Nonmedical opioid use and heroin use in a nationally representative sample of us high school seniors

Posterior spinal fusion for adolescent idiopathic scoliosis and the impact of postoperative intravenous dexamethasone supplementation

Postoperative care pathways for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion have demonstrated decreases in postoperative opioid consumption, improved pain control, and lead to decreased lengths of stay. Our objective was to implement postoperative steroids to reduce acute postoperative opioid consumption, pain scores, and length of stay. Dosing consisted of intravenous dexamethasone 0.1 mg/kg up to 4 mg per dose for a total of three doses at 8, 16, and 24 h postoperatively. As part of a quality initiative, we compared three cohorts of patients. The initial retrospective epidural cohort (EPI) (n = 59) had surgeon placed epidural catheters with infusion of ropivacaine 0.1% postoperatively for 18-24 h. Following an institutional change in postoperative care, epidural use was discontinued. A second cohort (n = 149), with prospectively collected data, received a surgeon placed erector spinae plane block and wound infiltration with a combination of liposomal and plain bupivacaine (LB). A third cohort (n = 168) was evaluated prospectively. This cohort received a surgeon placed erector spinae plane block and wound infiltration with liposomal and plain bupivacaine and additionally received postoperative dexamethasone for three doses (LB + D). Compared to the LB cohort, the LB + D cohort demonstrated statistically significant decreases in oral milligram morphine equivalents per kilogram at 0-24, 24-48, and 48-72 h. There was a statistically significant difference in median pain scores at 24-48 and 48-72 h in LB + D versus LB. The LB + D cohort's median length of stay in hours was significantly less compared to the LB cohort (52 h vs. 70 h, p < 0.0001). Postoperative intravenous dexamethasone was added to an established postoperative care pathway for patients undergoing posterior spinal fusion for idiopathic scoliosis resulting in decreased VAS pain scores, opioid consumption, and shorter length of stay.

Prescription drug monitoring programs and prescription pain medication misuse among U.S. high school students-2019

BACKGROUND

Prescription drug monitoring programs (PDMPs) are state-level databases that track and inform prescribing practices to reduce prescription drug diversion and misuse. To our knowledge, only three studies have examined the impact of PDMPs on opioid-related outcomes among adolescents, and none have focused on prescription pain medication misuse among adolescents.

METHODS

This study leveraged data from the 2019 National Youth Risk Behavior Survey (YRBS) to explore the associations between five categories of PDMP dimensions and the prevalence of self-reported prescription pain medication misuse. Demographic factors' associations with self-reported prescription pain medication misuse were also examined.

RESULTS

In 2019, none of the PDMP dimensions were associated with self-reported prescription pain medication misuse among U.S. high school students, adjusting for gender, grade, race/ethnicity, and sexual orientation.

CONCLUSIONS

None of the five PDMP dimensions were associated with lower prescription pain medication misuse, however further research is needed, especially as new YRBS data become available.

Examining the Critical Need for Tailored Adolescent Opioid Education: A National Study

OBJECTIVE

Prescription opioid education can be a preventative measure for opioid misuse. However, most research focuses on adult perspectives rather than adolescents. This study aimed to understand adolescents' attitudes, perceptions, knowledge about prescription opioids, and preferences and prior educational exposure to opioid safety.

METHODS

Data were collected from November to December 2020. Quota sampling through Qualtrics was used to recruit a national sample of 13- to 18-year-old adolescents who lived in the United States and could understand English.

RESULTS

A total of 774 responses were analyzed. The most frequently reported source of opioid information was speaking with parents (72%). More than half (54.7%) of participants preferred technology-based education. Participants with a personal history of opioid prescription scored no differently on safe handling and storage of opioids. There was a strong relationship between participants who reported prior knowledge of what opioids are and stopping their friend from using an opioid medication for non-medical purposes (χ2 (1, N = 684) = 3.5; p = 0.042). Participants with prior education on opioid disposal did not know that -returning opioids to the pharmacy was correct (χ2 (1, N = 425) = 3.8; p = 0.254).

CONCLUSIONS

Participants were less knowledgeable about safe storage and disposal of opioids, preferred technology-based education, and were extremely likely to talk to their parents about opioid information. Findings reaffirm the significance of opioid safety education and communication between adolescents and parents. Adolescent demographic characteristics, preferences, and prior knowledge should be considered when providing opioid safety education.

Outpatient Opioid Prescriptions are Associated With Future Substance Use Disorders and Overdose Following Adolescent Trauma

OBJECTIVE

This study aims to determine if outpatient opioid prescriptions are associated with future SUD diagnoses and overdose in injured adolescents 5 years following hospital discharge.

SUMMARY OF BACKGROUND DATA

Approximately, 1 in 8 adolescents are diagnosed with an SUD and 1 in 10 experience an overdose in the 5 years following injury. State laws have become more restrictive on opioid prescribing by acute care providers for treating pain, however, prescriptions from other outpatient providers are still often obtained.

METHODS

This was a retrospective cohort study of patients ages 12-18 admitted to 2 level I trauma centers. Demographic and clinical data contained in trauma registries were linked to a regional database containing 5 years of electronic health records and prescription data. Regression models assessed whether number of outpatient opioid prescription fills after discharge at different time points in recovery were associated with a new SUD diagnosis or overdose, while controlling for demographic and injury characteristics, and depression and posttraumatic stress disorder diagnoses.

RESULTS

We linked 669 patients (90.9%) from trauma registries to a regional health information exchange database. Each prescription opioid refill in the first 3 months after discharge increased the likelihood of new SUD diagnoses by 55% (odds ratio: 1.55, confidence interval: 1.04-2.32). Odds of overdose increased with ongoing opioid use over 2-4 years post-discharge ( P = 0.016-0.025).

CONCLUSIONS

Short-term outpatient opioid prescribing over the first few months of recovery had the largest effect on developing an SUD, while long-term prescription use over multiple years was associated with a future overdose.

Mortality during Resource Booms and Busts

Using national data on county-level mortality, coal mining, and shale development, we examine the effects of resource booms and busts on mortality in the United States. We find evidence that decreases in operating coal mines increased total all-cause mortality, non-drug mortality, and opioid overdose mortality, especially for counties with greater than 10 operating coal mines in 2000. Our model results for drug overdose mortality and opioid overdose mortality are sensitive to the panel's start year. For shale development, the shale boom is associated with increases in non-drug suicides but otherwise had little impact on mortality. Our findings suggest a potential role for job-training programs and the cultivation of local healthcare resources in regions suffering coal busts and suicide prevention in areas with shale development.

Longitudinal trajectories of prescription opioid misuse in adolescents

BACKGROUND

Adolescent misuse of prescription opioids is hazardous. This study aimed to generate data on prescription opioid misuse trajectories across adolescence and identify risk factors and mechanisms for more dangerous use trajectories.

METHODS

Using a prospective longitudinal cohort repeated measures design, baseline (Fall 2013) and seven semiannual assessments were administered through Spring 2017 in 10 public high schools in Los Angeles, CA. Frequency of past 30-day prescription opioid misuse was captured. Trajectory groups were identified using growth mixture modeling and multinomial logistic regression identified associations between baseline risk factors with membership in each trajectory group.

RESULTS

Overall, 3395 students were evaluated (53.4% female, Mean [SD] age at baseline=14.58[0.40]; range=12.83-16.29). Four discrete misuse trajectories were identified among 1062 students: (1) Minimal/Experimental (infrequent time-limited use; range of estimated mean number of days using prescription opioid across waves=0.0-0.6 days]; N = 705[20.8%]); (2) Low Deescalating (range=2.0-0.7 days; N = 189[5.6%]); (3) Moderate Escalating (range=0.7-3.6 days; N = 108[3.2%]); and (4) Frequent Persistent (range=4.7-9.4 days; N = 60[1.8%]). Students reporting tobacco, cannabis, alcohol use, or impulsivity in 9th grade were more likely to demonstrate membership in the Moderate Escalating trajectory class when compared to 2333 (68.7%) students reporting sustained abstinence. Female sex, peer opioid misuse, alcohol use, other substance use, impulsivity, or delinquent behavior reported in 9th grade was associated with membership in the Frequent Persistent trajectory class.

CONCLUSIONS

Prescription opioid misuse in adolescence appears to follow 4 discrete trajectories, including the potentially problematic Moderate Escalating and Frequent Persistent trajectories. Female sex, peer influences, substance use, and intrapersonal risk factors were associated with membership in these classes.

Addressing opioid medication misuse at point of service in community pharmacy: A study protocol for an interdisciplinary behavioral health trial

BACKGROUND

>1 in 3 of the 9 million individuals engaged in opioid medication misuse obtain legitimate opioid prescriptions and fill these in community pharmacies, which are subsequently misused. This study is testing the efficacy of a pharmacist-led intervention-Brief Intervention-Medication Therapy Management (BI-MTM)-compared to standard medication counseling (SMC) to address opioid medication misuse.

METHODS

Design. This study is a single-blinded 2-group parallel randomized trial within 13 community pharmacies that will enroll 350 individuals. Participant Recruitment. Pharmacy staff approach patients and ask about interest in completing a brief confidential screening tool, which includes opioid medication misuse assessment. Interested patients who report misuse are asked to provide informed consent. Enrolled patients are assessed for behavioral and physical health at enrollment, 2-months post-enrollment, and 6-months post-enrollment.

INTERVENTIONS

Following baseline assessment, participants are randomized (1:1 ratio) to: SMC, a medication information/counseling intervention or BI-MTM, an intervention comprised by 4 evidence-based components: medication therapy management, brief intervention, naloxone dispensing, and patient navigation.

ANALYSES

Primary analyses involve estimating 3-level generalized linear mixed models to relate repeated assessments across time of opioid medication misuse (i.e., the Prescription Opioid Misuse Index) to the intervention.

CONCLUSION

Study results will provide the first critical step towards integrating a highly accessible, low-cost approach to managing risks related to opioid use. Community pharmacies provide an incredibly important setting in which patients can receive high quality care to support health behavior change. Successfully completing this project sets the stage for a large-scale effectiveness study. (NCT#: NCT05141266).

Polysubstance Overdose Deaths in the Fentanyl Era: A Latent Class Analysis

OBJECTIVES

To elucidate the main latent classes of substances detected among overdose decedents, and latent class associations with age, sex, race, and jurisdiction of death in Maryland.

METHODS

We used toxicology data from the Office of the Chief Medical Examiner of Maryland for all decedents. We analyzed all cases of drug overdose deaths that occurred from 2016 to 2018 (N = 6566) using latent class analysis and regression.

RESULTS

Drug overdose deaths were concentrated in 2 of 24 counties in Maryland (Baltimore City and County). Fentanyl was involved in 71% of all drug overdose deaths, and the majority (76%) of these deaths included multiple substances. Three latent classes emerged: (1) fentanyl/heroin/cocaine (64%); (2) fentanyl/alcohol (18%); and (3) prescription drugs including opioids, benzodiazepines and antidepressants (18.0%). The fentanyl/heroin/cocaine class members were significantly younger (<30 years), female and White compared to the fentanyl/alcohol class, but more male and non-White than the prescription drugs class (all P < 0.05). Deaths in Baltimore City/County were more likely than in other locations to involve fentanyl/alcohol (P < 0.05).

CONCLUSIONS

The majority of fentanyl-involved overdose deaths in Maryland involved multiple substances, and several demographic and geographic differences in these patterns emerged. Geographically-targeted interventions that are tailored to reduce the harms associated with polysubstance use (including cocaine, alcohol, and prescription drugs) for different demographic groups are warranted.

Cumulative protective factors are associated with decreased risk for prescription opioid misuse among high school students

BACKGROUND

Multiple protective factors at the individual and environmental levels have been associated with prescription opioid misuse (POM) among adolescents. The literature may benefit by extending this research to consider the association between cumulative protective factors and current (ie, within the past 30 days) POM.

METHODS

The 2017 Virginia Youth Survey (part of the Youth Risk Behaviour Surveillance System) (N=3697) was used to investigate recent POM and the presence of individual and cumulative protective factors among high school students. Youth were asked to indicate whether they had engaged POM within the past 30 days. A set of protective factors representing youths' internal assets (eg, aspirational plans for education) and external resources (eg, family meals, safe school environment) were investigated as predictors of current POM, followed by testing of a cumulative protective factor score. Logistic regression models estimated ORs and 95% CIs.

RESULTS

When including demographics and risk factors in the model, none of the individual protective factors were significantly associated with current POM. Alternatively, the cumulative protective factor score was significantly associated with a decrease in the odds of current POM.

CONCLUSIONS

The cumulative protective factor score was significantly associated with a decrease in the odds of current POM among high school students in Virginia. Programmes designed to provide multiple forms of support may be effective strategies for preventing current POM.

Post-Procedural Opioid Prescribing in Children: A Survey of the American Academy of Pediatrics

INTRODUCTION

North America is in the midst of an opioid epidemic. The role of pediatric surgeons and other procedural specialists in this public health crisis remains unclear. There is likely considerable variation in the use of opioid and non-opioid analgesics, but the spectrum of practice is still uncertain.

METHODS

We performed an online survey in July 2018 of the 2086 pediatric surgeons and proceduralists who were active members in the American Academy of Pediatrics. The survey inquired about practice environment, use of opioid and non-opioid pain medications, and attitudes towards the opioid epidemic.

RESULTS

178 specialists completed the survey for a response rate of 8.5%. Most respondents utilize oral acetaminophen (86%) and ibuprofen (80%) after procedures >75% of the time. Self-reported opioid prescribing increases with age after both outpatient and inpatient procedures (P < 0.001). Pediatric general surgeons prescribe opioids less frequently than other specialists, particularly after inpatient procedures. The majority of respondents (81%) believe that the opioid epidemic is a major problem but only 31% indicated that they have a major role to play.

CONCLUSIONS

There is significant variation in opioid prescribing patterns as reported by pediatric surgeons and proceduralists. Guidelines are needed to standardize the use of non-opioid analgesics and decrease reliance on opioids for outpatient and inpatient procedures.

Emergency department strategies to combat the opioid crisis in children and adolescents

The opioid crisis has greatly affected not only adults but also children as well. As clinicians develop effective approaches to minimize pain and distress in children, the risks and benefits of opioids must be carefully considered. Children of parents with opioid use disorder are also at risk of living in unstable environments, performing poorly academically, engaging in future drug use, and having increased stress, which affects their development before entering adulthood. This statement focuses on the effects of the opioid crisis on children and adolescents and is intended to inform institutional policies, improve education, advocate for evidence-informed guidelines, and improve the care of children affected by the opioid epidemic who are seen in the emergency department.

Social-Ecological Predictors of Opioid Use Among Adolescents With Histories of Substance Use Disorders

Adolescent opioid misuse is a public health crisis, particularly among clinical populations of youth with substance misuse histories. Given the negative and often lethal consequences associated with opioid misuse among adolescents, it is essential to identify the risk and protective factors underlying early opioid misuse to inform targeted prevention efforts. Understanding the role of parental risk and protective factors is particularly paramount during the developmental stage of adolescence. Using a social-ecological framework, this study explored the associations between individual, peer, family, community, and school-level risk and protective factors and opioid use among adolescents with histories of substance use disorders (SUDs). Further, we explored the potential moderating role of poor parental monitoring in the associations between the aforementioned risk and protective factors and adolescent opioid use. Participants included 294 adolescents (M _age = 16 years; 45% female) who were recently discharged from substance use treatment, and their parents (n = 323). Results indicated that lifetime opioid use was significantly more likely among adolescents endorsing antisocial traits and those whose parents reported histories of substance abuse. Additionally, adolescents reporting more perceived availability of substances were significantly more likely to report lifetime opioid use compared to those reporting lower perceived availability of substances. Results did not indicate any significant moderation effects of parental monitoring on any associations between risk factors and lifetime opioid use. Findings generally did not support social-ecological indicators of opioid use in this high-risk population of adolescents, signaling that the social-ecological variables tested may not be salient risk factors among adolescents with SUD histories. We discuss these findings in terms of continuing care options for adolescents with SUD histories that target adolescents' antisocial traits, perceived availability of substances, and parent histories of substance abuse, including practical implications for working with families of adolescents with SUD histories.

"People Don't Just Start Shooting Heroin on Their 18th Birthday": A Qualitative Study of Community Stakeholders' Perspectives on Adolescent Opioid Use and Opportunities for Intervention in Baltimore, Maryland

Initiation of non-medical prescription opioid use (NMPO) during early adolescence is tightly linked to heroin and other drug use disorders and related sequelae in later adolescence and young adulthood. Few studies explore stakeholders’ perspectives on the burden and determinants of youth opioid use and barriers and facilitators to engaging youth in opioid use prevention and treatment services in urban settings with longstanding opioid epidemics. In-depth interviews were conducted with 22 stakeholders representing health and social service agencies in Baltimore, Maryland from May 2018- February 2019, to examine their perspectives on the burden and context of adolescent opioid use and identify barriers and facilitators to preventing and responding to adolescent opioid use. Transcripts were analyzed using the constant comparison method to identify themes. Most respondents described a recent uptick in opioid use independently, and in combination with other substances. As compared to heroin, NMPO was perceived to be more frequently used and less stigmatized among youth. Stakeholders perceived the process of transitioning from using NMPO to heroin as more common among White vs. Black youth and was perceived as occurring faster among White vs. Black youth. Some stakeholders believed racial differences in internal stigma against heroin use, and differential health service use among Black youth and White youth may have influenced these differences. Trauma and poverty were noted determinants of youth opioid use. Barriers to service provision included youth cognitive development, stigma and structural factors (e.g., disinvestment, lack of youth-centered and integrated services). Stakeholders perceive prevalent NMPO among Baltimore youth and identify multilevel barriers to delivering prevention, treatment and harm reduction services to this population. These findings encourage further investigation of determinants and consequences of opioid use among diverse racial/ethnic groups of youth in urban settings, and development of multilevel, youth-driven and youth-centered approaches to prevention and treatment.

Diffuse subcortical white matter injury and bilateral basal ganglia neuronal loss after acute opioid overdose

Opiate intoxication has been associated with life-threatening effects of sympathetic suppression and respiratory depression, but current literature is limited in describing its neurotoxic effects on the central nervous system. Here, we present the case of an otherwise high-functioning adolescent male who was found unresponsive after ingestion of approximately 3-4 fake oxycodone 10-325 mg pills laced with fentanyl. Magnetic resonance imaging showed evidence of diffuse T2 hyperintensities in the corpus callosum and bilateral frontal, parietal, and cerebellum indicative of diffuse white matter injury. In addition, there were distinct areas of restricted diffusion in the bilateral basal ganglia concerning for oxidative stress-mediated neuronal loss. His neurological exam improved with supportive treatment over the course of his hospitalization. Although limited literature has shown leukoencephalopathy to be associated with opioid overdose, we present a case of additional involvement of subcortical gray matter.

Initiation of nonmedical use of prescription opioids among high school students

Background: Nonmedical use of prescription opioids (NUPO) is associated with heroin use and other adverse outcomes among adolescents. To inform the timing of substance use prevention activities and which substances to target, we examined age at NUPO initiation, associations between substance use initiation and current (past 30-day) NUPO, and order of NUPO initiation relative to other substances. Methods: Data from 2,834 students aged 15 or older participating in the 2017 Virginia Youth Survey, the first Youth Risk Behavior Surveillance System survey to assess age at NUPO initiation and current NUPO, were analyzed in 2019. Students reported current NUPO and ages at initiation for cigarettes, alcohol, marijuana, and NUPO (categorized as 12 or younger, 13 or 14, 15 or older, or never). Associations between age at substance use initiation and current NUPO were examined using adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs). Results: Overall, 12% of students reported lifetime NUPO, with 2.4%, 4.0%, and 5.6% initiating at 12 or younger, 13 or 14, and 15 or older, respectively; 5.3% reported current NUPO. Initiating cigarettes, alcohol, and marijuana at each age category (compared with never) was associated with an increased prevalence of current NUPO after adjusting for demographics and initiation of other substances. Among students initiating NUPO, initiating NUPO at 12 or younger (compared with 15 or older) was associated with an increased prevalence of current NUPO after adjusting for demographics (aPR = 1.54, 95% CI: 1.10-2.16), but not after further adjustment for initiation of other substances (aPR = 1.38, 95% CI = 0.97-1.97). Among students initiating NUPO, 45.4% initiated NUPO before or during the same age as other substances. Conclusions: More than 6% of students initiated NUPO at 14 or younger. Younger substance use initiation was associated with current NUPO, suggesting that some students may benefit from prevention activities during early adolescence that address multiple substances.

Opioid use at the transition to emerging adulthood: A latent class analysis of non-medical use of prescription opioids and heroin use

BACKGROUND

Although rates of nonmedical opioid use are highest in late adolescence and emerging adulthood, efforts to understand the extent of the heterogeneity in opioid misuse during this time have been limited. The current study aimed to derive and define typologies of opioid use in high school students at the onset of emerging adulthood.

METHODS

Survey responses from a statewide sample of high school students aged 18 and 19 (N = 26,223) were analyzed. Group-based comparisons between participants reporting opioid use and those not reporting opioid use were conducted. Among those reporting opioid use (n = 1,636), we conducted a latent class analysis (LCA) to identify heterogeneous subgroups of opioid users on the basis of non-medical use of prescription opioids (NMUPO) and heroin use. The resulting classes were then compared across various risk and protective factors using multinominal logistic regression.

RESULTS

Consistent differences were observed between participants using opioids and participants not using opioids, with moderate to large effect sizes. Results from LCA revealed three subclasses: NMUPO-Any Use, NMUPO To Get High, and Heroin Use. Subclass differences were observed for non-opioid substance use, mental health, and demographics.

CONCLUSIONS

Findings from this study underscore the variability of youth who engage in opioid use in late adolescence. Results also indicate that opioid use during adolescence is likely indicative of a broader set of substance use and mental health issues.

Evaluating the Effectiveness of a Web-Based Program (POP4Teens) to Prevent Prescription Opioid Misuse Among Adolescents: Randomized Controlled Trial

Background

Prescription opioid (PO) use is common among adolescents in the United States. Despite recent declines from unprecedented peaks in adolescent PO use (eg, in 2012-2013), there is seemingly paradoxical evidence that PO-related consequences (eg, opioid use disorder and overdoses) are increasing. These trends and their possible consequences emphasize the importance of prevention efforts targeting PO misuse. To our knowledge, we have developed the first interactive web-based program (POP4Teens [P4T]) focused specifically on the prevention of PO misuse among adolescents.

Objective

This study aimed to evaluate the effectiveness of P4T, a web-based program designed to prevent adolescent PO misuse, in comparison with JustThinkTwice (JTT), an active control website, on PO-related attitudes, knowledge, risk perception, and intentions to use.

Methods

We conducted a web-based randomized controlled trial in 2018. A total of 406 adolescents (aged 12-17 years) were randomly assigned to either P4T or JTT. The outcome variables were attitudes, knowledge, and risk perceptions associated with PO misuse, intentions to use POs, and program feedback. Data were collected at baseline and at 1, 3, and 6 months.

Results

Both programs resulted in significant and sustained improvements in intention to use POs, increased perceived risk, impacted expectancies consistent with prevention, and improved PO refusal skills. P4T produced significantly greater increases in PO-related knowledge than JTT did, and it was reportedly easier to use and more liked. Baseline scores for youth reporting past-year medical use of POs, friends who engage in nonmedical use of POs, and/or poor mental health underscored their at-risk status compared with youth from the other groups.

Conclusions

P4T positively impacted all study variables that are known to prevent PO misuse among teens. Moreover, its web-based nature simplifies the dissemination and implementation of this novel tool designed to help meet the challenges of the evolving national opioid crisis.

Trial Registration

ClinicalTrials.gov NCT02737696; https://clinicaltrials.gov/ct2/show/NCT02737696

Functional connectivity of posterior cingulate gyrus in heroin dependents treated by methadone maintenance and protracted abstinence measures: an event-related fMRI study

Protracted abstinence (PA) and Methadone maintenance treatment (MMT) are two main types of heroin addiction treatment, however, the effects of both measures on the functional connectivity (FC) of the brain in heroin dependents in the drug cue event-related response are unclear. Functional magnetic resonance imaging (fMRI) based drug cue-reactivity task has been widely used in addiction research, which may provide a new way to understand the change of brain function during a certain period of treatment. The default function network (DMN) with posterior cingulate cortex (PCC) as the core is generally involved in the process of addiction. The aim of the present study was to explore the brain response of FC in patients with heroin-dependent during PA, MMT treatment under task-fMRI. Twenty-two heroin-dependent patients during PA, 18 heroin-dependent patients during MMT and 16 healthy control (HC) individuals were included to conduct the heroin cue-reactivity task during fMRI. The MMT and PA patients' subjective craving for heroin was evaluated. The psychophysiological interaction (PPI) analysis of SPM12 was used to get FC during the task state. There was a significant difference on FC between PCC and the right medial Prefrontal Cortex (mPFC) in three groups. The post-hoc analysis showed that there was a significant difference of brain regions between the MMT and the PA group. The FC of PCC-mPFC in the MMT group was significantly stronger than that in the PA group. Compared with the PA group, the FC of the DMN in the MMT group was significantly increased under drug cue response. Therefore, PA is more beneficial for the heroin-dependent patients to lower the salience value of drug related cues, in turn to reduce relapse risks. It also reflected the important role of PCC-mPFC pathway in heroin dependents induced by heroin cues.

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

IMPORTANCE

Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

OBJECTIVE

To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

EVIDENCE REVIEW

Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

FINDINGS

Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

CONCLUSIONS AND RELEVANCE

These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.

Situating the Continuum of Overdose Risk in the Social Determinants of Health: A New Conceptual Framework

Policy Points This article reconceptualizes our understanding of the opioid epidemic and proposes six strategies that address the epidemic's social roots. In order to successfully reduce drug-related mortality over the long term, policymakers and public health leaders should develop partnerships with people who use drugs, incorporate harm reduction interventions, and reverse decades of drug criminalization policies.

CONTEXT

Drug overdose is the leading cause of injury-related death in the United States. Synthetic opioids, predominantly illicit fentanyl and its analogs, surpassed prescription opioids and heroin in associated mortality rates in 2016. Unfortunately, interventions fail to fully address the current wave of the opioid epidemic and often omit the voices of people with lived experiences regarding drug use. Every overdose death is a culmination of a long series of policy failures and lost opportunities for harm reduction.

METHODS

In this article, we conducted a scoping review of the opioid literature to propose a novel framework designed to foreground social determinants more directly into our understanding of this national emergency. The "continuum of overdose risk" framework is our synthesis of the global evidence base and is grounded in contemporary theories, models, and policies that have been successfully applied both domestically and internationally.

FINDINGS

De-escalating overdose risk in the long term will require scaling up innovative and comprehensive solutions that have been designed through partnerships with people who use drugs and are rooted in harm reduction.

CONCLUSIONS

Without recognizing the full drug-use continuum and the role of social determinants, the current responses to drug overdose will continue to aggravate the problem they are trying to solve.

The Role of Social Skills in the Prevention of Drug Addiction in Adolescents

Background:

Substance abuse has turned into a great problem in the worldwide. Considering the increased prevalence of addiction in this study, we tried to assess the role of social skills aspects in tendency to addiction among the adolescents.

Materials and Methods:

This cross-sectional study was conducted on 600 high school students studying in the Isfahan City, Iran, from 2016 to 2018. The studied population was assessed using addiction tendency questionnaire and Matson's social skills questionnaire. Data were analyzed by Statistical Package for the Social Sciences software and independent t-test, Pearson and Spearman correlation, and linear regression test.

Results:

Social behavior (P = 0.002, r = −0.124), high self-esteem (P < 0.001, r = −0.381), and peer-communication (P < 0.001, r = −0.361) were inversely associated with a tendency to addiction and were independent predictors of it (P < 0.05). Aggression was associated with increased tendency to the addiction (P = 0.01, r = 0.103) but not a predictor.

Conclusion:

We found that appropriate social behaviors, inappropriate assertiveness, and functional communication were factors associated with less tendency to substance abuse in the adolescent.

Is South Africa being spared the global opioid crisis? A review of trends in drug treatment demand for heroin, nyaope and codeine-related medicines in South Africa (2012-2017)

INTRODUCTION

South Africa has seen a sharp increase in treatment admission trends for opioids despite beliefs that rates of opioid use remain low and do not represent a major problem. To advocate for the extension of Opioid Use Disorder (OUD) treatment and harm minimisation services in South Africa, better estimates of the extent of opioid use is needed. This paper responds to this need by describing (i) trends in treatment utilization for opioid-related problems in South Africa and (ii) differences in the profile of patients accessing treatment for different classes of opioids - heroin, 'nyaope' and codeine use.

METHODS

Data were collected from 83 specialist treatment centres participating in the South African Community Epidemiology Network on Drug Use between 2012 and 2017. Descriptive analyses were conducted to describe the sociodemographic profile of patients and multiple logistic regression was used to explore socio-demographic and clinical factors associated with admission to treatment for opioid use disorders (OUD) .

RESULTS

From January 2012 to December 2017, data from 11 2032 treatment episodes were collated. Of these, 20 319 (18.1%) were from patients admitted for an OUD. Over time, the proportion of overall opioid-related admissions increased significantly from 16.1% of all admissions in 2012 to 20.0% in 2017 (p <0.001). Data also suggests a significant increase in the overall proportion of patients reporting injection drug use, from 1.6% in 2013 to 3.5% in 2017 (p <0.001). Clear differences in employment status, referral sources between classes of opioids were also noted.

CONCLUSION

Over the last 5 years, South Africa has seen an increase in the proportion of opioid related disorders (OUD) treatment admissions. Public health interventions, evidence-based harm reduction approaches and improving access to treatment are among the interventions urgently needed to reduce the harms associated with the increased use of opioids in South Africa.

Nonmedical Use of Prescription Opioids, Heroin Use, Injection Drug Use, and Overdose Mortality in U.S. Adolescents

OBJECTIVE

We assessed overdose mortality by opioid types involved as well as interrelationships between nonmedical use of prescription opioids (NUPO) and heroin and injection drug use (IDU) among adolescents.

METHOD

We examined 2010 and 2016 overdose data by drug type for decedents in the United States ages 15-19 years from the Multiple Cause of Death Files. We also analyzed data from the 2017 National Youth Risk Behavior Survey, a nationally representative survey of high school students. We assessed lifetime NUPO and calculated heroin use and IDU by frequency of lifetime NUPO. Adjusted prevalence ratios (aPRs) were generated, and linear contrast analysis determined dose-response relationships between frequency of lifetime NUPO and the two outcomes.

RESULTS

The percentage of deaths involving prescription opioids that also involved illicit opioids such as heroin or fentanyl was 5.5% in 2010 and 25.0% in 2016. We observed a positive dose-response relationship with frequency of lifetime NUPO; aPRs were highest for 20 or more times of NUPO and heroin use (aPR = 49.49, 95% CI [33.39, 73.34]) and IDU (aPR = 44.37, 95% CI [23.16, 84.99]). However, aPRs for heroin and IDU were high even among those reporting just one or two occasions of NUPO (aPRs = 9.25, 95% CI [5.90, 14.49] and 6.63, 95% CI [3.99, 11.02], respectively).

CONCLUSIONS

Adolescent prescription opioid overdose deaths now frequently involve illicit opioids. Heroin use and IDU are higher among students reporting even a few instances of NUPO, indicating that students with any NUPO are an important risk group. Clinical, community, and school-based efforts can address NUPO, noting these associations.

Receipt of multiple outpatient opioid prescriptions is associated with increased risk of adverse outcomes in youth: opioid prescribing trends, individual characteristics, and outcomes from 2005 to 2016

Data on all outpatient opioid prescriptions (N = 71,647) to youth below age 21 (N = 42,020) from 2005 to 2016 were extracted from electronic medical records within a university hospital system in New Mexico (NM) as were demographic details and markers of morbidity/mortality. Relative risk was calculated for markers of morbidity/mortality based on sociodemographic characteristics. The sample was primarily male (55.0%), Hispanic/Latinx (50.1%), English-speaking (88.9%), and publicly insured (50.1%). Mean age was 13.54 (SD = 6.50). From 2005 to 2016, overall frequency of opioid prescriptions increased by 86.6% (from 2470 to 4610) with the largest increase (206.2%) observed from 2005 to 2008 (2470-7562). Patients who were older, white, and non-Hispanic were more likely to receive multiple opioid prescriptions. Large relative increases in morbidity and mortality were documented, although base rates remained low. The percentage of individuals within the sample who experienced an overdose increased steadily from 0 in 2005 to 1.09% in 2016. Incidence of mortality increased from 0.12% of the sample to 1.39% in 2016. The proportion of individuals who received a medication for the treatment of opioid dependence increased from 0.06% in 2005 to 0.44% in 2016. Significantly increased risk of adverse outcomes was observed in patients receiving multiple opioid prescriptions, and in patients who were older, of minority race, received their first prescription in an outpatient clinic, and publicly insured or uninsured. Results add to the growing literature concerning opioid prescription rates over time. They also provide important information on potential additive risks of adverse outcomes when pediatric patients receive multiple opioid prescriptions.

Prevalence and Health Characteristics of Prescription Opioid Use, Misuse, and Use Disorders Among U.S. Adolescents

PURPOSE

The prevalence of past-year prescription opioid use (POU), nonmedical POU (NMPOU), and POU disorder (POUD) and their correlates were examined in a national sample of American adolescents (N = 41,579).

METHODS

This study used data from the public-use files of the 2015, 2016, and 2017 National Surveys on Drug Use and Health, which captured substance use and mental health problems among noninstitutionalized individuals. Prevalence and specific types of prescription opioids and other substances used and misused in the past year were examined among adolescents. Logistic regression analyses were conducted to determine correlates (demographics, other substances used, past-year major depressive episode, school enrollment, two-parent household, number of lifetime medical conditions, and survey year) of POU, NMPOU, and POUD.

RESULTS

Multiple substance use was common within the past year. The most frequently used prescription opioids were hydrocodone, codeine, oxycodone, and other opioids among adolescents. Cannabis use disorder and alcohol use disorder were comparatively prevalent among opioid misusers. Several correlates (demographics, other substances used, lifetime medical conditions, major depressive episode, and survey year) of POU, NMPOU, and POUD were found.

CONCLUSIONS

In this national sample, multiple substance use was common among adolescents with past-year POU and NMPOU. Clinical screening for opioid use problems, assessment, and treatment expansion for POUD can focus on persons with substance use, mental health, and/or behavioral problems. Longitudinal studies are needed to better elucidate temporal associations between POU and NMPOU/POUD among adolescents, and more prevention and treatment research on rural residents and minority groups is needed.

Trends in opioid initiation among people who use opioids in three US cities

INTRODUCTION AND AIMS

The increased availability of prescription opioids (PO) and non-medical prescription opioids (NMPO) has fundamentally altered drug markets and typical trajectories from initiation to high-risk use among people who use opioids (PWUO). This multi-site study explores trends in opioid initiation in three US cities and associations with sociodemographic factors, current drug use and overdose risk.

DESIGN AND METHODS

We analysed survey data from a cross-sectional study of PWUO in Baltimore, Maryland (n = 173), Boston, Massachusetts (n = 80) and Providence, Rhode Island (n = 75). Age of first exposure to PO, NMPO and heroin was used to calculate opioid of initiation, and multinomial regression was employed to explore correlates of initiating with each.

RESULTS

Thirty-three percent of PWUO initiated with heroin, 24% with PO, 18% with NMPO and 24% with multiple opioids in their first year of use. We observed a reduction in heroin initiation and gradual replacement with PO/NMPO over time. Women were more likely to initiate with NMPO [relative risk ratio (RRR) 2.4; 95% confidence interval (CI) 1.1, 5.0], PO (RRR 2.2, 95% CI 1.1, 4.4) or multiple opioids (RRR 2.1, 95% CI 1.1, 4.2), than heroin. PWUO initiating with NMPO had significantly higher current benzodiazepine use, relative to those initiating with heroin (RRR 3.2, 95% CI 1.4, 7.4), and a high prevalence of current fentanyl use (30%).

DISCUSSION AND CONCLUSIONS

Our study highlights women and PWUO initiating with NMPO as key risk groups amid the changing landscape of opioid use and overdose, and discusses implications for targeted prevention and treatment.

Optimism and opioid misuse among justice-involved children

AIM

Adolescents in the criminal justice system, called justice-involved children (JIC), are particularly vulnerable in the modern opioid misuse (OM) epidemic. After release, relapse and overdose occur at higher rates than the general population. The current study assesses optimism and likelihood of P30D consumption of non-prescription or illicit opioids among JIC.

METHODS

The study examines a sample of 79,960 JIC from the Florida Department of Juvenile Justice. Multivariate logistic regression was employed, controlling for gender, race, family income, age, history of mental problems, history of depression, and county of residence.

RESULTS

JIC who reported very low optimism on the final screen had over 8 times the odds of meeting criteria for P30D OM compared to those with high optimism while adjusting for covariates.

CONCLUSIONS

Further research is needed to understand the potential for optimism to serve as a protective factor. Optimism can be developed, and therefore can possibly be incorporated to design novel interventions or integrated into empirically validated treatment programs to precipitate uptake.

Prescription opioid misuse among adolescents and emerging adults in the United States: A scoping review

The U.S. opioid epidemic is a critical public health problem. As substance use and misuse typically begin in adolescence and emerging adulthood, there is a critical need for prevention efforts for this key developmental period to disrupt opioid misuse trajectories, reducing morbidity and mortality [e.g., overdose, development of opioid use disorders (OUD)]. This article describes the current state of research focusing on prescription opioid misuse (POM) among adolescents and emerging adults (A/EAs) in the U.S. Given the rapidly changing nature of the opioid epidemic, we applied PRISMA Scoping Review (PRISMA-ScR) guidelines to identify empirical articles published in the past 5 years (January 2013-September 2018) from nine databases examining POM among A/EAs (ages 10-25) in the U.S. Seventy-six articles met our inclusion criteria focusing on POM in the following areas: cross-sectional surveys (n = 60), longitudinal cohort studies (n = 5), objective, non-self-reported data sources (n = 9), and interventions (n = 2). Final charted data elements were organized by methodology and sample, with results tables describing design, sample, interventions (where applicable), outcomes, and limitations. Most studies focused on the epidemiology of POM and risk/protective factors, including demographic (e.g., sex, race), individual (e.g., substance use, mental health), and social (e.g., peer substance use) factors. Despite annual national surveys conducted, longitudinal studies examining markers of initiation and escalation of prescription opioid misuse (e.g., repeated overdoses, time to misuse) are lacking. Importantly, few evidence-based prevention or early intervention programs were identified. Future research should examine longitudinal trajectories of POM, as well as adaptation and implementation of promising prevention approaches.

Prescription Opioid Misuse Among Adolescents

Although recent spikes in overdose deaths are largely attributable to heroin and fentanyl, prescription opioids still account for a significant percentage of overdose deaths. Additionally, overdose deaths are not a problem solely for adults; roughly 8% of all overdose deaths occur in persons aged 15 to 24. In addition to identifying factors that increase risk for misuse and negative outcomes among adolescents, research must examine the causal mechanisms that link these factors to increased risk. Finally, the extant research must serve as the foundation for prevention/intervention strategies and identify treatments that are effective among adolescents with opioid use disorders.

Initiation into heroin use among street-involved youth in a Canadian setting: A longitudinal cohort study

BACKGROUND

Emerging evidence suggests that non-medical prescription opioid (NMPO) use may be a risk factor for initiating heroin use; however, pathways from PO to heroin use among youth remain underexplored. We sought to examine the association between NMPO use and heroin initiation.

METHODS

Between September 2005 and June 2017 data were derived from an open prospective cohort of street-involved youth aged 14-28 who use illegal drugs in Vancouver, Canada. The study included 526 youth who had never used non-injection heroin, and 652 youth who had never used injection heroin at baseline. We used Cox proportional hazards regressions to examine the association between NMPO use - in addition to other substance use patterns - and subsequent initiation into non-injection and injection heroin use.

RESULTS

Among those who had never used non-injection heroin at baseline, 133 (25.3%) initiated non-injection heroin use during the study period. Among those who had never injected heroin at baseline, 137 (21.0%) initiated heroin injection during the study period. In multivariable analyses, NMPO use, crack use, and crystal methamphetamine use predicted non-injection heroin initiation (all p < 0.05). In separate multivariable analyses, non-injection heroin and crystal methamphetamine predicted heroin injection initiation (all p < 0.05).

CONCLUSIONS

Among street-involved youth in this setting, NMPO use predicted initiation into non-injection heroin use but not initiation into heroin injection. Interestingly, crack cocaine and crystal methamphetamine use were stronger predictors of heroin initiation than NMPO use was, suggesting that stimulant use may carry greater risks for heroin initiation than NMPO use.

A community pharmacy-led intervention for opioid medication misuse: A small-scale randomized clinical trial

BACKGROUND

Stemming the opioid epidemic requires testing novel interventions. Toward this goal, feasibility and acceptability of a Brief Motivational Intervention-Medication Therapy Management (BMI-MTM) intervention was examined along with its impact on medication misuse and concomitant health conditions.

METHODS

We conducted a two-group randomized trial in 2 community pharmacies. We screened patients for prescription opioid misuse at point-of-service using the Prescription Opioid Misuse Index. Participants were assigned to standard medication counseling (SMC) or SMC + BMI-MTM (referred to as BMI-MTM herein). BMI-MTM consists of a pharmacist-led medication counseling/brief motivational session and 8-weekly patient navigation sessions. Assessments were at baseline, 2-, and 3-months. Primary outcomes included feasibility, acceptability, and mitigation of opioid medication misuse. Secondary outcomes included pain and depression. Outcomes were analyzed with descriptive and multivariable statistics (intent-to-treat [ITT] and adjusted for number of sessions completed [NUMSESS]).

RESULTS

Thirty-two participants provided informed consent (74.4% consent rate; SMC n = 17, BMI-MTM n = 15; 3-month assessment retention ≥93%). Feasibility was demonstrated by all BMI-MTM recipients completing the pharmacist session and an average of 7 navigation sessions. BMI-MTM recipients indicated ≥4.2 (5 maximum) level of satisfaction with the pharmacist-led session, and 92.4% were satisfied with navigation sessions. Compared to SMC at 3-months, BMI-MTM recipients reported greater improvements in misuse (ITT: Adjusted Odds Ratio [AOR] = 0.13; 95% CI = 0.05, 0.35, p < 0.001.

NUMSESS

AOR = 0.05; 95% CI = 0.01, 0.25; p < 0.001), pain (ITT: В = 8.8, 95% CI=-0.95, 18.5, p = 0.08; NUMSESS: В = 14.0, 95% CI = 3.28, 24.8, p = 0.01), and depression (ITT: B= -0.44; 95% CI=-0.65, -0.22; p < 0.001.

NUMSESS

B= -0.64; 95% CI=-0.82, -0.46; p < 0.001).

CONCLUSIONS

BMI-MTM is a feasible misuse intervention associated with superior satisfaction and outcomes than SMC. Future research should test BMI-MTM in a large-scale, fully-powered trial.

Effects of CYP3A4 Polymorphisms on Drug Addiction Risk Among the Chinese Han Population

Background:Cytochrome P450 3A4 (CYP3A4) regulates pharmacokinetic and pharmacodynamic interactions during the process of drug absorption and metabolism, suggesting CYP3A4 plays an important role in drug addiction. However, the association between CYP3A4 polymorphisms and drug addiction risk is still not clear.

Methods: This case-control study included 504 drug addicts and 501 healthy controls from Xi'an, China. Four single nucleotide polymorphisms (SNP) in CYP3A4 (rs3735451, rs4646440, rs35564277, and rs4646437) were genotyped by Agena MassARRAY platform. After adjusting by age and gender, we calculated odd ratios (OR) and 95% confidence intervals (CI) by logistic regression to estimate the association between CYP3A4 polymorphisms and drug addiction risk.

Results: We found rs4646440 and rs4646437 were associated with decreased risk of drug addiction in codominant (rs4646440: OR = 0.41, 95%CI = 0.19–0.92, p = 0.030; rs4646437: OR = 0.19, 95%CI = 0.04–0.87, p = 0.032) and recessive (rs4646440: OR = 0.41, 95%CI = 0.19–0.91, p = 0.028; rs4646437: OR = 0.20, 95%CI = 0.04–0.90, p = 0.036) models. Rs3735451 and rs4646437 were associated with drug addiction risk in the subgroup of middle-aged people (44 < age ≤ 59) and elderly people (age ≥ 60), individually. For men, rs3735451, rs4646440, and rs4646437 had strong relationship with decreased risk of drug addiction (p < 0.05). The effects of rs3735451 on drug addiction risk were related to drug-using time (p < 0.05). We also observed one block (rs4646440 and rs35564277) in haplotype analysis.

Conclusion:CYP3A4 polymorphisms were associated with drug addiction risk among the Chinese Han population.

Trajectories of heroin use: A 15-year retrospective study of Mexican-American men who were affiliated with gangs during adolescence

BACKGROUND

Heroin use is a public health concern in the United States. Despite the unique etiology and patterns of heroin use among U.S. Latinos, long-term heroin trajectories and health consequences among Latinos are not well understood. This study aims to document the distinct heroin use trajectories for a group of street-recruited (non-treatment), young adult Mexican American men living in a disadvantaged community who were affiliated with gangs during their youth.

METHODS

One-time interviews conducted between 2009-2012 in San Antonio, TX collected retrospective data from a sample of 212 Mexican American young adult men who reported using heroin at least once. Group-based trajectory modeling was applied to determine discrete developmental trajectories of heroin use. ANOVA, Chi square tests, and multinomial logistic regression examined current (past year) social and health indicators among each trajectory group.

RESULTS

Five discrete heroin trajectories groups were identified: low use (n = 65); late accelerating (n = 31); early decelerating (n = 26); late decelerating (n = 38); and stably high (n = 52). Varying social and health consequences were found among the trajectory groups.

CONCLUSION

This study describes the unique heroin use trajectories and social and health outcomes among a high-risk subgroup of Mexican American men. The findings suggest that early intervention and intervention available in easy to access non-treatment spaces may be especially useful for groups of people who use relatively less heroin.

Age- and sex-related changes in the severity of physical and psychological dependence in morphine-dependent rats

Gender- and age-dependent effects on the severity of morphine dependence are still controversial. The aim of this study was to investigate the effects of age and sex on the severity of physical and psychological dependence in morphine-dependent rats. The adult/aged male and female Wistar rats were chronically treated with bi-daily doses (10 mg/kg, at 12 h intervals) of morphine for 14 days. Then, rats were tested for the severity of physical dependence on morphine (spontaneous withdrawal signs), anxiety-like (the elevated plus maze), depressive-like (sucrose preference test) and grooming behaviors after spontaneous morphine withdrawal. We found that the morphine withdrawal signs decreased after 3 and 7 days of withdrawal in female and male rats respectively, while there was no significant difference in overall dependence severity between the two sexes or ages. Also, we found that the withdrawal of morphine led to increased anxiety, depression and obsessive-compulsive behavior in the D (dependent)/Adult male and female rats. Also, the D/aged female and male rats exhibited a reduction in depressive-like behavior than the D/Adult rats. Moreover, the D/female rats exhibited a decreased obsessive-compulsive behavior in both age groups than male rats. We conclude that age has no effect on the duration of withdrawal from morphine and overall dependence severity. While, the duration of withdrawal from morphine was lower in female than male rats. Our results showed a sex difference on the duration of morphine withdrawal and an age difference in the expression of psychological dependence on morphine. Thus, therapeutic strategies may be different for opiate-dependent individuals in physical and psychological dimensions.

Sex differences in peer and parental risk factors for non-medical use of prescription opioids in youth

Background: Prescription opioid non-medical use (NMU) and its associated consequences have been of concern in the US in recent years.Objective: We examined peer influence and parental guidance, in addition to peer and parental sources of alcohol, on patterns of prescription opioid use, including NMU, among males and females separately. We hypothesized that peer influence and parental guidance would have a differential influence for males and females.Methods: The National Monitoring of Adolescent Prescription Stimulants Study (N-MAPSS) recruited youth 10-18 years from 10 US cities between 2008 and 2011 (n = 11,048). The cross-sectional survey included questions on past 30-day prescription opioid use (10,965 provided responses), with NMU defined as non-oral use and/or use of someone else's opioids. Multinomial logistic regression was conducted, examining medical use only and NMU in the past 30 days.Results: Among the 10,965 youth, 3.1% (n = 345) reported past 30-day NMU. Obtaining alcohol from parents was associated with increased odds of past 30-day NMU among males (OR = 2.49, 95%CI: 1.54,4.03) only. For each additional close friend who used other substances, odds of past 30-day NMU increased among males (OR = 1.23, 95%CI: 1.11,1.37) and females (OR = 1.15, 95%CI: 1.04,1.27). Increased number of close friends was associated with decreased odds of past 30-day NMU among males (OR = 0.87, 95%CI: 0.78,0.97) and females (OR = 0.86, 95%CI: 0.77,0.96).Conclusions: Peer and parental risk factors for prescription opioid NMU were identified among youth, although not all differed by sex. An increased number of close friends was a protective factor against prescription opioid NMU for both males and females.

Buprenorphine Treatment for Adolescents and Young Adults With Opioid Use Disorders: A Narrative Review

: In the past decade, a new cohort of adolescents and young adults with opioid use disorders (OUD) has emerged. While medications and psychosocial treatments are available, few adolescents and young adults with OUD can access and remain in treatment. Effective, practical, and scalable treatment paradigms for this young population are needed. Buprenorphine is a medication with unique pharmacological and regulatory characteristics that make it a promising component of adolescent and young adult OUD treatment models. Three randomized controlled trials and multiple observational studies have evaluated the use of buprenorphine to treat this population. However, data from these studies have not been consolidated into an up-to-date summary that may be useful to clinicians. The objective of this narrative review is to inform clinical practice by summarizing results of primary and secondary analyses from randomized controlled clinical trials and observational studies that have evaluated the use of buprenorphine to treat adolescents and young adults with OUD. Based on results from these studies, we encourage the conceptualization of OUD among youth as a chronic medical condition requiring a long-term management strategy. This includes treatment with buprenorphine in conjunction with medication-prescribing protocols that do not necessarily require daily clinic attendance for observed medication adherence. However, more study of treatment delivery models, addressing such issues as medication adherence and intensity requirements, is needed to determine practices that optimize outcomes for youth.

Persistence of extra-medical prescription pain reliever use and alcohol involvement among United States 12-20 year olds

The peak risk of first extramedical use of prescription pain relievers (PPRs) is in mid-adolescence, often after underage drinking has begun. This research aims to investigate discrete classes of similar young people based on their newly incident extramedical use of PPR and alcohol involvement, with empirical evaluation of the underlying structure of identified subgroups and their epidemiological distributions in the United States. The U.S. National Surveys on Drug Use and Health, 2002-2013, sampled, recruited, and assessed 24,789 newly incident extramedical PPR users ages 12-20 years, with self-interviews on PPR, alcohol, and covariates. Latent classes of persistence were formed using PPR and alcohol status variables. Then, age and sex were studied as potentially important predictors of class membership. Analysis-weighted estimates and delta method variances were derived. Three classes were distinguished by extramedical PPR and alcohol use patterns: (a) nonpersistent (79%), (b) intermittent (15%), and (c) persistent (6%). There were no differences across classes by age, but being female was associated with greater odds of being in the intermittent class or persistent class compared to the nonpersistent class. Presenting clinical features of alcohol and/or opioid dependence that have become manifest at or near time of first PPR use can be indicators of persisting in extramedical use of PPR, particularly for young people who have recently started extramedical PPR use. Persistent adolescent and young adult extramedical PPR users require tailored public health prevention and intervention strategies based on their vulnerability to continue use over time. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Prescription Opioid Misuse Associated With Risk Behaviors Among Adolescents

INTRODUCTION

With the ongoing opioid overdose epidemic in the U.S., it is important to explore how prescription opioid misuse correlates with health behaviors that increase the risk for adverse health outcomes among adolescents. The objective of this study is to determine if lifetime nonmedical use of prescription opioids is associated with health risk behaviors among adolescents.

METHODS

Data from the 2017 nationally representative Youth Risk Behavior Survey (14,765 high school students in Grades 9-12) were used to explore associations between lifetime nonmedical use of prescription opioids and 29 health risk behaviors. Logistic regression models (adjusted for sex, race/ethnicity, grade, and sexual identity) estimated adjusted prevalence ratios and 95% CIs. Analyses were completed in 2018.

RESULTS

Nonmedical use of prescription opioids was associated with all but 1 of the health risk behaviors included in the analyses. Substance use ranged from adjusted prevalence ratio=2.46 (current alcohol use) to adjusted prevalence ratio=17.52 (heroin use); violence victimization from adjusted prevalence ratio=1.80 (bullied at school) to adjusted prevalence ratio=3.12 (threatened or injured with a weapon); suicidal thoughts/behaviors from adjusted prevalence ratio=2.23 (considered suicide) to adjusted prevalence ratio=3.45 (attempted suicide); and sexual behavior from adjusted prevalence ratio=1.06 (did not use a dual pregnancy prevention method) to adjusted prevalence ratio=3.42 (4 or more sexual partners). Poor academic performance (adjusted prevalence ratio=1.53), receiving an HIV test (adjusted prevalence ratio=1.77), and having persistent feelings of sadness/hopelessness (adjusted prevalence ratio=1.80) were also associated with nonmedical use of prescription opioids.

CONCLUSIONS

Nonmedical use of prescription opioids is associated with many health risk behaviors. Opportunities to reduce nonmedical use of prescription opioids include screening pediatric patients for opioid use disorder, improved prescribing practices, and, from a primary prevention perspective, integrated evidence-based health education programs in schools.

Association of Nonmedical Prescription Opioid Use With Subsequent Heroin Use Initiation in Adolescents

IMPORTANCE

There is concern that nonmedical prescription opioid use is associated with an increased risk of later heroin use initiation in adolescents, but to our knowledge, longitudinal data addressing this topic are lacking.

OBJECTIVE

To determine whether nonmedical prescription opioid use is associated with subsequent initiation of heroin use in adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This prospective longitudinal cohort study conducted in 10 high schools in Los Angeles, California, administered 8 semiannual surveys from 9th through 12th grade that assessed nonmedical prescription opioid use, heroin use, and other factors from October 2013 to July 2017. Students were baseline never users of heroin recruited through convenience sampling. Cox regression models tested nonmedical prescription opioid use statuses at survey waves 1 through 7 as a time-varying and time-lagged regressor and subsequent heroin use initiation across waves 2 to 8 as the outcome.

EXPOSURES

Self-reported nonmedical prescription opioid use (past 30-day [current] use vs past 6-month [prior] use without past 30-day use vs no past 6-month use) at each wave from 1 to 7.

MAIN OUTCOMES AND MEASURES

Self-reported heroin use initiation (yes/no) during waves 2 to 8.

RESULTS

Of 3298 participants, 1775 (53.9%) were adolescent girls, 1563 (48.3%) were Hispanic, 548 (17.0%) were Asian, 155 (4.8%) were African American, 529 (16.4%) were non-Hispanic white, and 220 (6.8%) were multiracial. Among baseline never users of heroin in ninth grade with valid data (3298 [97% of cohort enrollees]; mean [SD] age, 14.6 [0.4] years), the number of individuals with outcome data available at each follow-up ranged from 2987 (90.6%) to 3200 (97.0%). The mean per-wave prevalence of prior and current nonmedical prescription opioid use from waves 1 to 7 was 1.9% and 2.7%, respectively. Seventy students (2.1%) initiated heroin use during waves 2 to 8. Prior vs no (hazard ratio, 3.59; 95% CI, 2.14-6.01; P < .001) and current vs no (hazard ratio, 4.37; 95% CI, 2.80-6.81; P < .001) nonmedical prescription opioid use were positively associated with subsequent heroin use initiation. For no, prior, and current nonmedical prescription opioid use statuses at waves 1 to 7, the estimated cumulative probabilities of subsequent heroin use initiation by wave 8 (42-month follow-up) were 1.7%, 10.7%, and 13.1%, respectively. In covariate-adjusted models, associations were attenuated but remained statistically significant and current nonmedical prescription opioid use risk estimates were stronger than corresponding associations of nonopioid substance use with subsequent heroin use initiation.

CONCLUSIONS AND RELEVANCE

Nonmedical prescription opioid use was prospectively associated with subsequent heroin use initiation during 4 years of adolescence among Los Angeles youth. Further research is needed to understand whether this association is causal.

Evaluation of GALNT16 polymorphisms to breast cancer risk in Chinese population

BACKGROUND

Polypeptide N-acetylgalactosaminyltransferase 16 (GALNT16) is an N-acetylgalactosaminyltransferase gene that alters protein O-glycosylation, which plays a role in tumor development. This study aims to explore the association of eight GALNT16 polymorphisms with susceptibility to breast cancer (BC).

METHODS

This case-control study included 563 BC patients and 552 age-matched healthy controls from the Chinese Han population. The genotypes of GALNT16 polymorphisms were detected using the Agena MassARRAY. The relationship between GALNT16 polymorphisms and BC risk was evaluated using a chi-squared test with an odds ratio (OR) and 95% confidence intervals (CI) under five genetic models.

RESULTS

We observed that rs2105269 and rs72625676 were associated with higher BC risk in younger patients with age ≤51 (rs2105269, codominant: p = .006; recessive: p = .005 additive: p = .018; and allele: p = .012; rs72625676, codominant: p = .038; recessive: p = .037). For rs1275678 polymorphism, there was a significantly decreased risk of BC among elder patients (codominant: p = .017; dominant: p = .019; additive: p = .030; and allele: p = .029). Further analysis by clinical characteristics showed rs2105269 was associated with tumor size and lymph node metastasis.

CONCLUSION

Our study suggests that GALNT16 polymorphisms are associated with BC susceptibility in Chinese population.

Trends in Adolescent Heroin and Injection Drug Use in Nine Urban Centers in the U.S., 1999-2017

PURPOSE

Although estimates of heroin and injection drug use (IDU) among U.S. adolescents have remained low and stable, national data may mask local variation in use. Adolescent use may be higher in urban areas, many of which have historically high rates of heroin use and IDU. We investigate trends in heroin use and IDU among 9th-12th grade students in major urban centers in the U.S.

METHODS

We used local Youth Risk Behavior Survey data from all large, urban school districts (n = 9) with at least 5 years of weighted, publicly available data. We used time series mean estimation to estimate the prevalence of heroin use and IDU among high school students from 1999 to 2017 and used logistic regression to test for linear and quadratic trends.

RESULTS

We observed statistically significant linear increases in (1) lifetime heroin use in New York (β = .43, 1%-3.9%), Chicago (β = .15, 3.1%-4.6%), and Milwaukee (β = .35, 2.8%-7.4%); and (2) lifetime IDU in New York (β = .34, .8%-2.7%), Orange County (β = .17, 2.2%-3.5%), and Miami-Dade County (β = .16, 2.7%-3.9%). Only San Bernardino experienced significant decreases in heroin use (β = -.34, 4.6%-1.6%) and IDU (β = -.20, 2.5%-1.9%) over the time period.

CONCLUSIONS

In contrast to national trends, the prevalence of heroin use is increasing among adolescents in certain urban centers in the U.S. Our results illustrate that national averages mask local variation in adolescent heroin use. Further research with locally representative samples is needed to inform public health policy and practice, especially in cities where heroin problems have been historically endemic and continue to rise.

Consideration of opioid agonist treatment in a pregnant adolescent: A case report and literature review

Background: Opioid use greatly increases the risk of overdose death, as well as contracting human immunodeficiency virus (HIV) and hepatitis. Opioid agonist treatment is recommended for pregnant women who are dependent on opioids. However, there is a dearth of studies on the use of opioid agonist treatment in pregnant teenagers. Case: Ms. A, a 15 year-old G1PO in foster care, presented to our tertiary women's hospital requesting opioid agonist treatment for use of pill opioids. She reported nasal inhalation of 5-6 opioid tablets daily, with recent attempts to self-taper using nonprescribed buprenorphine since learning of her pregnancy. Last reported opioid use was >24 hours prior to admission. Urine drug testing was positive only for opioids (negative for buprenorphine and methadone). She did not exhibit significant withdrawal symptoms while hospitalized. The psychiatric treatment team recommended deferring opioid agonist treatment and pursuing outpatient substance use treatment. Unfortunately, Ms. A did not attend outpatient treatment and was lost to follow up. Discussion: Based upon our experience and review of the studies regarding opioid use disorder (OUD) and perinatal and adolescent opioid use, we recommend that pregnant adolescents with OUD be referred to opioid agonist treatment with buprenorphine or methadone. Studies specifically addressing opioid agonist treatment in pregnant teenagers are needed.

Web-Based Prescription Opioid Abuse Prevention for Adolescents: Program Development and Formative Evaluation

Background

The unprecedented number of youths engaged in nonmedical use of prescription opioids (POs), as well as the myriad negative consequences of such misuse, emphasizes the importance of prevention efforts targeting this public health crisis. Although there are several science-based, interactive drug abuse prevention programs focused on preventing the use of nonprescription drugs in youths, to our knowledge, there are no science-based interactive programs that focus on the prevention of PO abuse among adolescents.

Objective

The aim of this study was to develop and conduct a formative evaluation of a science-based interactive Web-based program focused on the prevention of PO abuse among adolescents aged 12 to 17 years (Pop4Teens). This study was conducted to prepare for a randomized controlled trial designed to evaluate the effectiveness of Pop4Teens compared with an active control website, JustThinkTwice.com (Drug Enforcement Administration), in impacting knowledge and attitudes about POs and perceptions of risk associated with the abuse of POs, as well as intentions to use and actual use of POs.

Methods

We conducted 6 focus groups with 30 youths (a mean of 5 per group: the eligibility being aged 12-19 years) along a continuum of exposure to POs (in treatment for opioid use disorder, in general treatment for other substance use disorder, prescribed an opioid, and opioid-naïve) and writing sessions with 30 youths in treatment for opioid use disorder (12-19 years) to inform the development of the Web-based prevention tool. Feasibility and acceptability of a prototype of the Web-based intervention were then assessed through individual feedback sessions with 57 youths (drawn from the same populations as the focus groups).

Results

We successfully completed the development of a Web-based PO abuse prevention program (Pop4Teens). Analyses of focus group transcripts informed the development of the program (eg, quiz content/format, script writing, and story editing). Selected writing session narratives anchored the planned scientific content by lending credibility and informing the development of compelling storylines intended to motivate the youth to engage with the program. Feedback session data indicated that the Web-based tool could be potentially useful and acceptable. In addition, feedback session participants demonstrated significant increases in their knowledge of key topics related to the prevention of PO abuse after the exposure to sections of the Web-based program.

Conclusions

The opioid crisis is predicted to get worse before it gets better. An effective response will likely require a multipronged strategy inclusive of effective evidence-based prevention programs acceptable to, and accessible by, a majority of youths.

Prescription painkiller misuse and the perceived risk of harm from using heroin

BACKGROUND

Prescription opioid pain reliever misuse is associated with initiation of heroin use. The perceived risk of harm from substance use is a key factor in initiation. We hypothesized that prescription pain reliever misuse is associated with a lower perceived risk of harm from trying heroin and from regular use.

METHODS

Using the 2015-6 National Survey on Drug Use and Health (NSDUH), we evaluated the perceived risk of trying and regularly using heroin among heroin never-users. We estimated logistic regressions to assess the association between past-year prescription pain reliever misuse with the perceived risk of heroin initiation and regular use, adjusting for potential confounders.

RESULTS

The sample contained 84,312 adults and 27,814 adolescents. Four percent of adults and 3.7% of adolescents reported past-year prescription pain reliever misuse. 87.9% of adults and 65.9% of adolescents perceived trying heroin as a great risk. Pain reliever misuse was associated with a significantly lower odds of perceiving great risk of harm from trying heroin (adults: AOR = 0.760, 95%CI 0.614-0.941, p = 0.013; adolescents: AOR = 0.817, 95%CI 0.672-0.993, p = 0.042). Both age groups were more likely to report perceiving regular heroin use as a great risk of harm compared to trying heroin once or twice, but only adults showed significant association with of pain reliever misuse. (AOR = 0.539 95%CI 0.390-0.744, p < 0.001).

CONCLUSIONS

Past-year prescription pain reliever misuse was associated with lower perceived risk of harm from heroin initiation and regular use. Further understanding of risk perception and the association with heroin initiation might inform development of primary prevention interventions.

Prescription Opioid Use in a Population-Based Sample of Young Black Men Who Have Sex with Men: A Longitudinal Cohort Study

Background: Prescription opioid use (POU) among young adults is increasing. This represents a major public health concern due to the increased risks of opioid use misuse and opioid-related overdose. Limited research has examined the POU among young black men who have sex with men (YBMSM), a diverse group experiencing continued increases in HIV incidence over the past decade. Objective: This study aims to examine the prevalence and both the individual and network characteristics of POU among YBMSM. Methods: Data were from a longitudinal cohort study of 16-29 year old YBMSM (N = 514) between 2013 and 2016 in Chicago. Bivariate and multivariable associations were estimated using general estimating equations (GEE). Results: Approximately 4.2% of YBMSM reported POU in the past 12 months with a cumulative incidence rate of 4.1% over the 18-month follow-up period. YBMSM having criminal justice involvements, experiencing violence, or using any illicit drug other than marijuana in the past 12 months were more likely to report POU in the past 12 months. The presence of a mother figure, however, was associated with a decreased risk of POU in the past 12 months, while engaging in condomless anal sex with their named sexual partners was associated with an increased risk of POU in the past 12 months. Conclusions: This is one of the first studies to describe POU among a population-based sample of YBMSM. The high incidence rate of POU among YBMSM is alarming, and it underscores the need for further analysis on POU among this key population.

Sexual Orientation Disparities in Prescription Opioid Misuse Among U.S. Adults

INTRODUCTION

The opioid epidemic in the U.S. continues to increase in severity, and misuse of prescription opioids is of particular concern since it commonly precedes heroin use. This study examined whether sexual orientation (i.e., sexual identity and sexual attraction) is a risk factor for prescription opioid misuse and use disorder among a nationally representative sample of adults in the U.S.

METHODS

This study used data from adult participants (ages ≥18 years) in the 2015 National Survey on Drug Use and Health. Chi-square tests and logistic regression examined how sexual identity and sexual attraction relate to past-year and past-month prescription opioid misuse and past-year prescription opioid use disorder. Multivariable models examined associations controlling for demographic characteristics and other drug use. Gender-stratified analyses were also conducted. Data were analyzed in 2018.

RESULTS

In multivariable analyses, compared with those identifying as heterosexual, bisexual individuals were at 1.53 (95% CI=1.20, 1.97) and 1.66 (95% CI=1.14, 2.42) higher odds of reporting past-year and past-month misuse, respectively. In stratified analyses, female bisexuals remained at high risk. Regarding sexual attraction, compared with being attracted to only the opposite sex, being attracted to mostly the opposite sex (AOR=2.15, 95% CI=1.77, 2.63) or being equally attracted to both sexes (AOR=1.78, 95% CI=1.38, 2.30) were associated with higher odds for past-year opioid misuse. In stratified analyses, these associations were limited to females.

CONCLUSIONS

Sexual orientation disparities in opioid misuse and use disorder among a nationally representative sample of U.S. adults was found.