Government Legislation in Response to the Opioid Epidemic

Supporting medication-assisted recovery in recovery residences: staff support, managing built environment threats, and building a supportive network

Background: While medications for opioid use disorder (MOUD) are effective in reducing overdoses, widespread adoption and implementation of MOUD remains inadequate. Innovative approaches to promote MOUD use and to support people in their medication-assisted recovery (MAR) are needed. Recovery residences that serve people taking MOUD are steadily growing in number, yet little is known about how MOUD and the MAR pathway is promoted within the recovery residence setting.Objectives: The purpose of this qualitative analysis was to describe how recovery residences facilitate MOUD initiation and support residents' MAR pathway.Methods: We conducted interviews with 93 residents (59.1% male; 38.7% female) living in recovery residences located in five Texas cities that served people taking medication for opioid use disorder.Results: We found that recovery residence staff addressed linkage to care gaps in their communities by connecting people who might benefit from MOUD to appropriate providers. Recovery residence staff also strengthened participants' community of MAR-supportive peers by hosting or connecting residents to Medication-Assisted Recovery Anonymous meetings. Additionally, recovery residences helped some residents overcome common logistical barriers (e.g. transportation issues, housing instability, distance to providers) that hinder MOUD access.Conclusion: Recovery residences that serve people taking MOUD are a well-positioned recovery support service to promote MOUD initiation and the MAR pathway.

Appendectomy Pain Medication Prescribing Variation in the U.S. Military Health System

INTRODUCTION

Post-appendectomy opioid prescription practices may vary widely across and within health care systems. Although guidelines encourage conservative opioid prescribing and prescribing of non-opioid pain medications, the variation of prescribing practices and the probability of opioid refill remain unknown in the U.S. Military Health System.

MATERIALS AND METHODS

This retrospective observational cohort study evaluated medical data of 11,713 patients who received an appendectomy in the Military Health System between January 2016 and June 2021. Linear-mixed and generalized linear-mixed models evaluated the relationships between patient-, care-, and system-level factors and the two primary outcomes; the morphine equivalent dose (MED) at hospital discharge; and the probability of 30-day opioid prescription refill. Sensitivity analyses repeated the generalized linear-mixed model predicting the probability of opioid (re)fill after an appendectomy, but with inclusion of the full sample, including patients who had not received a discharge opioid prescription (e.g., 0 mg MED).

RESULTS

Discharge MED was twice the recommended guidance and was not associated with opioid refill. Higher discharge MED was associated with opioid/non-opioid combination prescription (+38 mg) relative to opioid-only, lack of non-opioid prescribing at discharge (+6 mg), care received before a Defense Health Agency opioid safety policy was released (+61 mg), documented nicotine dependence (+8 mg), and pre-appendectomy opioid prescription (+5 mg) (all P < .01). Opioid refill was more likely for patients with complicated appendicitis (OR = 1.34; P < .01); patients assigned female (OR = 1.25, P < .01); those with a documented mental health diagnosis (OR = 1.32, P = .03), an antidepressant prescription (OR = 1.84, P < .001), or both (OR = 1.54, P < .001); and patients with documented nicotine dependence (OR = 1.53, P < .001). Opioid refill was less likely for patients who received care after the Defense Health Agency policy was released (OR = 0.71, P < .001), were opioid naive (OR = 0.54, P < .001), or were Asian or Pacific Islander (relative to white patients, OR = 0.68, P = .04). Results from the sensitivity analyses were similar to the main analysis, aside from two exceptions. The probability of refill no longer differed by race and ethnicity or mental health condition only.

CONCLUSIONS

Individual prescriber practices shifted with new guidelines, but potentially unwarranted variation in opioid prescribing dose remained. Future studies may benefit from evaluating patients' experiences with pain management, satisfaction, and patient-centered education after appendectomy within the context of opioid prescribing practices, amount of medications used, and refill probability. Such could pave a way for standardized patient-centered procedures that both decrease unwarranted prescribing pattern variability and optimize pain management regimens.

Xylazine: A Drug Adulterant of Clinical Concern

PURPOSE OF REVIEW

The opioid epidemic has been responsible for significant morbidity and mortality in the USA and worldwide. As a result, it is essential to recognize the threat these potent drugs can cause when illicitly used. Specifically, introducing fentanyl as a drug adulterant has been shown to impact overdose rates drastically. In this regard, the Drug Enforcement Agency recently released a public safety alert announcing the new threat of a new adulterant called xylazine. Xylazine is a powerful animal sedative with a different mechanism of action when compared to illicit opioids such as heroin and fentanyl. Xylazine is typically injected intravenously via a syringe, often in combination with multiple other drugs. One of the most common drugs, xylazine, is taken in combination with fentanyl, with users of this drug combination describing xylazine as prolonging the euphoric sensation produced by fentanyl.

RECENT FINDINGS

Xylazine may cause adverse effects such as bradycardia, brief hypertension followed by hypotension, premature ventricular contractions, ataxia, slurred speech, sedation, and respiratory depression. Much of the recent literature on xylazine use in humans comes from case reports and review articles. Related to widespread use in veterinary medicine and increasing circulation in illicit drug markets, there is a critical need for public awareness and additional clinical-based studies to further increase understanding of mediated or modulated pharmacological effects of xylazine in humans. Further research is urgently needed to more clearly understand the implications of unregulated xylazine in the illicit drug market, to formulate public health interventions, and to implement harm reduction strategies.

Nationwide, County-Level Analysis of the Patterns, Trends, and System-Level Predictors of Opioid Prescribing in Surgery in the US: Social Determinants and Access to Mental Health Services Matter

BACKGROUND

The diversion of unused opioid prescription pills to the community at large contributes to the opioid epidemic in the US. In this county-level population-based study, we aimed to examine the US surgeons' opioid prescription patterns, trends, and system-level predictors in the peak years of the opioid epidemic.

STUDY DESIGN

Using the Medicare Part D database (2013 to 2017), the mean number of opioid prescriptions per beneficiary (OPBs) was determined for each US county. Opioid-prescribing patterns were compared across counties. Multivariable linear regression was performed to determine relationships between county-level social determinants of health (demographic, eg median age and education level; socioeconomic, eg median income; population health status, eg percentage of current smokers; healthcare quality, eg rate of preventable hospital stays; and healthcare access, eg healthcare costs) and OPBs.

RESULTS

Opioid prescription data were available for 1,969 of 3,006 (65.5%) US counties, and opioid-related deaths were recorded in 1,384 of 3,006 counties (46%). Nationwide, the mean OPBs decreased from 1.08 ± 0.61 in 2013 to 0.87 ± 0.55 in 2017; 81.6% of the counties showed the decreasing trend. County-level multivariable analyses showed that lower median population age, higher percentages of bachelor's degree holders, higher percentages of adults reporting insufficient sleep, higher healthcare costs, fewer mental health providers, and higher percentages of uninsured adults are associated with higher OPBs.

CONCLUSIONS

Opioid prescribing by surgeons decreased between 2013 and 2017. A county's suboptimal access to healthcare in general and mental health services in specific may be associated with more opioid prescribing after surgery.

"Being here is saving my life": Resident experiences of living in recovery residences for people taking medication for an opioid use disorder

INTRODUCTION

Medications for opioid use disorder (MOUD) are an effective treatment for addressing opioid use disorder. Despite MOUD's demonstrated effectiveness, MOUD-related stigma is prevalent throughout many recovery communities and subsequently limits persons taking MOUD access to recovery supports, including recovery housing. While recovery residences that serve people taking MOUD could be a critical recovery support, they are limited in number and understudied.

METHODS

We conducted in-depth interviews with 47 residents in medication-assisted recovery (MAR) living in 11 Texas-based recovery residences serving people taking MOUD to characterize residents' experiences and understand the impact that these homes had on their recovery.

RESULTS

We found that many participants could not previously access recovery housing and other recovery supports due to MOUD-related stigma, thus recovery homes that supported people in MAR were considered a groundbreaking opportunity. Recovery residences provided participants with a space in which they did not feel judged for taking MOUD, which facilitated participants' connections with their fellow housemates. Subsequently, participants no longer had to hide their MAR pathway and could be transparent about taking MOUD among their recovery residence community. Last, recovery homes provided a supportive environment in which participants' internalized MOUD-related stigma could evolve into acceptance of their MAR pathway.

CONCLUSIONS

Recovery residences that serve people in MAR provide a supportive, safe, nonjudgmental recovery environment in which residents develop relationships with other peers taking MOUD, share openly about their MAR, and are empowered to embrace their recovery pathway. These findings highlight the need for more recovery residences that are supportive of people taking MOUD as part of their recovery.

Opioid death projections with AI-based forecasts using social media language

Targeting of location-specific aid for the U.S. opioid epidemic is difficult due to our inability to accurately predict changes in opioid mortality across heterogeneous communities. AI-based language analyses, having recently shown promise in cross-sectional (between-community) well-being assessments, may offer a way to more accurately longitudinally predict community-level overdose mortality. Here, we develop and evaluate, TROP (Transformer for Opiod Prediction), a model for community-specific trend projection that uses community-specific social media language along with past opioid-related mortality data to predict future changes in opioid-related deaths. TOP builds on recent advances in sequence modeling, namely transformer networks, to use changes in yearly language on Twitter and past mortality to project the following year's mortality rates by county. Trained over five years and evaluated over the next two years TROP demonstrated state-of-the-art accuracy in predicting future county-specific opioid trends. A model built using linear auto-regression and traditional socioeconomic data gave 7% error (MAPE) or within 2.93 deaths per 100,000 people on average; our proposed architecture was able to forecast yearly death rates with less than half that error: 3% MAPE and within 1.15 per 100,000 people.

Disparities in years of potential life lost to Drug-involved overdose deaths in South Carolina

INTRODUCTION

South Carolina has experienced a surge in fatal overdoses, primarily fueled by opioid-involved overdose deaths. This work aims to quantify the burden of premature mortality due to fatal opioid-involved overdoses in South Carolina while documenting the contribution of synthetic opioids to excess mortality, examining substance specific geographic and demographic patterns of mortality burden, and measuring the effect of fatal opioid and synthetic opioid-involved overdoses on average lifespan.

METHODS

We obtained death certificates for fatalities involving opioids, cocaine, benzodiazepines, and psychostimulants (N = 3,726) in South Carolina from 2014 to 2018. Years of Potential Life Lost (YPLL) was used to examine gender, racial, and geographic disparities in mortality burden. We assessed the contribution of synthetic opioid poisoning to the overall opioid mortality burden over time and calculated the effect of fatal opioid and synthetic opioid-involved overdoses on average lifespan.

RESULTS

From 2014 to 2018, opioid-involved overdose deaths resulted in 124,451 YPLL. The average age of fatal male and female opioid-involved overdoses decreased 2.8 and 3.9 years, respectively. Synthetic opioids increasingly contributed to opioid YPLL, accounting for 22% in 2014 to 64% in 2018. Mortality burden was not shared equally between races, sexes, or rural/urban counties. The largest change occurred in black male synthetic opioid-involved deaths (2234%). Rural counties comprised 44-48% of the population adjusted YPLL despite containing 34% of the population.

CONCLUSION

Opioid-involved overdoses account for a critical cause of mortality in South Carolina, demonstrate significant impact on YPLL and highlight mortality burden disparities in gender, race, and rural/urban settings.

Pill Counting as an Intervention to Enhance Compliance and Reduce Adverse Outcomes with Analgesics Prescribed for Chronic Pain Conditions: A Systematic Review

PURPOSE OF REVIEW

Appropriate use of opioid analgesics is a key concern within the field of pain medicine. Several methods exist to discourage abuse and facilitate effective treatment regimens. Pill counting is often cited as one such method and frequently employed in varying fashions within clinical practice. However, to date, there is no published review of the evidence to support this practice. This was a comprehensive review of the available literature that was conducted with analysis of the efficacy and practical application of pill counting during treatment of chronic pain conditions.

RECENT FINDINGS

There is paucity in data regarding pill count importance in pain management. Pill count is a very important tool to monitor compliance of opioids use which in turn can prevent several complications associated with opioid misuse. Pill counting may be used in conjunction with other abuse deterrents, although increased support for this practice requires standardized methods of pill counting and further analysis of its effectiveness.

Epidemiology, investigation, management, and outcome of headache in emergency departments (HEAD study)-A multinational observational study

OBJECTIVE

To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs).

BACKGROUND

Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally.

METHODS

An international, multicenter, observational, cross-sectional study was conducted over one calendar month in 2019. Participants were adults (≥18 years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re-presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome.

RESULTS

We enrolled 4536 patients (67 hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%-75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non-SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti-inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In-hospital mortality was 0.3% (11/4526).

CONCLUSION

Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment.

Predictors of US states' adoption of naloxone access laws, 2001-2017

BACKGROUND

The opioid crisis has put an increasing strain on US states over the last two decades. In response, all states have passed legislation to implement a portfolio of policies to address the crisis. Although effects of some of these policies have been studied, research into factors associated with state policy adoption decisions has largely been lacking. We address this gap by focusing on factors associated with adoption of naloxone access laws (NAL), which aim to increase the accessibility and availability of naloxone in the community as a harm reduction strategy to reduce opioid-related morbidity and mortality.

METHODS

We used event history analysis (EHA) to identify predictors of the diffusion of naloxone access laws (NAL) from 2001, when the first NAL was passed, to 2017, when all states had adopted NAL. A variety of state characteristics were included in the model as potential predictors of adoption.

RESULTS

We found that state adoption of NAL increased gradually, then more rapidly starting in 2013. Consistent with this S-shaped diffusion process, the strongest predictor of adoption was prior adoption by neighboring states. Having a more conservative political ideology and having a higher percentage of residents who identified as evangelical Protestants were associated with later adoption of NAL.

CONCLUSION

States appear to be influenced by their neighbors in deciding whether and when to adopt NAL. Advocacy for harm reduction policies like NAL should take into account the political and religious culture of a state.

Opioid Free Ureteroscopy: What is the True Failure Rate?

OBJECTIVE

To determine the true failure rate of opioid free ureteroscopy (OF-URS) and rates of new-persistent opioid use utilizing a national prescription drug monitoring program.

MATERIAL AND METHODS

We identified 239 patients utilizing our retrospective stone database who underwent OF-URS from Februrary 2018-March 2020. In Feb 2018, we initiated a OF-URS pathway (diclofenac, tamsulosin, acetaminophen, pyridium and oxybutynin). Patients who had a contraindication to NSAIDs were excluded from primary analyses. A prescription drug monitoring program was then utilized to determine the number of patients who failed OF-URS (defined as receipt of an opioid within 31 days of surgery) as well as rates of new-persistent opioid use (defined as receipt of opioid 91-180 days after surgery). All statistical analyses were performed using SAS 9.4. Tests were 2-sided and statistical significance was set at P<0.05.

RESULTS

We found a OF-URS failure rate of 16.6% and 14.0% in the total and opioid naïve cohorts, respectively. Rates of new-persistent opioid use were 0.9% and 1.2%, respectively (lower than published expected rate of ~6% after URS with postoperative opioids). 91% of patients obtained opioid from alternative sources. Uni/multivariate analyses were performed for both cohorts. In the total cohort, benzodiazepine users had a lower risk of OF-URS failure on multivariate analysis. No variables were associated with OF-URS failure in the opioid naïve cohort.

CONCLUSION

The true failure rate of OF-URS is higher than previously thought at 16.6% and 14.0%. However, efforts to reduce opioid prescriptions with OF-URS pathways have successfully reduced new-persistent opioid use.

Characteristics of post-overdose public health-public safety outreach in Massachusetts

BACKGROUND

As a response to mounting overdose fatalities, cross-agency outreach efforts have emerged to reduce future risk among overdose survivors. We aimed to characterize such programs in Massachusetts, with focus on team composition, approach, services provided, and funding.

METHODS

We conducted a two-phase cross-sectional survey of public health and safety providers in Massachusetts. Providers in all 351 municipalities received a screening survey. Those with programs received a second, detailed survey. We analyzed responses using descriptive statistics.

RESULTS

As of July 2019, 44 % (156/351) of Massachusetts municipalities reported post-overdose outreach programs, with 75 % (104/138) formed between 2016-2019. Teams conducted home-based outreach 1-3 days following overdose events. Police departments typically supplied location information on overdose events (99 %, 136/138) and commonly participated in outreach visits (86 %, 118/138) alongside public health personnel, usually from community-based organizations. Teams provided or made referrals to services including inpatient addiction treatment, recovery support, outpatient medication, overdose prevention education, and naloxone. Some programs deployed law enforcement tools, including pre-visit warrant queries (57 %, 79/138), which occasionally led to arrest (11 %, 9/79). Many programs (81 %, 112/138) assisted families with involuntary commitment to treatment - although this was usually considered an option of last resort. Most programs were grant-funded (76 %, 104/136) and engaged in cross-municipal collaboration (94 %, 130/138).

CONCLUSIONS

Post-overdose outreach programs have expanded, typically as collaborations between police and public health. Further research is needed to better understand the implications of involving police and to determine best practices for increasing engagement in treatment and harm reduction services and reduce subsequent overdose.

Peripherally acting opioid analgesics and peripherally-induced analgesia

The management of pain, particularly chronic pain, is still an area of medical need. In this context, opioids remain a gold standard for the treatment of pain. However, significant side effects, mainly of central origin, limit their clinical use. Here, we review recent progress to improve the therapeutic and safety profiles of opioids for pain management. Characterization of peripheral opioid-mediated pain mechanisms have been a key component of this process. Several studies identified peripheral µ, δ, and κ opioid receptors (MOR, DOR, and KOR, respectively) and nociceptin/orphanin FQ (NOP) receptors as significant players of opioid-mediated antinociception, able to achieve clinically significant effects independently of any central action. Following this, particularly from a medicinal chemistry point of view, main efforts have been directed towards the peripheralization of opioid receptor agonists with the objective of optimizing receptor activity and minimizing central exposure and the associated undesired effects. These activities have allowed the characterization of a great variety of compounds and investigational drugs that show low central nervous system (CNS) penetration (and therefore a reduced side effect profile) yet maintaining the desired opioid-related peripheral antinociceptive activity. These include highly hydrophilic/amphiphilic and massive molecules unable to easily cross lipid membranes, substrates of glycoprotein P (a extrusion pump that avoids CNS penetration), nanocarriers that release the analgesic agent at the site of inflammation and pain, and pH-sensitive opioid agonists that selectively activate at those sites (and represent a new pharmacodynamic paradigm). Hopefully, patients with pain will benefit soon from the incorporation of these new entities.

Race, Ethnicity, and Insurance: the Association with Opioid Use in a Pediatric Hospital Setting

BACKGROUND

This study examined the association between race/ethnicity and health insurance payer type with pediatric opioid and non-opioid ordering in an inpatient hospital setting.

METHODS

Cross-sectional inpatient encounter data from June 2013 to June 2018 was retrieved from a pediatric children's hospital in Southern California (N = 55,944), and statistical analyses were performed to determine associations with opioid ordering.

RESULTS

There was a significant main effect of race/ethnicity on opioid and non-opioid orders. Physicians ordered significantly fewer opioid medications, but a greater number of non-opioid medications, for non-Hispanic African American children than non-Hispanic Asian, Hispanic/Latinx, and non-Hispanic White pediatric patients. There was also a main effect of health insurance payer type on non-opioid orders. Patients with government-sponsored plans (e.g., Medi-Cal, Medicare) received fewer non-opioid prescriptions compared with patients with both HMO and PPO coverage. Additionally, there was a significant race/ethnicity by insurance interaction on opioid orders. Non-Hispanic White patients with "other" insurance coverage received the greatest number of opioid orders. In non-Hispanic African American patients, children with PPO coverage received fewer opioids than those with government-sponsored and HMO insurance. For non-Hispanic Asian patients, children with PPO were prescribed more opioids than those with government-sponsored and HMO coverage.

CONCLUSION

Findings suggest that the relationship between race/ethnicity, insurance type, and physician decisions opioid prescribing is complex and multifaceted. Given that consistency in opioid prescribing should be seen regardless of patient background characteristics, future studies should continue to assess and monitor unequitable differences in care.