An update on oxycodone: lessons for death investigators in Australia

Reducing opioid use for chronic non-cancer pain in primary care using an evidence-based, theory-informed, multistrategic, multistakeholder approach: a single-arm time series with segmented regression

BACKGROUND

Many countries have high opioid use among people with chronic non-cancer pain. Knowledge about effective interventions that could be implemented at scale is limited. We designed a national intervention that included audit and feedback, deprescribing guidance, information on catastrophising assessment, pain neuroscience education and a cognitive tool for use by patients with their healthcare providers.

METHOD

We used a single-arm time series with segmented regression to assess rates of people using opioids before (January 2015 to September 2017), at the time of (October 2017) and after the intervention (November 2017 to August 2019). We used a cohort with historical comparison group and log binomial regression to examine the rate of psychologist claims in opioid users not using psychologist services prior to the intervention.

RESULTS

13 968 patients using opioids, 8568 general practitioners, 8370 pharmacies and accredited pharmacists and 689 psychologists were targeted. The estimated difference in opioid use was -0.51 persons per 1000 persons per month (95% CI -0.69, -0.34; p<0.001) as a result of the intervention, equating to 25 387 (95% CI 24 676, 26 131) patient-months of opioid use avoided during the 22-month follow-up. The targeted group had a significantly higher rate of incident patient psychologist claims compared with the historical comparison group (rate ratio: 1.37, 95% CI 1.16, 1.63; p<0.001), equating to an additional 690 (95% CI 289, 1167) patient-months of psychologist treatment during the 22-month follow-up.

CONCLUSIONS

Our intervention addressed the cognitive, affective and sensory factors that contribute to pain and consequent opioid use, demonstrating it could be implemented at scale and was associated with a reduction in opioid use and increasing utilisation of psychologist services.

Evaluation of a post-discharge pharmacist opioid review following total knee arthroplasty: a pre- and post-intervention cohort study

Background

More than 70% of patients continue to use opioid medications 3-weeks following total knee arthroplasty. Post-discharge pharmacist reviews improve medication management, however it’s effect on opioid usage is not known.

Aim

This study aimed to evaluate the impact of post-discharge pharmacist review on opioid use following a total knee arthroplasty.

Method

A pilot, cohort pre- and post-intervention study was undertaken on patients who had undergone a total knee arthroplasty and were supplied an opioid upon discharge from hospital. During the intervention, patients were contacted via telephone by a pharmacist approximately five days post-discharge to review analgesic usage, provide education and advice and communicate an opioid management plan to their general practitioner. The primary endpoint was the percentage of patients taking opioids 3-weeks post-discharge. Secondary endpoints included: percentage of patients obtaining an opioid refill; patient satisfaction with opioid supply and the pharmacist review.

Results

Pre- and post-intervention, 63 and 44 patients were included, respectively. The percentage of patients taking opioids 3-weeks post-discharge declined from 74.6 to 29.6% (p < 0.001) and the percentage requiring an opioid refill from their general practitioner declined from 71.4 to 36.4% (p  < 0.001). More patients were satisfied with opioid supply during the intervention period (79.5% cf. 47.6%, p = 0.001). Twenty-eight (63.6%) patients could recall the post-discharge pharmacist review, and all were either satisfied or extremely satisfied with the review.

Conclusion

Pharmacist-delivered post-discharge analgesia review reduced the percentage of patients taking opioids 3-weeks post-discharge following a total knee arthroplasty. This intervention has the potential to provide a smoother transition of care for patients supplied with opioids at the time of hospital discharge.

Opioid prescribing in general practice: an Australian cross-sectional survey

BACKGROUND

Prescribed opioid doses > 100 mg oral morphine equivalent (OME) and/or co-prescribing of sedating psychoactive medications increase the risk of unintentional fatal overdose. We describe general practice encounters where opioids are prescribed and examine high-risk opioid prescribing.

METHODS

The 2006-2016 BEACH study data, a rolling national cross-sectional survey of randomly selected GPs, was analysed.

RESULTS

Opioid prescribing increased 2006-2007 to 2015-2016, however, this plateaued across the latter half-decade. From 2012-2016 3,897 GPs recorded 389,700 encounters and at least one opioid was prescribed at 5.2%. Opioid encounters more likely involved males, those 45-64 years, concession card holders and the socioeconomically disadvantaged. GPs more likely to prescribe opioids were 55 years or older, male, Australian graduates, and in regional and remote areas. The most common problems managed with opioids involved chronic non-cancer pain. One-in-ten opioid prescribing episodes involved high-risk doses and 11% involved co-prescription of sedating psychoactive medications. Over one-third of GPs provided other (non-pharmacological) interventions at encounters with opioid prescriptions.

CONCLUSIONS

Only 5% of GP encounters involved an opioid prescription. Of concern, were: prescribing for chronic non-cancer pain, potentially high-risk opioid encounters where > 100 OME daily dose was prescribed, and/or there was co-prescription of sedating psychoactive medication. However, approximately one-in-three opioid prescribing encounters involved non-pharmacological interventions.

Oxycodone-Related Deaths: The Significance of Pharmacokinetic and Pharmacodynamic Drug Interactions

BACKGROUND AND OBJECTIVES

Oxycodone is frequently prescribed as well as detected in postmortem cases. Concurrent use of pharmacodynamically or pharmacokinetically interacting drugs can cause adverse effects or even fatal intoxication. The aims of this study were to investigate differences in prescriptions for and toxicological findings of pharmacodynamically and pharmacokinetically interacting drugs in fatal oxycodone-related intoxications and other causes of death. We also aimed to investigate the differences in prevalence of oxycodone prescriptions, and the detected postmortem oxycodone concentrations between fatal oxycodone-related intoxications and other causes of death.

METHODS

Forensic autopsy cases (2012-2018) where oxycodone was identified in femoral blood (n = 1236) were included. Medical history and prescription data were retrieved from national databases and linked to the forensic toxicology findings.

RESULTS

Oxycodone-related deaths were found to have higher blood concentrations of oxycodone (median 0.30 µg/g vs. 0.05 µg/g) and were less likely to have a prescription for oxycodone (OR 0.62) compared to nonintoxication deaths. Pharmacodynamically interacting drugs were prescribed in 79% and found in blood in 81% of the cases. Pharmacokinetically interacting drugs were rarely prescribed (1%). Oxycodone-related deaths were more likely to have prescriptions for a pharmacodynamically interacting drug (OR 1.7) and more often have co-findings of one or multiple pharmacodynamically interacting drugs (OR 5.6).

CONCLUSION

The results suggest that combined use of oxycodone and pharmacodynamically interacting drugs is associated with oxycodone-related death and that non-medical use of oxycodone is a potential risk factor for oxycodone-related intoxication.

Changing Pain Management Strategy from Opioid-Centric towards Improve Postoperative Cognitive Dysfunction with Dexmedetomidine

OBJECTIVE

This study was aimed to investigate the effectiveness of dexmedetomidine (DEX) on improving the level of pain and disability to find out the possible correlation between psychological factors with pain management satisfaction and physical function in patients with femoral neck fractures.

METHODS

One hundred twenty-four adult patients with stable femoral neck fractures (type I and II, Garden classification) who underwent internal fixation, were prospectively enrolled including 62 patients in the DEX group and 62 patients in the control group. The magnitude of disability using Harris Hip Score, Postoperative Cognitive Dysfunction (POCD) using Mini-Mental State Examination (MMSE score), Quality of Recovery (QoR-40), pain-related anxiety (PASS-20), pain management and pain catastrophizing scale (PCS) were recorded on the first and second day after surgery.

RESULTS

The DEX group on the first and second days after surgery exhibited higher quality of recovery scores, greater satisfaction with pain management, low disability scores, less catastrophic thinking, lower pain anxiety, greater mini mental state examination scores and less opioid intake and the differences were statistically significant compared with the control group (P<0.001). Emergence agitation and incidence of POCD were significantly less in the DEX group (P<0.001). Decreased disability was associated with less catastrophic thinking and lower pain anxiety, but not associated with more opioid intake (P<0.001). Higher QoR-40 scores had a negative correlation with more catastrophic thinking and more opioid intake (P<0.001). Greater satisfaction with pain management was correlated with less catastrophic thinking and less opioid intake (P<0.001).

CONCLUSION

Using DEX as an adjunct to anesthesia could significantly improve postoperative cognitive dysfunction and the quality of recovery and these improvements were accompanied by decrease in pain, emergence agitation, and opioid consumption by DEX administration. Since pain relief and decreased disability were not associated with prescribing greater amounts of opioid intake in the patients, improving psychological factors, including reducing catastrophic thinking or self-efficacy about pain, could be a more effective strategy to reduce pain and disability, meanwhile reducing opioid prescription in the patients. Our findings showed that DEX administration is safe sedation with anti-inflammatory, analgesic and antiemetic effects and it could help change pain management strategy from opioid-centric towards improved postoperative cognitive dysfunction.

Opioid use and misuse in children, adolescents, and young adults with cancer: a systematic review of the literature

Adolescents and young adults (AYAs) are at increased risk for negative opioid-related outcomes, including misuse and overdose. High-quality cancer care requires adequate pain management and often includes opioids for tumor- and/or treatment-related pain. Little is known about opioid use and misuse in children and AYAs with cancer, and we therefore conducted a systematic review of the literature using PRISMA guidelines to identify all relevant studies that evaluated opioid use and/or misuse among this population. Eleven studies were identified that met our inclusion criteria. The range of opioid use among the studies was 12-97%, and among the five studies that reported opioid misuse or aberrant behaviors, 7-90% of patients met criteria. Few studies reported factors associated with opioid misuse but included prior mental health and/or substance use disorders, and prior opioid use. In summary, opioid use is highly variable among children and AYAs with cancer; however, the range of use varies widely depending on the study population, such as survivors or end-of-life cancer patients. Few studies have examined opioid misuse and/or aberrant behaviors, and future research is needed to better understand opioid use and misuse among children and AYAs with cancer, specifically those who will be cured of their cancer and may subsequently experience adverse opioid-related outcomes.

Future projections of opioid use and cost in patients with chronic osteoarthritis pain in Spain

Background:

Opioids are widely used in moderate-to-severe chronic pain which is non-responsive to standard analgesics. Prescriptions have increased in Europe in the last decade, although remain lower than in USA. This work projected the future utilization and costs of opioids in chronic osteoarthritis (OA) pain in the Spanish National Health System (NHS).

Methods:

An epidemiological model was populated with the opioid dispensing trends from 2010 to 2019 using Spanish Medicinal Agency rates of opioid utilization in subjects over 18 years of age and the real-world OPIOIDS study to estimate chronic-OA-pain patients receiving opioids. A best-fitted trend analysis model was applied estimating the likely number of DHD (defined daily dose/1000 inhabitants per day) to calculate projected opioid utilization and costs for the period 2020–2029.

Results:

In 2010, an estimated 5.67 DHD were dispensed for the equivalent of 217,076 chronic OA pain patients per day [1.99 DHD, 76,084 refractory to non-steroidal anti-inflammatory drugs (NSAIDs)]. From these trends and OA prevalence, the projected number of DHDs is expected to increase more than threefold to 17.98 DHDs by the year 2029 for the equivalent of 727,356 chronic OA pain patients per day (8.18 DHD, 330,720 refractory to NSAIDs); 41.8% on strong opioids. The estimated cost was €116.9m (€45.0m in NSAID-refractory OA) in 2010 rising by 222% to €376.1m (€199.7m refractory to NSAIDs) by 2029.

Conclusion:

Chronic-OA-pain-related opioid dispensing and costs to the NHS are set to increase more than threefold from 2010 to 2029 in Spain. Using opioids for OA pain is concerning given disease chronicity and other related costs not computed in these projections.

Plain language summary

• Opioids are widely used in chronic pain which is non-responsive to standard analgesics. Prescriptions have increased in Europe, although remain lower than in USA. Osteoarthritis (OA) is a degenerative joint disease usually accompanied by pain. Despite not recommended, opioids use in OA have been expanded because this health condition is increasing with ageing and, also, because physicians both primary and specialist boosted their use.

• This study aimed to quantify the current burden of opioids used for chronic moderate-to-severe OA pain by estimating the number of defined daily doses per 1000 inhabitants per day (DHD) and associated costs, and to forecast the likely burden on the National Health System (NHS) in Spain for the years 2020–2029.

• In 2010, an estimated 5.67 DHDs were dispensed for the equivalent of 217,076 chronic OA pain patients per day. From these trends, the projected number of DHDs is expected to increase more than threefold to 17.98 DHDs by the year 2029 for the equivalent of 727,356 chronic OA pain patients per day; 41.8% on strong opioids. The estimated cost was €116.9m in 2010 rising by 222% to €376.1m by 2029.

• Chronic OA-pain-related opioid dispensing and costs to the NHS are set to increase substantially (threefold to more than fourfold) from 2010 to 2029 in Spain. Thus, using opioids for OA pain is concerning given disease chronicity, aging population and other related costs not computed in these projections. Our findings can inform payors and clinicians about ongoing discussions on appropriate analgesic management for longer-term OA pain, including resource requirements at a national level. Clinicians who prescribe opioids for OA pain should consider the potential implications of side effects such as sedation, cognitive deterioration, incremental need of caregivers, particularly in older people, and carefully consider the risk–benefit balance.

Oxycodone findings and CYP2D6 function in postmortem cases

Genetic disposition can cause variation in oxycodone pharmacokinetic characteristics and decrease or increase the expected clinical response. In forensic medicine, determination of cause of death or assessing time between drug intake and death can be facilitated by knowledge of parent and metabolite concentrations. In this study, the aim was to investigate if CYP2D6 genotyping can facilitate interpretation by investigating the frequency of the four CYP2D6 phenotypes, poor metabolizer, intermediate metabolizer, extensive metabolizer, and ultra-rapid metabolizer in postmortem cases, and to study if the CYP2D6 activity was associated with a certain cause of death, concentration, or metabolic ratio. Cases positive for oxycodone in femoral blood (n = 174) were genotyped by pyrosequencing for CYP2D6*3, *4, and *6 and concentrations of oxycodone, noroxycodone, oxymorphone, and noroxymorphone were determined by LC-MS/MS (LLOQ 0.005 µg/g). Digital droplet PCR was used to determine the copy number variation for CYP2D6*5. Cases were categorized by cause of death. It was found that poor and intermediate CYP2D6 metabolizers had significantly higher oxycodone and noroxycodone concentrations compared to extensive and ultra-rapid metabolizers. CYP2D6 phenotype were equally distributed between cause of death groups, showing that no phenotype was overrepresented in any of the cause of death groups. We also found that the concentration ratio between oxymorphone and oxycodone depended on the CYP2D6 activity when death was unrelated to intoxication. In general, a low metabolite to parent ratio indicate an acute intake. By using receiver operating characteristic (ROC) analysis, we conclude that an oxymorphone/oxycodone ratio lower than 0.075 has a high sensitivity for separating intoxications with oxycodone from other intoxications and non-intoxications. However, the phenotype needs to be known to reach a high specificity. Therefore, the ratio should not be used as a biomarker on its own to distinguish between different causes of death but needs to be complemented by genotyping.

Oxycodone Concentrations and Metabolic Ratios in Femoral Blood from Fatal Intoxications and Other Causes of Death using LC-MS-MS

Oxycodone (OC) is an opioid with strong analgesic effects widely used to treat acute and chronic pain. Interpretation of OC concentrations in postmortem cases is complicated due to tolerance and overlapping concentrations for fatal and non-fatal levels. In this study, our aim was to develop and validate a method for OC and its three metabolites: noroxycodone (NOC), oxymorphone (OM) and noroxymorphone (NOM) in postmortem femoral blood. Our goal was to define reference concentrations for intoxications and non-intoxications and investigate metabolic ratios in different causes of death. A rapid LC-MS-MS method using protein-precipitated postmortem blood was developed. Lower limit of quantitation was 0.005 μg/g blood for all analytes; upper limit of quantitation was 1.0 μg/g for OC and NOC and 0.25 μg/g for OM and NOM. The method displayed high precision (3.3-7.7%) and low bias (-0.3 to 12%). In total, 192 cases were analyzed and concentrations ranged from 0.005 to 13 μg/g for OC, 0.005 to 2.0 μg/g for NOC, 0.005 to 0.24 μg/g for OM, and 0.005 to 0.075 μg/g for NOM. We found a significant difference in OC concentration between the cases where OC contributed and those where it did not. In spite of that, we do not recommend the use of a specific blood concentration to distinguish fatal intoxications. Instead, the percentiles from our data set suggest that concentrations >0.2 μg/g are likely to have contributed to toxicity, but that concentrations as high as 0.3 might be tolerated without toxic effects. In addition, we also found that a low NOC/OC ratio could point toward an acute fatal intoxication. In conclusion, the OC concentration alone may not be sufficient to diagnose a fatal intoxication.

Disease Burden and Costs in Moderate-to-Severe Chronic Osteoarthritis Pain Refractory to Standard of Care: Ancillary Analysis of the OPIOIDS Real-World Study

Introduction

To determine the disease burden and costs in moderate-to-severe chronic osteoarthritis (OA) pain refractory to standard-of-care treatment in the Spanish National Health System (NHS).

Methods

Ancillary analysis of the OPIOIDS real-world, non-interventional, retrospective, 4-year longitudinal study including patients aged at least 18 years with moderate-to-severe chronic OA pain refractory to standard-of-care with sequential NSAIDs plus opioids. Burden assessment included measurement of analgesia, cognitive functioning, basic activities of daily living, severity and frequency of comorbidities, and all-cause mortality. Costs accounted for healthcare resource utilization and related costs (year 2018).

Results

Records of 13,317 patients were analyzed; 68.9 (14.7) years old, 71.3% (70.5–72.1%) women, 58.1% refractory to NSAID plus weak opioid and 41.9% to NSAID plus strong opioid, accounting for 10.7% (10.5–10.8%) of patients with chronic OA pain. Mean number of comorbidities was 2.9 (1.8) and its severity was 1.8 (1.7). Pain decreased by 0.9 points (12.2%) and cognitive declined by 2.3 points (9.1%, with 4.3% more patients with cognitive deficit) and dependency worsened by 0.4 points (0.5%, with 2.3% more patients with severe-to-total dependence) over a mean treatment period of 188.6 (185.4–191.8) days on NSAIDs followed by 400.6 (393.7–407.5) days on opioids. The adjusted mortality rate was higher in patients with OA taking NSAID plus strong opioids; hazard ratio 1.44 (1.26–1.65; p < 0.001). The 4-year healthcare cost was €7350/patient (€7193–7507 or €1838/year) and was higher in those taking strong versus weak opioids; €9886 (€9608–10,164, €2472/year) vs. €5519 (€5349–5689, €1380/year), p < 0.001. Analgesia cost (16.0% of total cost, 70.2% opioids) was higher with strong versus weak opioids, 19.6% vs. 11.3%, p < 0.001.

Conclusions

In routine clinical practice in Spain, patients with moderate-to-severe chronic OA pain refractory to standard analgesic treatment with NSAIDs plus opioids reported modest reductions in pain, while presenting a considerable burden of comorbidities, cognitive impairment, and dependency. Healthcare costs significantly increased for the NHS particularly with NSAIDs plus strong opioids.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-020-00271-y.

Opioid Use and Appropriateness of Supply After Total Knee or Hip Arthroplasty: An Australian Perspective

INTRODUCTION

Effective pain management after joint arthroplasty is essential for optimal participation in rehabilitation. However, this needs to be balanced with potential risks associated with opioid use and community exposure. The aim of this study was to evaluate opioid use and appropriateness of supply on discharge after total knee arthroplasty or total hip arthroplasty at a major Australian health service.

METHODS

A prospective observational study was undertaken at an Australian 980-bed metropolitan health service. Patient interviews were conducted 3 weeks after hospital discharge to evaluate analgesic management and functional outcomes. The primary end point was the number of hospital-supplied opioid pills remaining 3 weeks postdischarge. Secondary end points included (1) factors associated with opioid use 3 weeks postdischarge, (2) opioid use in patients with poor functional outcomes, and (3) proportion of opioid naive patients who became chronic opioid users.

RESULTS

One hundred forty patients were included, and 137 were supplied opioids on discharge. At 3 weeks postdischarge, the median number of opioid pills remaining was 0 (interquartile range 0 to 8). There were 77 patients (56.2%) still taking opioids; surgery type, opioid use before admission, and the number of "as required" doses used 24 hours before discharge were independent predictors of opioid continuation. Patients with poor functional outcomes were supplied with more opioids on discharge, often not satisfied with the quantity supplied and more likely to be taking opioids 3 weeks postdischarge. There were 5 of 93 opioid naive patients (5.3%) who developed chronic opioid usage.

DISCUSSION

More than half of the patients undergoing total knee arthroplasty or total hip arthroplasty were still using opioids at 3 weeks postdischarge. Most patients were not supplied with excessive quantities at discharge. Future research should focus on identifying patients at risk of prolonged opioid use and improving the transition of these patients into the community.

LEVEL OF EVIDENCE

Level II-Prognostic study = prospective observational study.

Pharmacists' perceived responsibility for patient care when there is a risk of misadventure: a qualitative study

OBJECTIVE

To investigate how community pharmacists view their responsibility for patient care in a scenario involving opioid use with significant risk of toxicity or misadventure.

METHODS

A case scenario was developed based on an Australian coronial inquiry involving a patient suffering fatal toxicity following misuse of opioids. Community pharmacists working in Brisbane, Queensland, were invited to take part in face-to-face semi-structured interviews at their place of work. Participants were asked how they would respond to the scenario in practice and their perceived responsibilities.

KEY FINDINGS

Twenty-one pharmacists were interviewed. Participants identified similar actions in response to the case, and potential barriers and enablers. Participants differed with regard to how they described their perceived scope of practice and degree of responsibility in response to the case. Most participants described their scope of practice in terms of medication management with a focus on patient outcomes. Some participants described a narrower scope of practice that focused on either medicine supply or legal aspects. Participants who described a medication management focus differed in their views regarding their responsibility for patient outcomes in the case.

CONCLUSION

Pharmacists in this study varied in terms of their perceived scope of practice and responsibility to patient outcomes in response to a case involving a patient at risk of opioid-related harm. Further work on pharmacist responsibility may reduce this variability.

Adverse drug reactions due to opioid analgesic use in New South Wales, Australia: a spatial-temporal analysis

Background

Pharmaceutical opioid analgesic use continues to rise and is associated with potentially preventable harm including hospitalisation for adverse drug reactions (ADRs). Spatial detection of opioid-related ADRs can inform future intervention strategies. We aimed to investigate the geographical disparity in hospitalised ADRs related to opioid analgesic use, and to evaluate the difference in patient characteristics between areas inside and outside the geographic clusters.

Methods

We used the all-inclusive Admitted Patient Dataset for an Australian state (New South Wales, NSW) to identify patients admitted for opioid-related ADRs over a 10-year period (July 2004 to June 2014). A space-time analysis was conducted using Kulldroff’s scan statistics to identify statistically significant spatial clusters over time. Relative risk (RR) was computed with p-value based on Monte Carlo Simulation. Chi-square test was used to compare proportional difference in patient clustering.

Results

During the study period, we identified four statistically significant geographic clusters (RRs: 1.63–2.17) during 2004–08; and seven clusters (RRs: 1.23–1.69) during the period 2009–14. While identified high-risk clusters primarily covered areas with easier access to health services, those associated with socioeconomically disadvantaged areas and individuals with mental health disorders experienced more unmet healthcare needs for opioid analgesic safety than those from the rest of the State. Older people (≥65 years and over) accounted for 62.7% of the total study population and were more susceptible to opioid-related ADRs than younger people,. In the first five-year period the clusters included a greater proportion of people with cancer in contrast to the second five-year period in which there was a lesser proportion of people with cancer.

Conclusions

These results suggest that there is significant spatial-temporal variation in opioid-related ADRs and future interventions should target vulnerable populations and high-risk geographical areas to improve safer use of pharmaceutical opioid analgesics.

Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study

OBJECTIVE

To determine time to opioid cessation post discharge from hospital in persons who had been admitted to hospital for a surgical procedure and were previously naïve to opioids.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study using administrative health claims database from the Australian Government Department of Veterans' Affairs (DVA). DVA gold card holders aged between 18 and 100 years who were admitted to hospital for a surgical admission between 1 January 2014 and 30 December 2015 and naïve to opioid therapy prior to admission were included in the study. Gold card holders are eligible for all health services that DVA funds.

MAIN OUTCOME MEASURES

The outcome of interest was time to cessation of opioids, with follow-up occurring over 12 months. Cessation was defined as a period without an opioid prescription that was equivalent to three times the estimated supply duration. The proportion who became chronic opioid users was defined as those who continued taking opioids for greater than 90 days post discharge. Cumulative incidence function with death as a competing event was used to determine time to cessation of opioids post discharge.

RESULTS

In 2014-2015, 24 854 persons were admitted for a surgical admission. In total 3907 (15.7%) were discharged on opioids. In total 3.9% of those discharged on opioids became chronic users of opioids. The opioid that the patients were most frequently discharged with was oxycodone; oxycodone alone accounted for 43%, while oxycodone with naloxone accounted for 8%.

CONCLUSIONS

Opioid initiation post-surgical hospital admission leads to chronic use of opioids in a small percentage of the population. However, given the frequency at which surgical procedures occur, this means that a large number of people in the population may be affected. Post-discharge assessment and follow-up of at-risk patients is important, particularly where psychosocial elements such as anxiety and catastrophising are identified.

Prevalence and incidence of prescription opioid analgesic use in Australia

AIMS

The aims of the current study were to determine the prevalence and incidence of prescription opioid analgesic use in Australia and compare the characteristics of people with and without cancer initiating prescription opioid analgesics.

METHODS

A retrospective population-based study was conducted using the random 10% sample of adults who were dispensed prescription opioid analgesics in Australia between July 2013 and June 2017 through the Pharmaceutical Benefits Scheme. Poisson regression was used to calculate rate ratios (RR) for opioid prevalence and incidence. The characteristics of people initiating opioids, including type of opioid initiated, total oral morphine equivalents dispensed, prescriber speciality, medical comorbidities, and past analgesic and benzodiazepine use, were compared for people with and without cancer.

RESULTS

Opioid prevalence increased {RR = 1.006 [95% confidence interval (CI) 1.004, 1.008]}, while incidence decreased [RR = 0.977 (95% CI 0.975,0.979)] from 2013/2014 to 2016/2017. There were between 287 677 and 307 772 prevalent users each year. In total, 769 334 adults initiated opioids between 2013/2014 and 2016/2017, and half of these initiations were by general practitioners. Initiation with a strong opioid occurred in 55.8% of those with cancer and 28.2% of those without cancer.

CONCLUSION

Rates of opioid use have remained high since 2013, with approximately 3 million adults using opioids and over 1.9 million adults initiating opioids each year. Between 2013 and 2017, opioid prevalence has slightly increased but incidence has decreased. People without cancer account for the majority of opioid use and are more likely to be initiated on short-acting and weak opioids. Initiation of strong opioids has increased over time, reinforcing concerns about increased use and the harms associated with strong opioids in the community.

Modifying emergency department electronic prescribing for outpatient opioid analgesia

OBJECTIVES

The aim of this study was to examine how changing the electronic ordering sequences for opioid analgesics affected ED outpatient prescribing, and subsequent unused opioid tablets remaining in the community available for diversion.

METHODS

A descriptive before and after study in adult patients prescribed an opioid analgesic by an ED prescriber for use in the outpatient setting. The hospital electronic prescribing system (FirstNet™) was modified to include smaller quantities of opioid analgesics for discharge. The change in quantity of opioid prescribed and change in quantity of opioid analgesic remaining in the community at follow up was measured pre- and post-intervention using a structured telephone interview.

RESULTS

Pre- and post-intervention, 102 and 106 patients were interviewed, respectively. Percentage of prescriptions for oxycodone quantity five tablets increased from 3% to 32% and for quantity 20 tablets fell from 40% to 24% post-intervention. For paracetamol with codeine, prescriptions for quantity 10 tablets increased from 2% to 24% while for quantity 20 tablets fell from 98% to 76%. Mean number of tablets prescribed per patient fell from 13.8 (SD = 5.1) to 10.8 (SD = 5.6) for oxycodone and from 19.8 (SD = 1.5) to 17.6 (SD = 4.2) for paracetamol with codeine. Fifty-eight percent of patients in both pre- and post-intervention groups used half or less of the medication prescribed.

CONCLUSION

Modification of an ED electronic prescribing system reduced overall quantities of opioid analgesics supplied and subsequently stored in the community but did not change the proportion of patients (>50%) who reported using half or less of their prescribed opioid medication.

Predictors of persistent prescription opioid analgesic use among people without cancer in Australia

AIMS

To identify patterns of opioid analgesic use and determine predictors of persistent opioid use among people without cancer.

METHODS

A population-based cohort study of Australians initiating prescription opioids from July 2013 to December 2015 was conducted using data from a random 10% sample of people who accessed medicines through Australia's Pharmaceutical Benefits Scheme. A 12-month retrospective period was used to define opioid initiation, exclude people with cancer and determine comorbidities. Persistent use over 12 months since initiation was identified through group-based trajectory modelling. Odds ratios (OR) and 95% confidence intervals (CIs) for predictors of opioid persistence were estimated using logistic regression.

RESULTS

The cohort consisted of 431 963 people without cancer who initiated opioids. A total of 11 323 (2.6%) persistent opioid users were identified. Predictors of persistence included initiation with transdermal formulations (OR 4.2, 95% CI 3.9-4.5), or initiation with total oral morphine equivalents (OME) ≥ 750 mg (3.7, 3.3-4.1), having depression (1.6, 1.5-1.7) or psychotic illness (2.0, 1.9-2.2). Previous dispensing of paracetamol (2.0, 1.9-2.1), pregabalin (2.0, 1.8-2.1) and benzodiazepines (1.53, 1.4-1.6) predicted persistence. Compared to people aged 18-44 years, those ≥75 years were 2.5 (2.3-2.6) times more likely to be persistent users.

CONCLUSIONS

Patient-specific characteristics (older age, prior history of mental health comorbidities and use of non-opioid analgesics) and prescriber choice of initial opioid (transdermal formulation and higher total OMEs) were found to strongly predict persistent use. This information may help prescribers target monitoring and early intervention efforts in order to prevent harms associated with the long-term use of opioids.

Pain Therapy Guided by Purpose and Perspective in Light of the Opioid Epidemic

Prescription opioid misuse is an ongoing and escalating epidemic. Although these pharmacological agents are highly effective analgesics prescribed for different types of pain, opioids also induce euphoria, leading to increasing diversion and misuse. Opioid use and related mortalities have developed in spite of initial claims that OxyContin, one of the first opioids prescribed in the USA, was not addictive in the presence of pain. These claims allayed the fears of clinicians and contributed to an increase in the number of prescriptions, quantity of drugs manufactured, and the unforeseen diversion of these drugs for non-medical uses. Understanding the history of opioid drug development, the widespread marketing campaign for opioids, the immense financial incentive behind the treatment of pain, and vulnerable socioeconomic and physical demographics for opioid misuse give perspective on the current epidemic as an American-born problem that has expanded to global significance. In light of the current worldwide opioid epidemic, it is imperative that novel opioids are developed to treat pain without inducing the euphoria that fosters physical dependence and addiction. We describe insights from preclinical findings on the properties of opioid drugs that offer insights into improving abuse-deterrent formulations. One finding is that the ability of some agonists to activate one pathway over another, or agonist bias, can predict whether several novel opioid compounds bear promise in treating pain without causing reward among other off-target effects. In addition, we outline how the pharmacokinetic profile of each opioid contributes to their potential for misuse and discuss the emergence of mixed agonists as a promising pipeline of opioid-based analgesics. These insights from preclinical findings can be used to more effectively identify opioids that treat pain without causing physical dependence and subsequent opioid abuse.

Forecasting the future burden of opioids for osteoarthritis

OBJECTIVE

To quantify the current national burden of opioids for osteoarthritis (OA) pain in Australia in terms of number of dispensed opioid prescriptions and associated costs, and to forecast the likely burden to the year 2030/31.

DESIGN

Epidemiological modelling.

METHODS

Published data were obtained on rates of opioid prescribing for people with OA and national OA prevalence projections. Trends in opioid dispensing from 2006 to 2016, and average costs for common opioid subtypes were obtained from the Pharmaceutical Benefits Scheme and Medicare Australia Statistics. Using these inputs, a model was developed to estimate the likely number of dispensed opioid prescriptions and costs to the public healthcare system by 2030/31.

RESULTS

In 2015/16, an estimated 1.1 million opioid prescriptions were dispensed in Australia for 403,954 people with OA (of a total 2.2 million Australians with OA). Based on recent dispensing trends and OA prevalence projections, the number of dispensed opioid prescriptions is expected to nearly triple to 3,032,332 by 2030/31, for an estimated 562,610 people with OA. The estimated cost to the Australian healthcare system was $AUD25.2 million in 2015/16, rising to $AUD72.4 million by 2030/31.

CONCLUSION

OA-related opioid dispensing and associated costs are set to increase substantially in Australia from 2015/16 to 2030/31. Use of opioids for OA pain is concerning given joint disease chronicity and the risk of adverse events, particularly among older people. These projections represent a conservative estimate of the full financial burden given additional costs associated with opioid-related harms and out-of-pocket costs borne by patients.

Exploring coronial determination of intent for poisoning-related deaths in Australia, 2001-2013

Background

In countries like the United States and the United Kingdom, systematic variation in the classification of intent in pharmaceutical poisoning deaths have been identified between jurisdictions. This study aimed to explore whether the coronial determination of intent (unintentional, intentional, undetermined) for pharmaceutical-related poisoning deaths may have affected death rates over time and by jurisdiction in Australia.

Methods

A retrospective examination of mortality records in the National Coronial Information System (NCIS) during 1 January 2001 to 31 December 2013 was conducted. The NCIS is a national internet-based data storage and retrieval system for deaths that were notified to a coroner. Pharmaceutical deaths due to unintentional, intentional or undetermined intent were identified using the NCIS classification. Proportions of the different intent classifications and the mortality rates by intent over time were compared between jurisdictions.

Results

There were 17,895 pharmaceutical-related poisoning deaths in Australia between 2001 and 2013 that had closed cases in the NCIS. Proportions of deaths classified as unintentional (48.3–66.3%), intentional (24.7–35.9%) and undetermined (6.7–24.7%) varied significantly among Australian jurisdictions. There were significant increases in the rate of classification of unintentional poisoning for some states, and significant increases in intentional poisoning classification in Western Australia, and decreases in New South Wales and Victoria. There was no significant change in classification of undetermined intent.

Conclusions

Significant variation in classifications of intent, both between state jurisdictions and over time, may be the result of regional differences in demographics and increases in prescription drug misuse. However, the inconsistent use of ‘undetermined’ intent between state jurisdictions suggests coroners may experience varying difficulty in retrospectively ruling on intent in the equivocal circumstances of pharmaceutical poisoning. The widespread use of psychological autopsy may assist coroners to classify intent, while the implementation of new classifications for pharmaceutical poisoning death may overcome some of the inherent difficulty in intent classification and improve the potential for injury surveillance irrespective of intent.

Evaluation of a targeted prescriber education intervention on emergency department discharge oxycodone prescribing

OBJECTIVES

The objective of this study was to evaluate the impact of an educational intervention on ED discharge opioid analgesic (OA) prescribing.

METHODS

A brief, one-on-one, educational intervention was delivered to ED OA prescribers by an ED clinical champion. The percentage of patients receiving (i) written advice regarding appropriate oxycodone use, (ii) written or verbal advice regarding appropriate post-discharge follow up and (iii) written general practitioner notification that oxycodone had been prescribed were determined pre- and post-intervention, through review of electronic patient records and structured patient telephone interviews conducted 3-7 days after ED attendance. Secondary outcomes included total amount prescribed and use of non-OA therapies. ED OA prescribers were surveyed to evaluate perceived effectiveness and intervention acceptability.

RESULTS

A total of 30 ED OA prescribers received the 5-min intervention. Pre- and post-intervention, 80 and 81 patients were interviewed, respectively. Percentage of patients given written OA information increased from 10% to 22% (P = 0.04) and those receiving follow-up advice increased from 61 to 94% (P < 0.01). General practitioner notification of OA prescription increased from 15% to 88% (P < 0.01). Risk ratio for achieving all three end-points was 7.5 (95% confidence interval 1.8-32, P = 0.01). Median total amount of oxycodone prescribed/patient decreased from 100mg to 50mg (P = 0.04). Non-OA therapies were used by 49% of pre-intervention and 85% of post-intervention patients (P = <0.01). All ED OA prescribers agreed the intervention would change their prescribing practices; 70% deemed the intervention appropriate for delivery in their work environment.

CONCLUSION

A brief, one-on-one educational intervention targeting ED OA prescribers was well received by clinicians and associated with improved quality of OA prescribing.

Determination of oxycodone and its major metabolites noroxycodone and oxymorphone by ultra-high-performance liquid chromatography tandem mass spectrometry in plasma and urine: application to real cases

Background:

Oxycodone is a narcotic drug widely used to alleviate moderate and severe acute and chronic pain. Variability in analgesic efficacy could be explained by inter-subject variations in plasma concentrations of parent drug and its active metabolite, oxymorphone. To evaluate patient compliance and to set up therapeutic drug monitoring (TDM), an ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) assay was developed and validated for the parent drug and its major metabolites noroxycodone and oxymorphone.

Methods:

Extraction of analytes from plasma and urine samples was obtained by simple liquid-liquid extraction. The chromatographic separation was achieved with a reversed phase column using a linear gradient elution with two solvents: acetic acid 1% in water and methanol. The separated analytes were detected with a triple quadrupole mass spectrometer operated in multiple reaction monitoring (MRM) mode via positive electrospray ionization (ESI).

Results:

Separation of analytes was obtained in less than 5 min. Linear calibration curves for all the analytes under investigation in urine and plasma samples showed determination coefficients (r

Conclusions:

Rapid extraction, identification and quantification of oxycodone and its metabolites both in urine and plasma by UHPLC-MS/MS assay was tested for its feasibility in clinical samples and provided excellent results for rapid and effective drug testing in patients under oxycodone treatment.

Initiation of strong prescription opioids in Australia: cohort characteristics and factors associated with the type of opioid initiated

AIMS

To describe the characteristics of Australians initiating strong opioids and examine the factors associated with the type of opioid initiated.

METHODS

Pharmaceutical Benefits Scheme dispensing records were extracted for a 10% sample of people who initiated a strong opioid treatment episode (buprenorphine, fentanyl, hydromorphone, morphine, oxycodone) between 29 September 2009 and 31 December 2013, as evidenced by the absence of a strong opioid dispensing for at least 90 days. The cohort was restricted to people with complete medicines ascertainment. Socio-demographic characteristics, previous dispensing histories and index opioid use were examined. Multinomial logistic regression was used to calculate adjusted relative risk ratios (aRRRs) and 95% confidence intervals (CIs) to determine the factors associated with the type of opioid medicine initiated, relative to oxycodone.

RESULTS

The cohort consisted of 125 335 people: 58.3% were female and 63.7% were aged ≥65 years. The most commonly initiated strong opioid was oxycodone (72.8%), usually 5 mg immediate-release tablets (76.1%). Compared to people aged 18-44 years, those ≥85 years were 14.18 times as likely (95% CI 12.67-15.87) to initiate morphine than oxycodone. Compared to people without a cancer treatment history, those with a cancer treatment history were 2.34 times as likely (95% CI 2.11-2.60) to initiate morphine than oxycodone.

CONCLUSIONS

The most commonly initiated strong opioid was oxycodone, usually at lower strengths. Those who initiated oxycodone were more likely to be younger with no previous cancer treatment history. As these are high-risk characteristics for potential harms, a judicious approach when initiating strong opioids for this group is necessary.

Pharmacokinetic and pharmacodynamic evaluation of oxycodone and naltrexone for the treatment of chronic lower back pain

INTRODUCTION

Chronic low back pain (CLBP) is a common and difficult illness to manage. Some individuals with CLBP have pain processing disorders and are also at risk for opioid abuse, misuse; addiction and diversion. Guidelines have been published to guide management; neuromodulation, exercise, mindfulness-based stress reduction and cognitive behavior therapies among other non-pharmacological reduce the pain of CLBP with minimal toxicity. Pharmacological management includes acetaminophen, NSAIDs and antidepressants, mainly duloxetine. Abuse-deterrent opioids have been developed which have been shown to reduce pain and opioid abuse risk. ALO-02 is a tamper-resistant sustained release opioid consisting of extended release oxycodone and sequestered naltrexone. Pivotal studies of ALO-02 have centered on patients with CLBP.

AREAS COVERED

This manuscript will review CLBP, the pivotal analgesic and clinical abuse potential studies of ALO-02. The opinion will cover whether opioids should be used for CLBP, when they should be used and opioid choices.

EXPERT OPINION

ALO-02 is one of several opioids which can be considered in the management of CLBP. The outcome to a trial of opioids should be function rather than analgesia. Most analgesic trials for CLBP have had analgesia as the primary outcome and function has not been vigorously studied as an outcome. Opioids should be considered as a trial only when other non-opioid analgesics have failed to improve analgesia and function. Universal precautions should be routinely part of phase III analgesic trial particularly for chronic non-malignant pain.

Dealing with drug-seeking behaviour

People who misuse prescription drugs most commonly seek prescriptions for opioids and benzodiazepines. Other prescription drugs that are misused include the newer antipsychotics such as quetiapine and olanzapine, and stimulants such as dexamphetamine and methylphenidate. Health professionals should be aware of behaviours that may indicate drug seeking, but dependency on prescription drugs can occur at any age, within any cultural group and across any educational class. Patients with dependencies may not necessarily display obvious drug-seeking behaviours. All general practices should have a practice policy on prescribing drugs of dependence. GPs should register with the Prescription Shopping Information Service. There is strong evidence in Australia of increasing harms from prescription drugs of dependence, including deaths from overdose. Before prescribing any drug of dependence, health professionals require an understanding of the patient's biopsychosocial status, and the evidence-based indications and potential significant harms of these drugs.

Drug diversion

Prescription drug diversion has significant health, legal and social implications. Deaths from misuse of prescription drugs account for a significant proportion of overdose deaths. The drugs most commonly involved are analgesics, particularly opioids, and psychoactive drugs, particularly benzodiazepines. Diverted drugs are most often sourced from a family member or friend, but are also sourced from overseas pharmacies or laboratories, or bought from drug dealers. Drug diversion can be mitigated by good prescribing practices. Systems for monitoring the prescribing and dispensing of medicines are being instituted across Australia.