability to opioid misuse, in addition to heritable genetic liability. An understudied aspect of this "missing heritability" is the developmental presentation of these cross-generational phenotypes. This is an especially relevant question in the context of inherited addiction-related phenotypes, given the prominent role of developmental processes in the etiology of psychiatric disorders. Paternal morphine self-administration was previously shown to alter the sensitivity to the reinforcing and antinociceptive properties of opioids in the next generation. Here, phenotyping was expanded to include the adolescent period, with a focus on endophenotypes related to opioid use disorders and pain. Paternal morphine exposure did not alter heroin or cocaine self-administration in male and female juvenile progeny. Further, baseline sensory reflexes related to pain were unaltered in morphine-sired adolescent rats of either sex. However, morphine-sired adolescent males exhibited a reduction in social play behavior. Our findings suggest that, in morphine-sired male offspring, paternal opioid exposure does not affect opioid intake during adolescence, suggesting that this phenotype does not emerge until later in life. Altered social behaviors in male morphine-sired adolescents indicate that the changes in drug-taking behavior in adults sired by morphine-exposed sires may be due to more complex factors not yet fully assessed.

Low-dose naltrexone for treatment of pain in patients with fibromyalgia: a randomized, double-blind, placebo-controlled, crossover study

Introduction

Fibromyalgia (FM) is a chronic fluctuating, nociplastic pain condition. Naltrexone is a µ-opioid-receptor antagonist; preliminary studies have indicated a pain-relieving effect of low-dose naltrexone (LDN) in patients with FM. The impetus for studying LDN is the assumption of analgesic efficacy and thus reduction of adverse effects seen from conventional pharmacotherapy.

Objectives

First, to examine if LDN is associated with analgesic efficacy compared with control in the treatment of patients with FM. Second, to ascertain the analgesic efficacy of LDN in an experimental pain model in patients with FM evaluating the competence of the descending inhibitory pathways compared with controls. Third, to examine the pharmacokinetics of LDN.

Methods

The study used a randomized, double-blind, placebo-controlled, crossover design and had a 3-phase setup. The first phase included baseline assessment and a treatment period (days -3 to 21), the second phase a washout period (days 22-32), and the third phase a baseline assessment followed by a treatment period (days 33-56). Treatment was with either LDN 4.5 mg or an inactive placebo given orally once daily. The primary outcomes were Fibromyalgia Impact Questionnaire revised (FIQR) scores and summed pain intensity ratings (SPIR).

Results

Fifty-eight patients with FM were randomized. The median difference (IQR) for FIQR scores between LDN and placebo treatment was -1.65 (18.55; effect size = 0.15; P = 0.3). The median difference for SPIR scores was -0.33 (6.33; effect size = 0.13; P = 0.4).

Conclusion

Outcome data did not indicate any clinically relevant analgesic efficacy of the LDN treatment in patients with FM.

Identifying barriers and facilitators for nurse practitioners' opioid management of chronic pain

BACKGROUND

Drug overdose deaths greatly increased during the COVID-19 pandemic, with 100,306 cases occurring in the United States over 12 months from 2020 to 2021, an increase of 28.5% from the year before. Three quarters of these deaths involved opioids, and this epidemic has seriously complicated chronic pain management. The role of nurse practitioners (NPs) in opioid prescription has expanded since Affordable Care Act passage in 2010, but their prescription of opioids for chronic pain management is not well understood.

OBJECTIVES

This integrative review aimed to identify barriers, facilitators, and other factors influencing NPs' management of chronic pain with opioids.

DATA SOURCES

Five databases were searched for the highest level of evidence in articles published from 2011 to 2021. Search results were refined to focus on NPs' chronic pain management via opioid prescription.

CONCLUSIONS

Nine studies were selected for the review. Six identified themes were indicative of barriers, facilitators, and other factors affecting NPs' opioid management: nurse practitioner education, patient subjectivity and patient education, systemic change and alternative treatment access, interprofessional collaboration, nurse practitioner prescriptive authority, and practice environment. States and schools of nursing should modify policy and curricula to better support NPs' opioid management and reduce associated prescription barriers.

IMPLICATIONS FOR PRACTICE

NPs' opioid management can best be improved by providing them with current guideline-based education regarding opioid prescription, emphasizing patient education, supplying NPs with systemic support, encouraging interprofessional collaboration, and solving the prescriptive authority issues. Enhancing NPs' opioid prescription and chronic pain management knowledge would help to mitigate the opioid epidemic.

Can Anti-inflammatory Drugs used in Plastic Surgery Procedures Increase the Risk of Hematoma?

BACKGROUND

Anti-inflammatory drugs are commonly used to lower inflammation which is linked to a variety of disorders. It acts by inhibiting cyclooxygenase-mediated prostaglandin synthesis at the molecular level. Hematoma is related with the use of anti-inflammatory medications. However, the specific link is still unknown. Thus, the main objective of the study is to find out the association of hematoma with ant-inflammatory drugs.

MATERIAL AND METHODS

The relevant studies were searched in PubMed and screened based on inclusion and exclusion criteria. The quality of full-text studies was assessed using suitable Newcastle-Ottawa Scale. The overall estimate was calculated in terms of odds ratio with 95% confidence interval. The random effect model was used. The qualitative analysis of publication bias was done through funnel plot.

RESULTS

The overall estimate measures [OR 1.01 (0.50, 2.06)] have shown non-significant risk of hematoma with use of anti-inflammatory drugs in plastic surgery as compared to non-anti-inflammatory drugs. The heterogeneity among studies was found to be 34%. The subgroup analysis of individual drugs was not done due to availability of a smaller number of studies.

CONCLUSION

Based on available data, there is no significant risk of hematoma with use of anti-inflammatory drugs in plastic surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Quality of Life and Opioid Use Motives: Direct and Indirect Associations with Risky Opioid Use in a Community Sample of Adults

Purpose: The opioid epidemic in the United States has resulted in mass mortality and economic costs exceeding $1 trillion. Poor health-related quality of life is evident among individuals entering treatment for opioid use disorder (OUD). Yet, little research has examined the influence of quality of life on risky opioid use among non-treatment-seeking adults. To help inform OUD prevention efforts, this study examined the association among quality of life domains, opioid use motives, and risky opioid behaviors in a community sample of opioid users. Methods: Participants (N = 278) were adults who endorsed past month opioid use and were not currently in treatment for OUD. Participants responded to questions regarding their opioid use and misuse, opioid use motives, opioid use consequences, and quality of life. Results: The physical health domain of quality of life was associated with risky opioid use. Specifically, poorer physical health predicted risky opioid use and this relationship was partially explained by more social and pain motives to use opioids. Surprisingly, no other quality of life domains predicted risky opioid use. Conclusion: This study represents a meaningful first step in identifying optimal targets for OUD prevention efforts with community samples. Our findings suggest that physical health is an important quality of life indicator to prevent opioid-related harm and development of OUD.

Opioid use after outpatient elective general surgery: quantifying the burden of persistent use

Purpose

Surgery is a major risk factor for chronic opioid use among patients who had not recently been prescribed opioids. This study identifies the rate of, and risk factors for, persistent opioid use following laparoscopic cholecystectomy and open inguinal hernia repair in patients not recently prescribed opioids.

Methods

This retrospective population-based cohort study included all patients who had not been prescribed opioids in the 6 months prior to undergoing open inguinal hernia repair or laparoscopic cholecystectomy from January 2013 to July 2016 in Ontario. Opioid prescription was identified from the provincial Narcotics Monitoring System and data were obtained from the Institute for Clinical Evaluative Sciences. The primary outcome was persistent opioid use after surgery (3, 6, 9 and 12 months). Associated risk factors and prescribing patterns were also examined.

Results

Among the 90,326 patients in the study cohort, 80% filled an opioid prescription after surgery, with 11%, 9%, 5% and 1% filling a prescription at 3, 6, 9 and 12 months, respectively. Significant variability was identified in the type of opioid prescribed (41% codeine, 31% oxycodone, 18% tramadol) and in regional prescribing patterns (mean prescription/region range, 135-225 oral morphine equivalents). Predictors of continued opioid use included age, female gender, lower income quintile and being operated on by less experienced surgeons.

Conclusion

Most patients who undergo elective cholecystectomy and hernia repair will fill a prescription for an opioid after surgery, and many will continue to fill opioid prescriptions for considerably longer than clinically anticipated. There is important variability in opioid type, regional prescribing patterns and risk factors that identify strategic targets to reduce the opioid burden in this patient population.

Comparative analysis of two laser wavelengths in the stimulation of acupuncture points for analgesic effects in an animal model

This study compares the effectiveness of two laser wavelengths for stimulating acupoints in an experimental model of acute postoperative pain. Forty-five Wistar rats were randomly assigned to receive treatment on their left hind paw, contralateral to a surgical procedure. Laser treatments were performed with Green Laser-GL (532 nm, 70 mW and 7 J/cm² of energy), Red Laser-RL (660 nm, 100 mW and 7 J/cm² of energy), or with Laser Off-LO. After each application, the animals were evaluated with a Von Frey analgesiometer to check for painful sensitivity on their right (with surgery) and left (without surgery) hind paws. Neuropeptides and cytokine levels in the incision site tissue of the right paw were measured by ELISA after 1, 6 and 24 hours. It was possible to observe that, in this pain model, both lasers promoted analgesia and that the GL altered the levels of TNF-α and IL-1β.

The Effect of Medical Cannabis on Pain Level and Quality of Sleep among Rheumatology Clinic Outpatients

Introduction

Medical cannabis (MC) is becoming increasingly popular for the treatment of chronic pain conditions. In this study, we evaluated the effect of MC treatment on pain level and quality of sleep of patients with different medical conditions at the rheumatology clinic.

Methods

Patients licensed for the use of MC at the rheumatology clinics at different settings were located and contacted. Their demographic and clinical parameters were documented, including type of medical cannabis consumed, way of consumption, and current monthly consumed amount. These patients were contacted by phone and asked about the effect on pain level and quality of sleep.

Results

A total of 351 patients were located, and 319 completed the questionnaire. Mean age was 46 ± 12 years, 76% were female, 82% had fibromyalgia, ∼9% had mechanical problems, ∼4% had inflammatory problems, ∼4% had neurological problems, and ∼1% had other problems. The average monthly consumed dose of MC was 31, 35, 36, and 32 g, with mean pain level reduction of 77%, 82%, 83%, and 57%, and mean sleep quality improvement of 78%, 71%, 87%, and 76% among patients with fibromyalgia, mechanical, neuropathic, and inflammatory problems, respectively. Mean THC and CBD contents were 18.38% ± 4.96 and 2.62% ± 4.87, respectively. The THC concentration, duration of MC consumption, and MC consumption dose had independent significant correlations with pain reduction while only the duration of MC consumption had an independent significant correlation with sleep quality improvement.

Conclusions

MC had a favorable effect on pain level and quality of sleep among all spectrums of problems at the rheumatology clinic.

Reduction of oral liquid controlled drugs discrepancy in day-to-day practice

OBJECTIVES

The storage, use and disposal of controlled drugs (CDs) in hospitals and other healthcare centres are governed by a combination of government legislation and local policy. In the UK, a running balance must be kept for Schedule 2 CDs and when discrepancies arise, they must be investigated and reconciled. Policies on acceptable discrepancies are varied and based on anecdotal evidence. This study was designed to simulate dosing and stock check procedures for oxycodone oral solution, as a sample CD solution, and evaluate where the volume losses that cause discrepancies could arise from.

METHODS

Hypromellose solutions were formulated to simulate oxycodone commercial solutions. These were used to simulate dosing and stock check practices. Quantification of volume loss during simulated routine dosing and stock check of viscous oral CD formulations were performed in triplicate.

KEY FINDINGS

Dosing with enteral syringes via a fitted rubber bung never resulted in volume loss. Volume loss was always observed during stock checks with no statistical difference between methods used.

CONCLUSIONS

The findings of this study support the following recommendations. Hospital pharmacy departments should provide oxycodone and other CD liquid formulation bottles pre-fitted with a bung and make sure personnel use enteral syringes that are compatible with the chosen adaptor and of the most appropriate size for the intended dose. Stock checks should be limited to the minimum required by law or local policy.

Sex differences in type and occurrence of adverse reactions to opioid analgesics: a retrospective cohort study

OBJECTIVES

Sex as a biological variable affects response to opioids. However, few reports describe the prevalence of specific adverse reactions to commonly prescribed opioids in men and women separately. A large cohort was used to investigate sex differences in type and occurrence of adverse reactions associated with use of codeine, tramadol, oxycodone and hydrocodone.

DESIGN

Retrospective cohort study.

SETTING

Participants in the Right Drug, Right Dose, Right Time (RIGHT) Study.

PARTICIPANTS

The medical records of 8457 participants in the RIGHT Study who received an opioid prescription between 1 January 2004 and 31 December 2017 were reviewed 61% women, 94% white, median age (Q1-Q3)=58 (47-66).

PRIMARY AND SECONDARY OUTCOME MEASURES

Adverse reactions including gastrointestinal, skin, psychiatric and nervous system issues were collected from the allergy section of each patient's medical record. Sex differences in the risk of adverse reactions due to prescribed opioids were modelled using logistic regression adjusted for age, body mass index, race and ethnicity.

RESULTS

From 8457 participants (of which 449 (5.3%) reported adverse reactions), more women (6.5%) than men (3.4%) reported adverse reactions to at least one opioid (OR (95% CI)=2.3 (1.8 to 2.8), p<0.001). Women were more likely to report adverse reactions to tramadol (OR (95% CI)=2.8 (1.8 to 4.4), p<0.001) and oxycodone (OR (95% CI)=2.2 (1.7 to 2.9), p<0.001). Women were more likely to report gastrointestinal (OR (95% CI)=3.1 (2.3 to 4.3), p<0.001), skin (OR (95% CI)=2.1 (1.4 to 3.3), p=0.001) and nervous system issues (OR (95% CI)=2.3 (1.3 to 4.2), p=0.004).

CONCLUSIONS

These findings support the importance of sex as a biological variable to be factored into pain management studies.

Fentanyl-related overdose during incarceration: a comprehensive review

BACKGROUND

Fentanyl and related compounds have recently saturated the illicit drug supply in the United States, leading to unprecedented rates of fatal overdose. Individuals who are incarcerated are particularly vulnerable, as the burden of opioid use disorder is disproportionately higher in this population, and tolerance generally decreases during incarceration.

METHODS

We conduct a systematic search for publications about fentanyl overdoses during incarceration in PubMed and PsycINFO, as well as lay press articles in Google, from January 1, 2013 through March 30th, 2021.

RESULTS

Not a single fentanyl overdose was identified in the medical literature, but 90 overdose events, comprising of 76 fatal and 103 nonfatal fentanyl overdoses, were identified in the lay press. Among the 179 overdoses, 138 occurred in jails and 41 occurred in prisons, across the country.

CONCLUSIONS

Fentanyl-related overdoses are occurring in correctional facilities with unknown but likely increasing frequency. In addition to the need for improved detection and reporting, immediate efforts to 1) increase understanding of the risks of fentanyl and how to prevent and treat overdose among correctional staff and residents, 2) ensure widespread prompt availability of naloxone and 3) expand the availability of medications to treat opioid use disorder for people who are incarcerated will save lives.

Virtual reality: physiological and behavioral mechanisms to increase individual pain tolerance limits

ABSTRACT

Immersive virtual reality (VR) consists of immersion in artificial environments through the use of real-time render technologies and the latest generation devices. The users feel just as immersed as they would feel in an everyday life situation, and this sense of presence seems to have therapeutic potentials. However, the VR mechanisms remain only partially known. This study is novel in that, for the first time in VR research, appropriate controls for VR contexts, immersive characteristics (ie, control VR), and multifaceted objective and subjective outcomes were included in a within-subject study design conducted on healthy participants. Participants received heat thermal stimulations to determine how VR can increase individual heat-pain tolerance limits (primary outcome) measured in degrees Celsius and seconds while recording concurrent autonomic responses. We also assessed changes in pain unpleasantness, mood, situational anxiety, and level of enjoyment (secondary outcomes). The VR induced a net gain in heat-pain tolerance limits that was paralleled by an increase of the parasympathetic responses. VR improved mood, situational anxiety, and pain unpleasantness when participants perceived the context as enjoyable, but these changes did not influence the increases in pain tolerance limits. Distraction increased pain tolerance limits but did not induce such mood and physiological changes. Immersive VR has been anecdotally applied to improve acute symptoms in contexts such as battlefield, emergency, and operating rooms. This study provides a mechanistic framework for VR as a low-risk, nonpharmacological intervention, which regulates autonomic, affective (mood and situational anxiety), and evaluative (subjective pain and enjoyment ratings) responses associated with acute pain.

Factors associated with non-medical use of prescription drugs among individuals with a legitimate prescription for medical purposes: A population-based study

Background:

Psychoactive prescription drugs are known to have abuse potential. This study was aimed at studying the non-medical use of prescription drugs (NMUPD) among individuals with prescriptions for anxiolytics, sedatives, or strong analgesics. We examined the association of socio-demographics, binge drinking, the number of drug prescriptions, and drug types prescribed for medical purposes with NMUPD among the general Finnish population.

Methods:

Data were derived from population-based (ages 15–69 years) Drug Surveys conducted in Finland in 2006, 2010, and 2014. The response rates varied between 48% and 55%. Individuals with prescriptions for one or more prescription drugs in the last 12 months were included (n = 1,602) and divided into three groups: medical use only, NMUPD, and NMUPD with illicit drug use (ILLICIT USE). Multinomial logistic regression was used.

Results:

Among individuals with a prescription for at least one prescription drug, 5.7% reported NMUPD. Living alone and being outside the labour force were associated with NMUPD. Younger age, living in a large city, living alone, and unemployment were associated with ILLICIT USE. Frequent binge drinking and a high number of drug prescriptions were associated with both NMUPD and ILLICIT USE. Those reporting ILLICIT USE were more likely to have a prescription for sedatives.

Conclusions:

Although NMUPD is on a rather low level among those who have a prescription for legitimate purposes, having multiple prescriptions increased the likelihood of NMUPD. Low socio-economic position and binge drinking are associated with NMUPD and this should be taken into account when planning interventions and preventive actions.

The use of oral opioids to control children's pain in the post-codeine era

Pain is a common problem for children, and pain management comprises both pharmacologic and nonpharmacologic measures. For moderate to severe pain, oral opioids have been a popular choice for the last few decades. Codeine has historically been the best-known oral opioid for use in children. However, availability and use of codeine have sharply declined due to safety concerns. A variety of other opioids have been used in place of codeine, but data are limited regarding their efficacy and safety in children. While the same pathways metabolize oral oxycodone as codeine, oxycodone's pharmacokinetics varies widely. There are also limited data on the safety and efficacy of oral hydromorphone and tramadol use for children. Oral morphine is the opiate alternative to codeine for which there is the most evidence of safety and efficacy in children. Research is needed to investigate both other opioids and non-opioid approaches to guide evidence-based analgesic therapy and treatment for moderate-to-severe pain in children.

Les opioïdes par voie orale en remplacement de la codéine pour contrôler la douleur chez les enfants

La douleur est un problème courant chez les enfants. Des mesures pharmacologiques et non pharmacologiques sont utilisées pour la prendre en charge. Depuis quelques décennies, les opioïdes par voie orale sont populaires pour soulager la douleur modérée à grave. La codéine a longtemps été l'opioïde par voie orale le plus connu pour les enfants. Pour des raisons de sécurité, elle est désormais nettement moins accessible et moins employée. Divers autres opioïdes la remplacent, mais les données sur leur efficacité et leur sécurité sont limitées chez les enfants. L'oxycodone par voie orale emprunte les mêmes voies métaboliques que la codéine, mais sa pharmacocinétique est très variable. Les données sur la sécurité et l'efficacité de l'hydromorphone et du tramadol par voie orale chez les enfants sont également limitées. Lorsqu'on y recourt au lieu de la codéine, la morphine par voie orale est l'opiacé dont la sécurité et l'efficacité sont les mieux démontrées chez les enfants. Des recherches devront être réalisées pour explorer d'autres approches relatives aux médicaments opioïdes et non opioïdes, afin d'orienter les traitements analgésiques fondés sur des données probantes qui soulageront la douleur modérée à grave chez les enfants.

Generational Effects of Opioid Exposure

The inheritance of substance abuse, including opioid abuse, may be influenced by genetic and non-genetic factors related to the environment, such as stress and socioeconomic status. These non-genetic influences on the heritability of a trait can be attributed to epigenetics. Epigenetic inheritance can result from modifications passed down from the mother, father, or both, resulting in either maternal, paternal, or parental epigenetic inheritance, respectively. These epigenetic modifications can be passed to the offspring to result in multigenerational, intergenerational, or transgenerational inheritance. Human and animal models of opioid exposure have shown generational effects that result in molecular, developmental, and behavioral alterations in future generations.

Point-of-care naloxone distribution in the emergency department: A pilot study

PURPOSE

Opioid overdose education and naloxone distribution (OEND) for use by laypersons has been shown to be safe and effective, but implementation in the emergency department (ED) setting is challenging. Recent literature has shown a discouragingly low rate of obtainment of naloxone that is prescribed in the ED setting. We conducted a study to evaluate the feasibility of point-of-care (POC) distribution of naloxone in an ED, hypothesizing a rate of obtainment higher than prescription fill rates reported in previous studies.

SUMMARY

A multidisciplinary team of experts, including pharmacists, physicians, nurses, and case management professionals used an iterative process to develop a protocol for POC OEND in the ED. The protocol includes 5 steps: (1) patient screening, (2) order placement in the electronic health record (EHR), (3) a patient training video, (4) dispensing of naloxone kit, and (5) written discharge instructions. The naloxone kits were assembled, labeled to meet requirements for a prescription, and stored in an automated dispensing cabinet. Two pharmacists, 30 attending physicians, 65 resident physicians, and 108 nurses were trained. In 8 months, 134 orders for take-home naloxone were entered and 117 naloxone kits were dispensed, resulting in an obtainment rate of 87.3%. The indication for take-home naloxone kit was heroin use for 61 patients (92.4%).

CONCLUSION

POC naloxone distribution is feasible and yielded a rate of obtainment significantly higher than previous studies in which naloxone was prescribed. POC distribution can be replicated at other hospitals with low rates of obtainment.

A history of opioid exposure in females increases the risk of metabolic disorders in their future male offspring

Worldwide consumption of opioids remains at historic levels. Preclinical studies report intergenerational effects on the endogenous opioid system of future progeny following preconception morphine exposure. Given the role of endogenous opioids in energy homeostasis, such effects could impact metabolism in the next generation. Thus, we examined diet-induced modifications in F1 male progeny of morphine-exposed female rats (MORF1). When fed a high fat-sugar diet (FSD) for 6 weeks, MORF1 males display features of emerging metabolic syndrome; they consume more food, gain more weight, and develop fasting-induced hyperglycemia and hyperinsulinemia. In the hypothalamus, proteins involved in energy homeostasis are modified and RNA sequencing revealed down-regulation of genes associated with neuronal plasticity, coupled with up-regulation of genes associated with immune, inflammatory, and metabolic processes that are specific to FSD-maintained MORF1 males. Thus, limited preconception morphine exposure in female rats increases the risk of metabolic syndrome/type 2 diabetes in the next generation.

Pleasure, addiction, and hypocretin (orexin)

The hypocretins/orexins were discovered in 1998. Within 2 years, this led to the discovery of the cause of human narcolepsy, a 90% loss of hypothalamic neurons containing these peptides. Further work demonstrated that these neurons were not simply linked to waking. Rather these neurons were active during pleasurable behaviors in waking and were silenced by aversive stimulation. This was seen in wild-type mice, rats, cats, and dogs. It was also evident in humans, with increased Hcrt release during pleasurable activities and decreased release, to the levels seen in sleep, during pain. We found that human heroin addicts have, on average, an increase of 54% in the number of detectable Hcrt neurons compared to "control" human brains and that these Hcrt neurons are substantially smaller than those in control brains. We found that in mice, chronic morphine administration induced the same changes in Hcrt neuron number and size. Our studies in the mouse allowed us to determine the specificity, dose response relations, time course of the change in the number of Hcrt neurons, and that the increased number of Hcrt neurons after opiates was not due to neurogenesis. Furthermore, we found that it took a month or longer for these anatomical changes in the mouse brain to return to baseline. Human narcoleptics, despite their prescribed use of several commonly addictive drugs, do not show significant evidence of dose escalation or substance use disorder. Similarly, mice in which the peptide has been eliminated are resistant to addiction. These findings are consistent with the concept that an increased number of Hcrt neurons may underlie and maintain opioid or cocaine use disorders.

Modeling Mitigation Strategies to Reduce Opioid-Related Morbidity and Mortality in the US

IMPORTANCE

The US opioid epidemic is complex and dynamic, yet relatively little is known regarding its likely future impact and the potential mitigating impact of interventions to address it.

OBJECTIVE

To estimate the future burden of the opioid epidemic and the potential of interventions to address the burden.

DESIGN, SETTING, AND PARTICIPANTS

A decision analytic dynamic Markov model was calibrated using 2010-2018 data from the National Survey on Drug Use and Health, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey, the US Census, and National Epidemiologic Survey on Alcohol and Related Conditions-III. Data on individuals 12 years or older from the US general population or with prescription opioid medical use; prescription opioid nonmedical use; heroin use; prescription, heroin, or combined prescription and heroin opioid use disorder (OUD); 1 of 7 treatment categories; or nonfatal or fatal overdose were examined. The model was designed to project fatal opioid overdoses between 2020 and 2029.

EXPOSURES

The model projected prescribing reductions (5% annually), naloxone distribution (assumed 5% reduction in case-fatality), and treatment expansion (assumed 35% increase in uptake annually for 4 years and 50% relapse reduction), with each compared vs status quo.

MAIN OUTCOMES AND MEASURES

Projected 10-year overdose deaths and prevalence of OUD.

RESULTS

Under status quo, 484 429 (95% confidence band, 390 543-576 631) individuals were projected to experience fatal opioid overdose between 2020 and 2029. Projected decreases in deaths were 0.3% with prescribing reductions, 15.4% with naloxone distribution, and 25.3% with treatment expansion; when combined, these interventions were associated with 179 151 fewer overdose deaths (37.0%) over 10 years. Interventions had a smaller association with the prevalence of OUD; for example, the combined intervention was estimated to reduce OUD prevalence by 27.5%, from 2.47 million in 2019 to 1.79 million in 2029. Model projections were most sensitive to assumptions regarding future rates of fatal and nonfatal overdose.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the opioid epidemic is likely to continue to cause tens of thousands of deaths annually over the next decade. Aggressive deployment of evidence-based interventions may reduce deaths by at least a third but will likely have less impact for the number of people with OUD.

Dual-Acting Peripherally Restricted Delta/Kappa Opioid (CAV1001) Produces Antinociception in Animal Models of Sub-Acute and Chronic Pain

Background

The development of highly efficacious alternatives to mu-opioid analgesics represents an urgent unmet medical and public health need. In the presence of inflammation both delta- and kappa-opioid agonists, acting on peripheral sensory neurons, mediate analgesia. The dual-acting, peripherally restricted kappa/delta-opioid agonist, CAV1001, was tested in four rodent pain models.

Methods

Experiment 1 – Formalin testing in mice. Three doses (1–10 mg/kg) of CAV1001 or ICI204448 at 30 minutes were tested after formalin injection. Spontaneous nocifensive responses were video recorded. Experiment 2 – Complete Freund’s Adjuvant (CFA)-induced arthritis. CFA was injected into the ankle joint of rats. Joint compression thresholds (JCT) were measured. CAV1001 was compared to celecoxib. Experiment 3 – Spinal nerve ligation (SNL) in rats. Paw compression thresholds (PCT) were measured. CAV1001 was compared to gabapentin. Experiment 4 – MMRT-1 bone cancer implantation into the rat tibia. Weight-bearing was assessed. CAV1001 was compared to morphine.

Results

In Phase 2 of the formalin model, CAV1001 (1 mg/kg) significantly reduced pain behaviors to a degree comparable to the peripherally restricted kappa-opioid agonist, ICI204448 (10 mg/kg). CAV1001 (10 mg/kg) effectively eliminated pain behaviors associated with phase 2. In the CFA-induced arthritis model, a significant increase in JCTs, similar to the comparator celecoxib, was observed with CAV1001 at 1 mg/kg at 2 hours; CAV1001 (10 mg/kg) was effective at 1 hour. In the SNL model, both the comparator gabapentin and CAV1001 (5 mg/kg) significantly reduced PCT at 2 hours, but at 4 hours, the CAV1001 thresholds improved to baseline. CAV1001 10 mg/kg significantly improved weight bearing at 4-hour post-dosing compared to baseline following MMRT-1 implantation.

Conclusion

CAV1001 demonstrated efficacy in several different preclinical pain models. Time- and dose-dependent differences in the efficacy of CAV1001 amongst these rodent pain models parallel the degree of underlying inflammation.

Conduct disorder and attention-deficit/hyperactivity disorder as risk factors for prescription opioid use

BACKGROUND

Existing studies of attention deficit/hyperactivity disorder (ADHD), conduct disorder (CD), and substance use or substance use disorders have produced mixed results, with some identifying a direct link between ADHD and general or disordered substance use and others suggesting that comorbid CD may explain this relationship. Insufficient research has addressed the issue, which is particularly relevant in the context of the opioid crisis. This study examined the association of probable ADHD and childhood CD with self-reported opioid use in a general-population sample.

METHOD

The 2011-2013 cycles of the CAMH Monitor, a cross-sectional survey of adults (18+ years) from Ontario, Canada provided data from 6074 respondents. Binary logistic regressions were conducted of self-reported medical, non-medical, and any prescription opioid use in the previous 12 months, assessing demographic characteristics, perceived physical and mental health, and probable ADHD, childhood (before age 15 years) symptoms of CD, or their combination.

RESULTS

Adjusting for potential covariates, probable ADHD alone was not associated with prescription opioid use. Childhood symptoms of CD significantly predicted non-medical use (OR = 2.10, 95% CI = 1.10, 4.03). ADHD and CD symptoms combined significantly predicted medical (OR = 3.27, 95% CI = 1.20, 8.91), non-medical (OR = 4.73, 95% CI = 1.05, 21.30), and any (OR = 3.02, 95% CI = 1.13, 8.11) prescription opioid use, although a low base rate of non-medical use may have negatively affected model fit.

CONCLUSIONS

Previous findings relating ADHD to opioid use could be explained, in part, by the high rate of comorbidity between ADHD and CD. These data support prevention and treatment programs targeting individuals with comorbid ADHD and CD symptoms.

Neuromodulation for Intractable Pain

Over 7% of the Western population suffer from intractable pain and despite pharmacotherapy, many patients’ pain is refractory [...]

Naloxone counseling: Confidence and attitudes of student pharmacists after a volunteer syringe exchange experience

INTRODUCTION

Our objective was to assess how a naloxone counseling experience impacted student pharmacists' confidence in counseling patients on naloxone use and their attitudes towards people who use drugs.

METHODS

Students who completed a naloxone counseling experience at a syringe exchange program were recruited to conduct individual interviews. Investigators asked student participants open-ended questions to identify their perceptions in the following domains: experiences with naloxone, reported impact of naloxone counseling experience on confidence, experiences with people who use drugs, value of the experience, and suggestions for improvement for the experience.

RESULTS

Fifteen student pharmacists participated in semi-structured interviews. Fourteen of these students reported the experience as extremely valuable in developing their confidence with naloxone. The average change in confidence was 5.2 points on a 1 through 10 scale, and seven of the student pharmacists independently suggested that a naloxone counseling experience be incorporated the required doctor of pharmacy curriculum. The qualitative themes that emerged from student feedback were breaking down the stigma of addiction and feeling useful during this experience.

CONCLUSIONS

Participation in a naloxone counseling experience at a syringe exchange program was perceived as helpful in improving student pharmacist confidence in counseling patients on naloxone use. Incorporation of required experiential learning about naloxone and people who use drugs may positively impact student pharmacists by giving them more confidence and experience with this underserved population.

IRE1α-XBP1 signaling in leukocytes controls prostaglandin biosynthesis and pain

Inositol-requiring enzyme 1[α] (IRE1[α])-X-box binding protein spliced (XBP1) signaling maintains endoplasmic reticulum (ER) homeostasis while controlling immunometabolic processes. Yet, the physiological consequences of IRE1α-XBP1 activation in leukocytes remain unexplored. We found that induction of prostaglandin-endoperoxide synthase 2 (Ptgs2/Cox-2) and prostaglandin E synthase (Ptges/mPGES-1) was compromised in IRE1α-deficient myeloid cells undergoing ER stress or stimulated through pattern recognition receptors. Inducible biosynthesis of prostaglandins, including the pro-algesic mediator prostaglandin E2 (PGE₂), was decreased in myeloid cells that lack IRE1α or XBP1 but not other ER stress sensors. Functional XBP1 transactivated the human PTGS2 and PTGES genes to enable optimal PGE₂ production. Mice that lack IRE1α-XBP1 in leukocytes, or that were treated with IRE1α inhibitors, demonstrated reduced pain behaviors in PGE₂-dependent models of pain. Thus, IRE1α-XBP1 is a mediator of prostaglandin biosynthesis and a potential target to control pain.

Mechanical Characterization of Thermally Annealed Tablets Containing Polyethylene Oxide for Abuse Deterrence

The abuse of prescription opioid drugs is a well-documented and very serious problem. One of the typical first steps an abuser will take is to manipulate a tablet into to a fine powder. To deter this behavior, formulators use crush-resistant technologies like polyethylene oxide (PEO). When heat-treated, PEO creates a hard, flexible tablet that cannot be easily ground down into a fine powder. We investigated the effects of PEO molecular weight (MW), annealing temperature, and annealing time on tablet compression deformation behavior and fracture resistance. These tests were designed to represent an abuser's attempt to smash and grind a tablet, respectively. Annealing temperatures above the melting point of PEO showed the most improvement in mechanical properties compared with that in unannealed tablets. The minimum annealing time was dependent on the polymer MW and annealing temperature. Tablets were manipulated using a coffee grinder, and the particle size of the resulting powders was measured. The particle size correlated well with fracture toughness, demonstrating that increasing fracture toughness increases the manipulation resistance of a PEO tablet.

The rising crisis of illicit fentanyl use, overdose, and potential therapeutic strategies

Fentanyl is a powerful opioid anesthetic and analgesic, the use of which has caused an increasing public health threat in the United States and elsewhere. Fentanyl was initially approved and used for the treatment of moderate to severe pain, especially cancer pain. However, recent years have seen a growing concern that fentanyl and its analogs are widely synthesized in laboratories and adulterated with illicit supplies of heroin, cocaine, methamphetamine, and counterfeit pills, contributing to the exponential growth in the number of drug-related overdose deaths. This review summarizes the recent epidemic and evolution of illicit fentanyl use, its pharmacological mechanisms and side effects, and the potential clinical management and prevention of fentanyl-related overdoses. Because social, economic, and health problems that are related to the use of fentanyl and its analogs are growing, there is an urgent need to implement large-scale safe and effective harm reduction strategies to prevent fentanyl-related overdoses.

Reversal of Peripheral Neuropathic Pain by the Small-Molecule Natural Product Physalin F via Block of CaV2.3 (R-Type) and CaV2.2 (N-Type) Voltage-Gated Calcium Channels

No universally efficacious therapy exists for chronic pain, a disease affecting one-fifth of the global population. An overreliance on the prescription of opioids for chronic pain despite their poor ability to improve function has led to a national opioid crisis. In 2018, the NIH launched a Helping to End Addiction Long-term plan to spur discovery and validation of novel targets and mechanisms to develop alternative nonaddictive treatment options. Phytochemicals with medicinal properties have long been used for various treatments worldwide. The natural product physalin F, isolated from the Physalis acutifolia (family: Solanaceae) herb, demonstrated antinociceptive effects in models of inflammatory pain, consistent with earlier reports of its anti-inflammatory and immunomodulatory activities. However, the target of action of physalin F remained unknown. Here, using whole-cell and slice electrophysiology, competition binding assays, and experimental models of neuropathic pain, we uncovered a molecular target for physalin F's antinociceptive actions. We found that physalin F (i) blocks CaV2.3 (R-type) and CaV2.2 (N-type) voltage-gated calcium channels in dorsal root ganglion (DRG) neurons, (ii) does not affect CaV3 (T-type) voltage-gated calcium channels or voltage-gated sodium or potassium channels, (iii) does not bind G-protein coupled opioid receptors, (iv) inhibits the frequency of spontaneous excitatory postsynaptic currents (EPSCs) in spinal cord slices, and (v) reverses tactile hypersensitivity in models of paclitaxel-induced peripheral neuropathy and spinal nerve ligation. Identifying CaV2.2 as a molecular target of physalin F may spur its use as a tool for mechanistic studies and position it as a structural template for future synthetic compounds.

A Retrospective 4-year Outcome Study of Veterans Admitted to an Acute Inpatient Detoxification Unit for Opioid Use Disorder

BACKGROUND AND OBJECTIVES

With 47 600 opioid-related deaths in 2017, the yearly deaths have surpassed the HIV/AIDS peak yearly death rates. Residential rehabilitation (RR) and medication-assisted treatments (MAT) are commonly utilized treatments for opioid use disorder (OUD).

METHODS

All patients (n = 182) who were admitted to the Boston Veterans Health Administration for inpatient admission for medically supervised opioid withdrawal in 2015 were included. Deceased patients were matched 1:1, based on age and sex to living patients from the 182-patient cohort. Nationwide electronic medical records were analyzed from 2015 through 2018. Via multilinear regression, risk factor correlation to all-cause mortality (the dependent variable) was our main outcome. Primary risk factors included recurrent admissions for medically supervised withdrawals and exposure to RR or MAT. Secondary risk factors were opioid use traits, nonopioid drug use, partner support, education level, homelessness, and employment.

RESULTS

18.4% (n = 34) were deceased by the time of follow-up-equivalent to 4760 deaths per 100 000 person-years. A total of 61.8% (n = 21) of these deaths were directly related to opioid use. Completion of RR correlated with lower predicted mortality (β = -8.21, P = 0.03). In contrast, attending RR but not completing correlated with higher predicted mortality rate (β = 6.51, P = 0.046). Concurrent benzodiazepine use (β = 8.99, P = 0.047), generalized anxiety disorder (β = 7.13, P = 0.03) and major depressive disorder (β = 5.44, P = 0.04) increased risk of death.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

OUD carries a shockingly high lethality in Veterans requiring inpatient admission for opioid withdrawal, particularly when there are untreated comorbid psychiatric conditions. RR and MAT are correlated to lower all-cause mortality in this population and should be highly utilized. Given the extremely high mortality, intensive system-wide interventions are needed for the care of Veterans with OUD. On the basis of the reduced predicted mortality with RR and MAT, further research into novel MATs as well as refining RR programs should be a major focus. (Am J Addict 2019;28:318-323).

Assessing the utility of an IoS application in the perioperative care of spine surgery patients: the NeuroPath Pilot study

BACKGROUND

In an attempt to improve care while decreasing costs and postoperative pain, we developed a novel IoS mobile health application, NeuroPath. The objective of this innovative app is to integrate enhanced recovery after surgery (ERAS) principles, patient education, and real-time pain and activity monitoring in a home setting with unencumbered two-way communication.

METHODS

The NeuroPath application was built over 18 months, with support from Apple, Medable, the Department of Information-Technology and the Department of Neurosurgery. Target areas addressed by NeuroPath include patient prep for surgery, perioperative risk mitigation, activity monitoring, wound care, and opioid use management. These target areas are monitored through a provider app, which is downloaded to the care providers IPad Mini. The provider app permits real time viewing of wound healing (patient incision photographs), activity levels, pain levels, and narcotic usage. Participants are given a daily To-Do list, via the Care Card section of the interface. The To-Do list presents the patient with specific tasks for exercise, instructions to wash incision area, pre-operative instructions, directions for discussing medication with care team, among other patient specific recommendations.

RESULTS

Of the 30 patients enrolled in the pilot study, there was a range of activity on the app. Patients with high involvement in the app logged in nearly every day from a week pre-op to >45 days post-op. Data for patients that utilized the app and uploaded regularly show trends of appropriately healing wounds, decreasing levels of pain, increasing step counts, and discontinuation of narcotics.

CONCLUSIONS

This pilot study of the NeuroPath app demonstrates its potential utility for improving quality of patient care without increased costs. Participants who regularly used the app showed consistent improvement throughout the post-operative recovery period (increasing ambulation, decreasing pain and guided reduction in narcotic usage).

Transversus abdominis plane block with liposomal bupivacaine for pain control after cesarean delivery: a retrospective chart review

Background

Adverse effects of opioid analgesics and potential for chronic use are limitations in the cesarean setting. Regional anesthesia using transversus abdominis plane (TAP) block post-cesarean delivery may improve analgesia and reduce opioid consumption. Effectiveness of TAP block using liposomal bupivacaine (LB) to reduce post-cesarean pain is unknown.

Methods

We performed a single-center retrospective chart review of patients aged ≥18 years who underwent cesarean delivery with a multimodal pain management protocol with or without TAP block with LB 266 mg. Assessments included postsurgical opioid consumption; area under the curve (AUC) of numeric rating scale pain scores from 0 to 3 days; proportion of opioid-free patients; discharge- and post-anesthesia care unit (PACU)-ready time; times to ambulation, solid food, and bowel movement; hospital length of stay (LOS); and adverse events (AEs). Data were analyzed in the total population and in first- and repeat-cesarean subgroups using Wilcoxon, chi-squared, and Student’s t-tests.

Results

Of 201 patients, 101 were treated with LB TAP block (LB-TAPB) and 100 without LB-TAPB. Treatment with LB-TAPB vs without LB-TAPB significantly reduced mean post-surgical opioid consumption (total, 47%; first-cesarean, 54%; repeat-cesarean, 42%; P<0.001 each) and mean AUC of pain scores (total, 46%; first-cesarean, 57%; repeat-cesarean, 40%; P<0.001 each). Patients treated with LB-TAPB had significantly shorter mean discharge-ready times (2.9 vs 3.6 days; P=0.006), PACU-ready times (138 vs 163 minutes; P=0.028), and LOS (2.9 vs 3.9 days; P<0.001). LB-TAPB significantly decreased mean times to ambulation and solid food by 39% and 31% (P<0.01 each), respectively, and numerically reduced mean time to bowel movement (26%; P=0.05). Fewer patients treated with LB-TAPB vs without LB-TAPB reported an AE (34% vs 50%; P=0.026).

Conclusion

These results suggest multimodal pain management incorporating TAP block with LB 266 mg is an effective approach to reducing opioid requirements and improving analgesia post-cesarean delivery.

Improved Admixture Vaccine of Fentanyl and Heroin Hapten Immunoconjugates: Antinociceptive Evaluation of Fentanyl-Contaminated Heroin

Fentanyl and its derivatives have become pervasive contaminants in the U.S. heroin supply. Previously, we reported a proof-of-concept vaccine designed to combat against heroin contaminated with fentanyl. Herein, we optimized the admixture vaccine and found that it surpassed the individual vaccines in every antinociceptive test, including a 10% fentanyl to heroin formulation. It is anticipated that other co-occurring drug abuse disorders may also be examined with admixture vaccines.

A Randomized Controlled Trial of Liposomal Bupivacaine Parasternal Intercostal Block for Sternotomy

BACKGROUND

Optimal pain control continues to be a concern in cardiac surgery. Current strategies for postoperative pain management often yield suboptimal results. The superiority of Exparel (Pacira Pharmaceuticals, Inc, Parsippany, NJ) in providing postoperative pain control and opioid sparing is equivocal. This prospective, randomized, double-blind study examines the efficacy of Exparel as a novel single-dose application parasternal nerve block in postoperative pain control and opioid sparing.

METHODS

This single-surgeon study included 79 patients undergoing median sternotomy for coronary revascularization. Study participants were randomized to either the drug or a control arm. Each participant received Exparel or normal saline placebo administered as a parasternal nerve block. Postoperative pain was rated according to the nonverbal pain scale or numeric rating scale. Total amount of narcotic pain medication used and patients' pain scores within the first 72 hours postoperatively were compared. Secondary outcomes compared the intensive care unit length of stay, hospital length of stay, time to extubation, time to return of bowel function, and time to return to work or daily activities.

RESULTS

The primary endpoint of pain levels between the two groups demonstrated no significant difference when analyzing the individual time points postoperatively. However, overall pain levels were significantly lower in the study drug group (p = 0.04). There was no significant difference in the amount of analgesics required postoperatively or in secondary endpoints between the groups.

CONCLUSIONS

Exparel does not provide an opioid-sparing benefit or any secondary outcome benefit compared with placebo. Exparel may be associated with a marginal decrease in postoperative pain levels. (Parasternal Nerve Bock in Cardiac Patients; NCT01826851.).

Social Influences in Animal Models of Opiate Addiction

Opiate addiction has reached an epidemic prevalence in recent years, yet social influences on the use and abuse of opiates has been widely understudied. In particular, the neurobiological substrates of opiate addiction and their modulation by social influences are largely unknown, perhaps due to the lack of widespread incorporation of social variables into animal models of opiate addiction. As reviewed here, animal models such as oral and intravenous drug self-administration, conditioned place preference, behavioral sensitization, and the effects of various stressors, have been useful in identifying some of the neurochemical circuitry that mediate social influences on opiate addiction. However, it is clear from our review that newer paradigms that incorporate various social elements are greatly needed to provide more translational insights into the neurobiological basis of opiate addiction. These elements include social and environmental enrichment, presence of conspecifics, and procedures that require subjects to exert effort to engage in prosocial behavior. A wider implementation of social variables into animal models of opiate addiction will help inform neurobehavioral strategies to increase the efficacy of treatment.

Quality Improvement Initiative to Improve Postoperative Pain with a Clinical Pathway and Nursing Education Program

BACKGROUND AND AIMS

We created a multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery.

DESIGN

A multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery.

SETTINGS

Pain management education of postanesthesia recovery room nurses through a practical intervention has the potential to improve patient pain experience, especially in those with a history of opioid tolerance.

PARTICIPANTS/SUBJECTS

Postanesthesia recovery nurses/postanesthesia patients.

METHODS

The intervention included two components: a clinical pain pathway on multimodal analgesia for both opioid-naïve and opioid-tolerant patients undergoing surgery and an educational program on pain management for frontline clinical nurses in the postanesthesia care unit (PACU). We measured the intervention's impact on time to pain relief, PACU length of stay, and patient satisfaction with pain management, as measured by self-report.

RESULTS

Patient PACU surveys indicated a decrease in the percent of patients with opioid tolerance who required more than 60 minutes to achieve adequate pain relief (from 32.7% preintervention to 21.3% postintervention). Additionally, after the intervention, the average time from a patient's PACU arrival to his or her discharge criteria being met decreased by 53 minutes and PACU stay prolongation as a result of uncontrolled pain for opioid-tolerant patients decreased from 45.2% to 25.7%. The sample size was underpowered to perform statistical analysis of this improvement.

CONCLUSIONS

After the combined intervention of a clinical pain pathway and interactive teaching workshop, we noted shortened PACU length of stay, reduced time to reach pain control, and improved overall patient satisfaction. Although we could not determine statistical significance, our findings suggest improved management of acute postoperative pain, especially for patients who are opioid tolerant. Because of the paucity of data, we were not able to conduct the analysis needed to evaluate quality improvement projects, as per SQUIRE 2.0. could be adopted by any institution.