Pregabalin misuse in methadone maintenance treatment patients in Israel: Prevalence and risk factors

Fentanyl abuse proportion in methadone maintenance treatment, and patients' knowledge about its risks

INTRODUCTION

Fentanyl is not yet routinely monitored among methadone maintenance treatment (MMT) patients in Israel. We aimed 1. to evaluate urine fentanyl proportion changes over 3 years and characterize patients' characteristics 2. To study patients' self-report on fentanyl usage, and compare knowledge about fentanyl risk, before and following brief educational intervention.

METHODS

Fentanyl in the urine of all current MMT patients was tested every 3 months year between 2021 and 2023, and patients with positive urine fentanyl were characterized. Current patients were interviewed using a fentanyl knowledge questionnaire (effects, indications, and risks) before and following an explanation session.

RESULTS

Proportion of fentanyl ranged between 9.8 and 15.1%, and patients with urine positive for fentanyl (September 2023) were characterized as having positive urine for pregabalin, cocaine, and benzodiazepine (logistic regression). Of the current 260 patients (87% compliance), 78(30%) self-reported of fentanyl lifetime use ("Ever"), and 182 "never" use. The "Ever" group had higher Knowledge scores than the "Never", both groups improved following the explanatory session (repeated measure). The "Ever" group patients were found with urine positive for cannabis and benzodiazepine on admission to MMT, they were younger, did not manage to gain take-home dose privileges and had a higher fentanyl knowledge score (logistic regression).

CONCLUSIONS

In the absence of routine fentanyl tests, a high knowledge score, shorter duration in MMT, benzodiazepine usage on admission, and current cannabis usage, may hint of the possibility of fentanyl abuse.

Causes and circumstances of death in stimulant and opioid use-A comparative study

AIMS

To investigate the individual characteristics, causes and circumstances around deaths in stimulant use, and to examine how individuals who died with stimulants in their body differ from individuals who died with opioids in their body.

METHODS

This study includes individuals who died during the years 2000-2018 and underwent a forensic autopsy at Forensic Medicine in Lund, Skåne County, Sweden. All individuals over 18 years of age with stimulants (n = 310), opioids (n = 2,039) or both stimulants and opioids (n = 385) in the body at the time of death, were included. The three groups were assessed regarding gender, age, place of death, BMI, other substances detected in forensic toxicological analysis, organ weights and underlying and contributing causes of death. The data were analysed by frequency and proportion calculations, cross-tabulations and comparisons of medians.

RESULTS

The median age at death of the study population (n = 2,734) was 45.5 years (interquartile range ☯IQR] 32-60 years) and 73.2% were men. The most common cause of death in the stimulant group was suicide (26.8%), higher proportion compared to the opioid group (20.8%) (p = 0.017) and in the polysubstance group accidental poisoning (38.2%), higher proportion compared to the opioid group (18.0%) (p<0.001). Death by transport accidents was significantly associated with the stimulant group (p<0.001) as well as death by other accidents (p = 0.016).

CONCLUSIONS

Individuals who died with stimulants in their body died at a higher rate from suicide, transport accidents and other accidents, compared to individuals who died with opioids in their body. This study indicates the need to identify and prevent psychiatric conditions, elevated suicide risk, and risk-taking behaviors among people who use stimulants.

Trends in Pregabalin Use and Prescribing Patterns in the Adult Population: A 10-Year Pharmacoepidemiologic Study

BACKGROUND AND OBJECTIVE

Pregabalin is steadily gaining popularity worldwide, with epidemiological studies indicating an increase in labeled, off-labeled, and recreational uses. In Israel, pregabalin prescriptions are not regulated by the controlled substances legislations, prompting a need to examine its usage trends for potential policy adjustments. The objective of this study was to assess trends in pregabalin prescribing during a 10-year period, to characterize demographic and clinical characteristics of individuals prescribed pregabalin, and to identify risk factors associated with high-intensity pregabalin use.

METHODS

This retrospective, longitudinal study examined trends in pregabalin prescribing from 2010 to 2019 based on data extracted from the Clalit Health Services (CHS) electronic database. Annual pregabalin prescribing rate was calculated individually for each reporting year. A univariable analysis was conducted to compare the demographic and clinical characteristics of pregabalin users in 2019 with those in 2010. Multivariable regression analysis was performed to assess dose-related patterns by specific demographic and clinical characteristics.

RESULTS

Pregabalin prescription rate more than doubled over 10 years [odds ratio (OR) 2.3, p = 0.001], reaching 7.2 [95% confidence interval (CI) 7.18-7.28] prescriptions per 100 CHS members in 2019. The highest prescription rates were observed among the elderly population (13.2 and 24.1 prescriptions per 100 CHS members for those aged 55-74 and over 75 years old, respectively). Same-year administration of pregabalin with opioids, benzodiazepines, and Z-drugs was common; however, the percentage of patients using these drugs together declined in 2019 compared with 2010 (p < 0.001). Males, patients with low socioeconomic status, patients aged 35-54 years, and those who consumed opioids, benzodiazepines, and Z-drugs received higher pregabalin doses.

CONCLUSION

Pregabalin use has increased significantly in the Israeli adult-based CHS population, consistent with worldwide data. A growing use over time may indicate overprescription. More studies are needed on misuse patterns to identify populations most susceptible to high-dose and high-intensity pregabalin use.

Managing the misuse potential and risk of psychological harm from gabapentinoids in primary care in New Zealand

Gabapentinoid prescribing is increasing in New Zealand. International evidence suggests that this prescribing trend is followed by increasing harms, including misuse, dependence, overdose, and psychological harms including suicidal thoughts or behaviours. However, there is limited guidance for prescribers on how to manage these potential harms. Here, we summarise the current international literature and identify three main risk factors that can be used for screening purposes when considering prescribing a gabapentinoid, to identify patients that may be at greater risk of harm. Based on current knowledge of harms, we provide guidance to prescribers on monitoring patients taking gabapentinoids. Finally, we summarise the evidence regarding tapering, and highlight key knowledge gaps including other interventions, referral, and data from primary care populations.

Post-traumatic stress disorder due to sexual abuse and its relation to pain sensitivity among patients in methadone maintenance treatment

We studied whether post-traumatic stress disorder (PTSD) due to sexual abuse is related to pain indices among methadone maintenance treatment (MMT) patients. Pain threshold was determined, and suprathreshold pain levels were rated among 18 patients with PTSD and sexual abuse, and 38 patients without PTSD (20 with and 18 without sexual abuse). Patients with PTSD had higher proportion of chronic pain and high-perceived stress, and lower pain threshold, with similar supra-threshold ratings. Patients with benzodiazepine in urine had higher pain thresholds and they rated supra-threshold stimuli lower. However, the analgesic effect was not observed among PTSD patients.

Why Switch? - Motivations for Self-Substitution of Illegal Drugs

Self-substitution is the conscious switch from one drug to another for reasons such as price, availability, desired effect, or perceived benefit of the substitute drug. Purpose/Objectives: This study aimed to describe drug use patterns and motivations associated with substitution. We examined correlates of lifetime substitution among individuals with substance use disorder. Methods: A cross-sectional study of 771 treatment-enrolled individuals. We used self-report for determining the lifetime prevalence, correlates, and motivations for substitution. Results: Of the 771 respondents, 570 (73.9%) reported ever substituting their preferred substance. The main incentives for substitution were availability (23.7%) and curiosity (20.2%). Among heroin or cannabis preferers, improved effects or less adverse effects of the substitute drug, self-medication, and managing withdrawal symptoms were significant substitution incentives. Increased odds for substitution were observed for past 12 months use of cannabis (OR = 1.51, CI = 1.06-4.52), prescription opioids (OR = 2.86, CI = 1.81-4.52), novel psychoactive substances (OR = 2.68, CI = 1.64-4.36), and repeated admission (OR = 1.50, CI = 1.05-2.14). Older age at onset-of-use was negatively associated with substitution (OR = 0.95, CI = 0.93-0.98). Conclusions: Self-substitution of one substance for another is a highly prevalent behavior among treatment-enrolled patients with substance use disorder. Clinicians caring for substance use disorder patients should be aware of substitution patterns involving the use of highly potent substances, which constitutes a risk to patients. Results underscore the benefit of substitution patterns analyses, as they reveal important information on the characteristics of persons who use drugs and their motivations.

Abuse and Misuse of Pregabalin and Gabapentin: A Systematic Review Update

BACKGROUND

A 2017 systematic review (SR) identified 59 studies examining gabapentinoid (pregabalin and gabapentin) misuse/abuse. Evidence of gabapentinoid misuse/abuse has since grown substantially.

OBJECTIVE

Update previous SR and describe new insights regarding gabapentinoid abuse.

METHODS

A SR of PubMed was conducted to identify studies published from 7/29/2016-8/31/2020. Four searches were performed using the following terms: "gabapentin [MeSH] OR pregabalin [MeSH] OR gabapentinoid" AND one of the following substance misuse/abuse-related terms: "substance-related disorders [MeSH]", "overdose", "abuse", or "misuse". Clinicaltrials.gov and the Cochrane Library database were searched to identify ongoing studies or similar SRs. Reference lists of included studies were reviewed to identify additional literature. All studies with novel data related to pregabalin and/or gabapentin abuse, misuse, or overdose conducted during the study period were included. Articles not written in English, review articles, and animal studies were excluded.

RESULTS

Fifty-five studies were included (29 [52.7%] from North America, 17 [30.9%] Europe, 6 [10.9%] Asia, and 3 [5.5%] Australia). Forty-six observational studies and 10 case reports/series were included (one manuscript included both). Twenty (36.4%) studied gabapentin only, 18 (32.7%) pregabalin only, and 17 (30.9%) both pregabalin/gabapentin. These studies corroborate findings from the previous SR that gabapentinoids are increasingly abused or misused to self-medicate, that gabapentinoids can produce desirable effects alone but are often used concomitantly with other drugs, and that opioid use disorder is the greatest risk factor for gabapentinoid abuse. While the original SR identified the largest studies having been published in Europe, this review identified several more generalisable US studies that have subsequently been conducted. The most concerning finding was increased evidence of associated patient harm, including increased hospital utilisation and opioid-related overdose mortality risk.

CONCLUSION

Evidence suggests that gabapentinoid misuse/abuse represents a growing trend that is causing significant patient harm. Prescribers should exercise appropriate caution with use in high-risk populations and monitor for signs of misuse or abuse.

Patterns and correlates of prescribed and non-prescribed pregabalin use among a sample of people who inject drugs in Australia

INTRODUCTION AND AIMS

Pregabalin is a gamma-aminobutyric acid analogue registered and subsidised for the treatment of neuropathic pain in Australia. Despite pre-clinical evidence of low abuse potential, there are increasing reports of extramedical use and overdose deaths involving pregabalin. This study aimed to describe patterns of pregabalin use among an Australian sample of people who inject drugs (PWID) and identify sociodemographic, substance use and mental/physical health correlates of prescribed and non-prescribed use.

DESIGN AND METHODS

Data were obtained from the 2018 Illicit Drug Reporting System, comprising a cross-sectional sample of 905 PWID recruited from Australian capital cities. Multinomial logistic regression was used to identify correlates of past 6-month prescribed and non-prescribed pregabalin use.

RESULTS

One-quarter (25%) of participants reported any past 6-month pregabalin use, with 10% reporting prescribed use and 15% non-prescribed use. Past 6-month use of prescribed benzodiazepines and non-prescribed pharmaceutical opioids were associated with both prescribed and non-prescribed pregabalin use compared to no recent pregabalin use. Pain/discomfort on the day of interview was significantly associated with prescribed pregabalin use. Recent use of non-prescribed benzodiazepines and illicit stimulants and past year non-fatal overdose were significantly associated with non-prescribed pregabalin use (compared to no recent pregabalin use).

DISCUSSION AND CONCLUSIONS

Pregabalin use was relatively common among an Australian sample of PWID. Benzodiazepine and pharmaceutical opioid use were positively correlated with both prescribed and non-prescribed pregabalin use, suggesting that education campaigns regarding the risks of harm associated with concomitant use of these substances are warranted (targeting both health professionals and consumers).

Interpol review of controlled substances 2016-2019

This review paper covers the forensic-relevant literature in controlled substances from 2016 to 2019 as a part of the 19th Interpol International Forensic Science Managers Symposium. The review papers are also available at the Interpol website at: https://www.interpol.int/content/download/14458/file/Interpol%20Review%20Papers%202019.pdf.

Preliminary Evidence of Pregabalin Misuse among Prescription and/or Illicit Opioid (Mis)users

Pregabalin is approved for the management of neuropathic pain, partial-onset seizures, and fibromyalgia. Although it is considered to have low potential for abuse, reports of misuse of pregabalin are emerging. The present study contributes to this literature by presenting preliminary evidence of pregabalin misuse. Mixed method interviews were conducted with prescription and/or illicit opioid (mis)users who reported a history of pregabalin misuse (N = 5). During semi-structured interviews, respondents provided descriptions of this practice, including motivation, route of administration, source, and drugs used/misused in combination with pregabalin. Motivations for pregabalin misuse included the self-treatment of physical pain (N = 1) and to achieve a desired psychoactive effect and/or combat opioid withdrawal symptoms (N = 4). Respondents described the misuse of pregabalin to potentiate the effects of heroin and cocaine, to feel "tipsy," and to experiment. We believe this report represents the first detailed contextual data about the misuse of pregabalin in the U.S. These misuse practices may represent an early indication of a growing problem. The recent permissibility of lower price generic versions has the potential to increase availability, decrease prices, and exacerbate pregabalin misuse.

Pregabalin Abuse in Combination With Other Drugs: Monitoring Among Methadone Patients

INTRODUCTION

In recent years, there has been an increase in the non-medical use of psychoactive prescription drugs including pregabalin (PGB). Studies have shown that multiple drug users and patients in methadone treatment programs administered PGB at high dosages in order to achieve euphoria, reduce withdrawal symptoms, or potentiate the effects of methadone. For these reasons, accurate toxicological monitoring is required for these high-risk individuals.

MATERIALS AND METHODS

The present study investigated whether PGB could be detected in the hair samples of 250 patients with a history of opiate dependency, and under toxicological surveillance assess their compliance with methadone maintenance therapy.

RESULTS

Opiates were found in 54/250 of all hair samples, while cannabis was present in 74/250 patients, cocaine was detected in 21/250 patients, and benzodiazepines without prescription were identified in 49/250 patients. As expected, methadone was present in all 250 patients (100%). PGB without prescription was found in the hair samples of 35/250 patients (14%). Of these, 91.43% were male, 48.57% were <30 y old, and 45.71% were between ages 30 and 50 y. There were no apparent associations among PGB use, daily methadone dosage, and duration of methadone maintenance therapy. Psychiatric comorbidities were present in 25.71% of the patients abusing PGB. Anxiety (55.56%) and depression (33.33%) were the most prevalent psychiatric disorders.

DISCUSSION

Most of the patients taking PGB (57.14%) used other drugs (especially opiates) concurrently. The utility of hair analysis is explained by easy and rapid sample collection and the ability of the hair to reflect long-term drug use and incorporate drug metabolites. The findings of this study suggested that PGB has significant potential for abuse by high-risk populations such as opioid users and patients with dual diagnosis. These risks are particularly high in cases of poly-drug use and drug intake that are not in compliance with prescription guidelines.

Prevalence of Novel Psychoactive Substance (NPS) Use in Patients Admitted to Drug Detoxification Treatment

BACKGROUND

About 15 years ago, a diverse group of new recreational psychotropic substances began to emerge, which were marketed for example as "legal highs," "research chemicals," or "designer drugs." These substances were later subsumed under the label "Novel Psychoactive Substances" (NPS). Important NPS classes are cathinones, synthetic cannabimimetics, phenethylamines, and herbal drugs. The health care system for psychotropic substance use disorders (SUDs) traditionally focused on a few substances, such as alcohol, heroin, cocaine, amphetamines, or cannabis. Users of illicit substances often engage in polydrug use. However little is known about the prevalence of NPS use within the group of "classical" illicit substance users.

OBJECTIVE

We investigated lifetime and recent use of NPS and other drugs in patients who underwent in-patient detoxification treatment from illicit drugs in Germany.

METHODS

In a multicenter study with eight participating facilities, patients admitted to treatment underwent a standardized interview at admission, concerning their past and current substance use. The interview comprised classical substances of abuse, NPS, and rarely used substances such as LSD. In addition, participating sites had the opportunity to analyze their patients' routine drug screenings by means of gas chromatography/mass spectrometry (GC/MS), which permitted detection of NPS.

RESULTS

Interviews from 295 patients could be analyzed. Most patients were opiate dependent and multiple substance users. About 32% reported use of synthetic cannabimimetics during lifetime, but usually only a few times. An important reason for their use was that NPS were not detected by drug testing in prisons or drug treatment facilities. Cathinones, herbal drugs or other NPS had rarely been used during lifetime. NPS use during the last 30 days before admission was nearly zero. This was confirmed by urine analysis results. In contrast, lifetime and current use of opiates, alcohol, cocaine, benzodiazepines, and cannabis was high. In addition, 18% reported of regular unprescribed pregabalin use during lifetime, and 20% had recently used pregabalin.

CONCLUSION

Patients admitted to drug detoxification treatment showed multiple substance use, but this did not include NPS use. The diversion of legal medications such as pregabalin in this group is a serious concern.

Drug Abuse and Behavioral Transgressions during Methadone Maintenance Treatment (MMT) are Related to High Psychopathy Levels

Introduction: Studies which used the Psychopathy Checklist-Revised (PCL-R) among methadone maintenance treatment (MMT) patients focused mostly on methodological issues, without addressing its relationship to patients' misconduct during treatment. This paper tests the hypothesis that high PCL-R scores are related to high rates of drug abuse, and high numbers of behavioral transgressions in MMT during a 7-year period. Material and Methods: 107 MMT patients were recruited from a MMT clinic in Israel, and were administered the PCL-R. The questionnaires results as well as routine drug test findings were recorded between 7/2007 and 11/2007. Seven years later (7/2014), repeated drug test results were analyzed, and the number of behavioral transgressions during the entire period was computed. Results: High levels of psychopathy were related to drug test results indicating any illicit drug use, cocaine use and benzodiazepines misuse at the beginning of study, and limited to benzodiazepines misuse among patients who stayed in treatment at the 7-year follow-up. However, higher scores on different PCL-R facets were significantly associated with different types of drugs. The PCL-R's total score and all but the antisociality facet were positively correlated with a higher number of behavioral transgressions (such as, threats and/or verbal and physical aggression). Conclusions: Administration of the PCL-R during MMT may help identify patients with high illicit drug use levels and a higher chance of committing behavioral transgressions during treatment.