Prescription drug abuse: epidemiology, regulatory issues, chronic pain management with narcotic analgesics

Addictive profiles of Lebanese university students in terms of smoking, alcohol, and illegal drug use

The Lebanese economic crisis, financial crisis, and USD shortage were conducive to an increased drug addiction especially for students who feel that their future in Lebanon is not safe, as well as the psychological fragility of the Lebanese people, and the more permissive sociocultural context. Our study aimed to assess the addiction levels and profiles of university students in Lebanon, and thus to evaluate the rapid rising in dependence regarding smoking, alcohol, and illegal drug use during this crisis. This cross-sectional study was carried out between February and September 2020. A total of 467 participants (315 females, 152 males; Mage = 23.48 ± 6.03) were recruited through convenience sampling through several universities in Lebanon's governorates. Participants received the online link to the survey. Students were divided into three clusters as follows: cluster 1, which corresponds to students with moderate addictions; cluster 2, which corresponds to students with high addictions; and cluster 3, which corresponds to students with low addictions. When comparing cluster 1 to cluster 3, the results of the multinomial regression showed that older age (aOR=1.08) and having a high monthly income compared to no income (aOR=2.78) were significantly associated with higher odds of being in cluster 1 compared to cluster 3. When comparing cluster 2 to cluster 3, the results of the multinomial regression showed that female gender (aOR=0.19) was significantly associated with lower odds of being in cluster 2 compared to cluster 3, whereas having a dead (aOR=16.38) or divorced parent (aOR=6.54) and having a low (aOR=3.93) or intermediate income compared to zero income (aOR=4.71) were significantly associated with higher odds of being in cluster 2 compared to cluster 3. The results of our study revealed a considerable prevalence of addiction to alcohol, illicit drugs, and specially to smoking, among Lebanese university students. These findings emphasize the need to implement firm policies and rules in an attempt to minimize the tendency of the young population to engage in such addictions.

Topical Fixed-Dose Combinations: A Way of Progress for Pain Management?

Pain, a severe public health problem, can affect patient quality of life when inadequately controlled. Considering that pain pathophysiological mechanisms are complex, combining active pharmaceutical ingredients (APIs) with multiple and synergistic mechanisms of action represents a potentially more effective therapeutic approach than conventional monotherapy treatments. In turn, topical drug delivery has clear advantages over other routes of administration, such as high levels of efficacy, better safety profile and great patient compliance. In this context, the combination of two or more APIs in a single dosage form - fixed-dose combination product (FDC) - for topical administration may represent a promising therapeutic option in the field of pain management. Considering the above mentioned, the purpose of this manuscript is to address an overview of some general aspects regarding pain management and FDCs, as well as the regulatory environment that has to be taken into consideration during their development. Special emphasis will be given to fixed-dose combinations for topical administration with analgesic and/or anti-inflammatory activity. Market drivers of the topical FDC currently approved are ultimately pointed out, and new opportunities in pain management highlighted.

Prescription Drug Misuse and Child Maltreatment Among High-Risk Families

Prescription drug misuse is increasingly common in the United States. To date, little is known about how prescription drug misuse relates to negative parenting behaviors like child maltreatment, even though use of illicit drugs increases rates of both child neglect and physical abuse. This study used secondary data from the Fragile Families and Child Well-Being Study (FFCWS), a clustered national sample of families at high risk for both prescription drug misuse and child maltreatment (n = 2,917). Data from mothers who participated in the 9-year follow-up of this study were used to create logistic regression models examining prescription drug misuse and physically aggressive and neglectful parenting, while controlling for demographic and psychosocial variables. Black, non-Hispanic mothers and mothers in worse health had higher odds of physically aggressive parenting. Mothers in worse health and those who used other illicit drugs had greater odds of neglectful parenting. There were no relationships between prescription drug misuse and either parenting outcome. The findings do not provide evidence that prescription drug misuse is a risk factor for child maltreatment. Further research examining this issue and potential progression from prescription drug misuse to other illicit drug use could help clarify whether this behavior is related to negative outcomes for children.

Predictors, rates, and trends of opioid use disorder among patients hospitalized with chronic pancreatitis

Background

Patients with chronic pancreatitis (CP) suffer from pain and receive increased opioid prescriptions with a high risk of opioid use disorder (OUD). We studied the predictors, trends and outcomes of OUD among patients hospitalized with CP.

Methods

Records with CP (with/without OUD) were extracted from the Nationwide Inpatient Sample (NIS) 2012-2014, and the association of OUD with the burden of CP was calculated. We then charted the trends of OUD and its interaction with concomitant CP from NIS 2007-2014 (SAS 9.4).

Results

In the period 2012-2014, 4349 (4.99%) of the 87,068 CP patients had concomitant OUD, with higher risk among patients who were young, females, white vs. Hispanics, and individuals with chronic back pain, arthritis, non-opioid substance use, mental health disorders, and those hospitalized in urban centers. OUD was associated with a longer hospital stay (6.9 vs. 6.5 days, P=0.0015) but no significant difference in charges ($47,151 vs. $49,017, P=0.0598) or mortality (1.64% vs. 0.74%, P=0.0506). From 2007-2014, the average yearly rate of OUD was 174 cases per 10,000 hospitalizations (174/10,000), almost 3 times higher among CP vs. non-CP (479/10,000 vs. 173/10,000, P<0.001), and it increased from 2007 to 2014 (135/10,000 to 216/10,000, P<0.001). The yearly increase was 2.7 times higher among patients with CP vs. non-CP (29.9/10,000 vs. 11.3/10,000 hospitalizations/year, P<0.001).

Conclusions

CP is associated with higher rates and trends of OUD. Patients with CP at high risk of OUD may benefit from alternate analgesic regimens or surveillance for OUD when they are prescribed opioids.

Evaluation of Opioid Use in Acute Pancreatitis in Absence of Chronic Pancreatitis: Absence of Opioid Dependence an Important Feature

BACKGROUND

Chronic opioid use and dependence is common in patients with chronic pancreatitis. Patients with acute pancreatitis are frequently treated with opioids, but their risk for ongoing use is not well known. The aim of our study is to characterize opioid use in patients after an episode of acute pancreatitis and to assess persistent, chronic, and daily opioid use in such patients in the absence of chronic pancreatitis.

METHODS

This is a single-center review of prospectively enrolled patients with acute pancreatitis. Using the Massachusetts Prescription Awareness Tool, we recorded all opioid prescriptions (ie, frequency, duration, and amount) for patients from December 2016 to September 2019, after index hospitalization for acute pancreatitis. Patients with chronic pancreatitis were excluded. We used univariate and multivariate analysis to determine predictors of opioid use at discharge and subsequent follow-up over 18 months.

RESULTS

Of 235 enrolled patients who were opioid-naïve, 123 patients (52.3%) received opioids at discharge after index hospitalization. In follow-up over 18 months, 40 patients (17.0%) received additional opioid prescriptions. These patients had more severe disease, longer length of stay, and higher pain score at discharge. Patients with prior history of acute pancreatitis, local complications, and higher pain scores were twice as likely to subsequently be prescribed opioids. Persistent opioid use was seen only in recurrent acute pancreatitis. There was no daily or chronic opioid use.

CONCLUSIONS

In the absence of chronic pancreatitis, there was no daily or chronic use of opioids in patients with acute pancreatitis. Persistent use was only seen in patients with recurrent acute pancreatitis. These patients are at increased risk of chronic opioid use and dependence.

The 21st Century Opioid Addiction: A Concept Analysis and Implications for Nursing

INTRODUCTION

Opioid addiction is a mounting problem and concern in all parts of the world. Drug overdose related to opioid addiction was the leading cause of accidental death in the United States in 2015; this extends to people across all ages, races, genders, and socioeconomic statuses. It is estimated that 21 million Americans aged 12 years or older has one form of substance use disorder, of which 2 million involves the use of prescription pain relievers. The cost of opioid misuse is estimated to be $78.5B based on 2013 data. This amount has exponentially increased more than $20 billion per year compared with 6 years ago.

PURPOSE

We conducted a concept analysis of opioid addiction in the 21st century and present its implications for nursing.

METHODS

Walker and Avant's eight steps for analyzing a concept were utilized.

RESULTS

Uses of opioid addiction from the perspectives of healthcare, sociology, law, and economics are presented. Defining attributes of opioid addiction based on review of the literature include physical dependence to opioids, psychological craving for opioids, habitual use, and lack of self-control. Antecedents, consequences, and empirical referents are also identified. Model, related, and contrary cases are developed.

CONCLUSION

This concept analysis article enhances understanding of the current opioid addiction crisis that is affecting the country.

IMPLICATIONS TO NURSING

Nurses are in a position to play critical roles in the fight against opioid addiction. Nursing opportunities exist starting from the bedside and can reach up to the White House.

Medicaid trends in prescription opioid and non-opioid use by HIV status

BACKGROUND

Pain is more common among people living with HIV (PLWH) than their counterparts; however, it is unclear whether analgesic use differs by HIV status.

METHODS

We analyzed Medicaid pharmacy claims from adults in 14 US states from 2001 to 2009 to identify opioid and non-opioid analgesic prescriptions and compared prescribing trends by HIV status. We accounted for clinical and demographic differences by using inverse probability weights and by restricting the sample to a subgroup with a common comorbidity, diabetes, chosen for its high prevalence and association with lifestyle and chronic pain. We estimated the incidence of chronic opioid therapy (COT) (≥90 consecutive days with an opioid prescription) among opioid-naïve individuals.

RESULTS

Rates of opioid and non-opioid use increased approximately two-fold from 2001 to 2009. PLWH received approximately twice as many prescriptions as those without HIV. In an unadjusted Cox regression, PLWH were three times more likely to receive COT compared to those without HIV (hazard ratio (HR) = 3.06, 95% CI 2.76-3.39). When restricting to patients with diabetes and adjusting for age, sex, state, comorbidity score, depression, bipolar disorder, and schizophrenia, the HR decreased to 1.26 (95% CI 0.97-1.63).

CONCLUSIONS

Higher opioid use among PLWH was largely a function of patients' demographic characteristics and health status. The high incidence of COT among PLWH underscores the importance of practice guidelines that minimize adverse events associated with opioid use.

Electronic Health Record-Based Screening for Substance Abuse

Existing methods of screening for substance abuse (standardized questionnaires or clinician's simply asking) have proven difficult to initiate and maintain in primary care settings. This article reports on how predictive modeling can be used to screen for substance abuse using extant data in electronic health records (EHRs). We relied on data available through Veterans Affairs Informatics and Computing Infrastructure (VINCI) for the years 2006 through 2016. We focused on 4,681,809 veterans who had at least two primary care visits; 829,827 of whom had a hospitalization. Data included 699 million outpatient and 17 million inpatient records. The dependent variable was substance abuse as identified from 89 diagnostic codes using the Agency for Healthcare Quality and Research classification of diseases. In addition, we included the diagnostic codes used for identification of prescription abuse. The independent variables were 10,292 inpatient and 13,512 outpatient diagnoses, plus 71 dummy variables measuring age at different years between 20 and 90 years. A modified naive Bayes model was used to aggregate the risk across predictors. The accuracy of the predictions was examined using area under the receiver operating characteristic (AROC) curve in 20% of data, randomly set aside for the evaluation. Many physical/mental illnesses were associated with substance abuse. These associations supported findings reported in the literature regarding the impact of substance abuse on various diseases and vice versa. In randomly set-aside validation data, the model accurately predicted substance abuse for inpatient (AROC = 0.884), outpatient (AROC = 0.825), and combined inpatient and outpatient (AROC = 0.840) data. If one excludes information available after substance abuse is known, the cross-validated AROC remained high, 0.822 for inpatient and 0.817 for outpatient data. Data within EHRs can be used to detect existing or predict potential future substance abuse.

Opioid misuse in gastroenterology and non-opioid management of abdominal pain

Opioids were one of the earliest classes of medications used for pain across a variety of conditions, but morbidity and mortality have been increasingly associated with their chronic use. Despite these negative consequences, chronic opioid use is increasing worldwide, with the USA and Canada having the highest rates. Chronic opioid use for noncancer pain can have particularly negative effects in the gastrointestinal and central nervous systems, including opioid-induced constipation, narcotic bowel syndrome, worsening psychopathology and addiction. This Review summarizes the evidence of opioid misuse in gastroenterology, including the lack of evidence of a benefit from these drugs, as well as the risk of harm and negative consequences of opioid use relative to the brain-gut axis. Guidelines for opioid management and alternative pharmacological and nonpharmacological strategies for pain management in patients with gastrointestinal disorders are also discussed. As chronic pain is complex and involves emotional and social factors, a multimodal approach targeting both pain intensity and quality of life is best.

Adding Genetic Testing to Evidence-Based Guidelines to Determine the Safest and Most Effective Chronic Pain Treatment for Injured Workers

Published guidelines for treating injured workers include the need for personalized treatment to manage chronic pain symptoms and increase functional status. However, they often fail to clarify how to objectively personalize these treatments. Further, certain patients need analgesic relief beyond the short term. In these cases, it is not sufficient or reasonable to utilize the typical broad protocol-based justifications for reduction of opioids and other medications in a haphazard manner based purely on poor response, without attempting to elucidate possible pharmacogenetic reasons for this. These guidelines acknowledge the problem of substance abuse and set forth methods for treatment and prevention. Although it has been established in the scientific community that an individual's experience of pain and likelihood for addiction both have genetic components, genetic testing is not routinely included as part of the overall treatment plan for injured workers with chronic pain. Because decisions in cases of workplace injury should be based on scientific evidence, genetic testing results can add some objective information to the existing subjective and objective clinical data; help ascertain the efficacy and potential for toxicity of treatment; and therefore provide more information for accurate clinical decisions. We propose the addition of genetic testing to consensus guidelines for treating injured workers in order to improve patients' functional status, increase productivity, improve safety of prescribing, decrease the likelihood of substance abuse, and save on overall healthcare costs.

Burning through the pain: treatments for diabetic neuropathy

The rise in the global burden of diabetes is spurring an increase in the prevalence of its complications. Diabetic peripheral neuropathy (DPN) is a common and devastating complication of diabetes, with multiple clinical manifestations. The most common is a symmetrical length-dependent dysfunction and damage of peripheral nerves. The management of DPN rests on three tenets: intensive glycaemic control, even though the evidence of benefit is questionable in people with type 2 diabetes; pathogenetic therapies; and symptomatic treatment. A number of pathogenetic treatments have been evaluated in phase III clinical trials, including α-lipoic acid (stems reactive oxygen species formation), benfotiamine (prevents vascular damage) and aldose-reductase inhibitors (reduce flux through the polyol pathway), protein kinase C inhibitors (prevent hyperglycaemia-induced activation of protein kinase C), nerve growth factors (stimulate nerve regeneration) and Actovegin® (improves tissue glucose and oxygen uptake). However, none have gained US Food and Drug Administration or European Medicines Agency (EMA) approval, questioning the validity of current trial designs and the endpoints deployed to define efficacy. For painful diabetic neuropathy, clinical guidelines recommend: atypical analgesics for pain relief, including duloxetine and amitriptyline; the γ-aminobutyric acid analogues gabapentin and pregabalin; opioids, including Tapentadol; and topical agents such as lidocaine and capsaicin. No single effective treatment exists for painful DPN, highlighting a growing need for studies to evaluate more potent and targeted drugs, as well as combinations. A number of novel potential candidates, including erythropoietin analogues and angiotensin II type 2 receptor anatagonists are currently being evaluated in phase II clinical trials.

Is Admission to the Intensive Care Unit Associated With Chronic Opioid Use? A 4-Year Follow-Up of Intensive Care Unit Survivors

PURPOSE

To describe opioid use before and after intensive care unit (ICU) admission and to identify factors associated with chronic opioid use upto 4 years after ICU discharge.

METHODS

Retrospective review of adult patients admitted to the ICU at a tertiary care center between January 1, 2005, to December 31, 2008. We defined "nonuser," "intermittent," and "chronic" opioid status by abstinence, use in <70%, and >70% of days for a given time period, respectively. We assessed opioid use at 3 months prior to ICU admission, at discharge, and annually for upto 4 years following ICU discharge.

RESULTS

A total of 2595 ICU patients were included for surgical (48.6%), medical (38.4%), and undetermined (13%) indications. The study population included both elective (26.9%) and emergent (73.1%) admissions. Three months prior to ICU admission, 76.9% were nonusers, 16.9% used opioids intermittently, and 6.2% used opioids chronically. We found an increase in nonuser patients from 87.8% in the early post-ICU period to 95.6% at 48-month follow-up. Consequently, intermittent and chronic opioid use dropped to 8.6% and 3.6% at discharge and 2.6% and 1.8% at 48-month follow-up, respectively. Prolonged hospital length of stay was associated with chronic opioid use.

CONCLUSION

Admission to ICU and duration of ICU stay were not associated with chronic opioid use.

Low dispositional mindfulness predicts self-medication of negative emotion with prescription opioids

OBJECTIVES

Although evidence is mounting that opioids are abused to self-medicate negative emotions, little is known about the traits and factors linked to opioid self-medication. One potentially crucial psychological correlate is dispositional mindfulness. Thus, the purpose of this study was to describe the prevalence of opioid self-medication among a treatment-seeking sample of prescription opioid-dependent individuals and specifically examine the relationship between dispositional mindfulness and opioid self-medication.

METHODS

Participants in acute detoxification or intensive outpatient treatment for prescription opioid dependence (n = 79) were recruited from a regional hospital's addictions treatment unit for this cross-sectional study. Sociodemographic data were collected along with surveys of opioid self-medication, pain level, and dispositional mindfulness.

RESULTS

Self-medication of negative affective states with opioids was quite common, with 94.9% of individuals sampled reporting self-medication behaviors. In adjusted analyses, individuals engaging in more frequent opioid use tended to self-medicate negative emotions with opioids more often than those engaging in more intermittent opioid use (β = 0.33; P < 0.05). Importantly, irrespective of opioid use frequency and other clinical and sociodemographic covariates, dispositional mindfulness was inversely associated with opioid self-medication (β = -0.42; P < 0.001), such that less mindful individuals reported using opioids more frequently to self-medicate negative emotions.

CONCLUSIONS

Self-medication of negative emotions with opioids was prevalent in this sample and related to low dispositional mindfulness. Plausibly, increasing mindfulness may decrease opioid self-medication. Addictive automaticity and emotion regulation are discussed as potential mechanisms linking low dispositional mindfulness and self-medication.

Methadone related deaths compared to all prescription related deaths

BACKGROUND

Methadone is increasingly implicated in unintentional overdose deaths. Despite major interventions, rates continue to remain high. One primary intervention, Prescription Drug Monitoring Programs (PDMP) are limited in their ability to impact this epidemic due to federal law restricting Opioid Treatment Programs (OTPs) from sharing data to PDMPs, despite being a major source of Methadone dispensing.

METHODS

This retrospective, observational study analyzed all prescription-related deaths occurring in San Diego County during the year 2013 with a specific focus on methadone-related deaths. All patients designated by medical examiner to have died by unintentional prescription were then referenced in the California PDMP, the Controlled Substance Utilization Review and Evaluation System (CURES).

RESULTS

As a whole, patients who died had a high number of average prescriptions, 21, and averaged 4.5 different providers, and three different pharmacies. Methadone-related deaths (MRD) accounted for 46 out of the 254 total patient deaths (18.1%). Methadone prescriptions were found in 14 patients with PDMP reports, 10 of who had methadone on toxicology report. Notably, 100% of methadone prescribed by primary care specialists. MRD patients were less likely to have toxicology reports matching PDMP data compared to other related drug deaths (20.6 vs. 61.2%, p<0.0001). Of the 46 methadone deaths, only 10 (29.4%) had prescriptions for methadone recorded in the database. Out of the 51 patients with only one drug recorded at death, methadone was most common (n=12; 23.5%). While all deaths had a notably high rate of chronic prescriptions at death (68.8% compared to 2% for all patients in CURES), there was no significant difference between MRD and other drug-related deaths (73.5 vs. 67.8%, p=0.68, respectively). MRD patients were less likely than other drug patients to have matching PDMP data without any illicit substance or alcohol (14.7 vs. 41.4%, p=0.003, respectively).

CONCLUSION

Methadone is a long-acting opioid that carries a higher risk profile than other opioids. In San Diego, the great majority of MRD had no data on methadone in the statewide PDMP database, bringing to question the restriction of OTP clinics from uploading information into the database. A risk-benefit analysis should be made to consider changing laws that would allow for OTP to input data into PDMP. OTP should make it standard of care to check PDMP data on their patients. Methadone prescribed for pain management should be limited to the most compliant patients.

Patients' knowledge of pain agreements

This study was conducted to determine patients' knowledge of pain agreements.

METHODS

Descriptive quantitative survey design. A 28-item questionnaire regarding patients' knowledge of pain agreements was distributed to pain management office patients.

RESULTS

Participants (N = 76) scored 30%-100% (mean 80%) on knowledge of 10 pain agreement items.

CONCLUSIONS

Patients demonstrated moderate knowledge of terms.

Treating Diabetic Neuropathy: Present Strategies and Emerging Solutions

Diabetic peripheral neuropathies (DPN) are a heterogeneous group of disorders caused by neuronal dysfunction in patients with diabetes. They have differing clinical courses, distributions, fiber involvement (large or small), and pathophysiology. These complications are associated with increased morbidity, distress, and healthcare costs. Approximately 50% of patients with diabetes develop peripheral neuropathy, and the projected rise in the global burden of diabetes is spurring an increase in neuropathy. Distal symmetrical polyneuropathy (DSPN) with painful diabetic neuropathy, occurring in around 20% of diabetes patients, and diabetic autonomic neuropathy (DAN) are the most common manifestations of DPN. Optimal glucose control represents the only broadly accepted therapeutic option though evidence of its benefit in type 2 diabetes is unclear. A number of symptomatic treatments are recommended in clinical guidelines for the management of painful DPN, including antidepressants such as amitriptyline and duloxetine, the γ-aminobutyric acid analogues gabapentin and pregabalin, opioids, and topical agents such as capsaicin. However, monotherapy is frequently not effective in achieving complete resolution of pain in DPN. There is a growing need for head-to-head studies of different single-drug and combination pharmacotherapies. Due to the ubiquity of autonomic innervation in the body, DAN causes a plethora of symptoms and signs affecting cardiovascular, urogenital, gastrointestinal, pupillomotor, thermoregulatory, and sudomotor systems. The current treatment of DAN is largely symptomatic, and does not correct the underlying autonomic nerve deficit. A number of novel potential candidates, including erythropoietin analogues, angiotensin II receptor type 2 antagonists, and sodium channel blockers are currently being evaluated in phase II clinical trials.

Narcotic use and misuse in Crohn's disease

BACKGROUND

The rate of narcotic misuse in the inflammatory bowel disease population is not well studied. The primary aim of this study was to determine in Crohn's disease (CD) whether a concurrent functional gastrointestinal disorder (FGID) was associated with increased rates of chronic narcotic use. Second, we aimed to identify potential risk factors for narcotic misuse.

METHODS

A retrospective chart review of patients with CD followed at the University of Virginia's Gastroenterology Clinic from 2006 to 2011 was performed. The prescription monitoring program was accessed to confirm narcotic prescription filling histories. Narcotic misuse was defined as narcotic prescriptions filled from 4 or more prescribers and at 4 or more different pharmacies.

RESULTS

Nine hundred thirty-one patients with CD were included in the study cohort. Eighty-seven (9.3%) patients were identified as having a concurrent FGID, and 192 (20%) were taking chronic narcotics. Patients with FGID were more likely to be taking chronic narcotics (44% versus 18%, P < 0.001). Thirty-seven percent (32/87) of patients with an FGID were misusing narcotics, compared with 9.6% (81/844) (P < 0.0001). Multivariate logistic regression demonstrated a significant association of misuse in patients with a concurrent FGID (odds ratio = 3.33, 95% confidence interval, 1.87-5.93).

CONCLUSIONS

Twenty percent of patients with CD were using chronic narcotics with higher rates in those with FGID. Using the prescription monitoring program, a significant proportion of patients with CD with an FGID were misusing narcotics. We would recommend screening for narcotic misuse in patients with CD with a concomitant FGID and consider using prescription monitoring programs to identify others at risk for misuse.

Abuse and misuse of antidepressants

BACKGROUND

Rates of prescription drug abuse have reached epidemic proportions. Large-scale epidemiologic surveys of this under-recognized clinical problem have not included antidepressants despite their contribution to morbidity and mortality. The purpose of this review is to look specifically at the misuse of antidepressants and how this behavior may fit into the growing crisis of nonmedical use of prescription drugs.

METHODS

We conducted a comprehensive search on PubMed, Medline, and PsycINFO using the search terms "antidepressant", "abuse", "misuse", "nonmedical use", "dependence", and "addiction", as well as individual antidepressant classes (eg, "SSRI") and individual antidepressants (eg, "fluoxetine") in various combinations, to identify articles of antidepressant misuse and abuse.

RESULTS

A small but growing literature on the misuse and abuse of antidepressants consists largely of case reports. Most cases of antidepressant abuse have occurred in individuals with comorbid substance use and mood disorders. The most commonly reported motivation for abuse is to achieve a psychostimulant-like effect. Antidepressants are abused at high doses and via a variety of routes of administration (eg, intranasal, intravenous). Negative consequences vary based upon antidepressant class and pharmacology, but these have included seizures, confusion, and psychotic-like symptoms.

CONCLUSION

The majority of individuals prescribed antidepressants do not misuse the medication. However, certain classes of antidepressants do carry abuse potential. Vulnerable patient populations include those with a history of substance abuse and those in controlled environments. Warning signs include the presence of aberrant behaviors. Physicians should include antidepressants when screening for risky prescription medication use. When antidepressant misuse is detected, a thoughtful treatment plan, including referral to an addiction specialist, should be developed and implemented.

Hair drug testing results and self-reported drug use among primary care patients with moderate-risk illicit drug use

BACKGROUND

This study sought to examine the utility of hair testing as a research measure of drug use among individuals with moderate-risk drug use based on the internationally validated Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST).

METHODS

This study is a secondary analysis using baseline data from a randomized trial of brief intervention for drug misuse, in which 360 adults with moderate-risk drug use were recruited from two community clinics in New Mexico, USA. The current study compared self-reported drug use on the ASSIST with laboratory analysis of hair samples using a standard commercially available 5-panel test with assay screening and gas chromatography/mass spectrometry (GC/MS) confirmation. Both self-report and hair testing covered a 3-month period.

RESULTS

Overall concordance between hair testing and self-report was 57.5% (marijuana), 86.5% (cocaine), 85.8% (amphetamines), and 74.3% (opioids). Specificity of hair testing at standard laboratory cut-offs exceeded 90% for all drugs, but sensitivity of hair testing relative to self-report was low, identifying only 52.3% (127/243) of self-disclosed marijuana users, 65.2% (30/46) of cocaine users, 24.2% (8/33) of amphetamine users, and 2.9% (2/68) of opioid users. Among participants who disclosed using marijuana or cocaine in the past 3 months, participants with a negative hair test tended to report lower-frequency use of those drugs (p<.001 for marijuana and cocaine).

CONCLUSIONS

Hair testing can be useful in studies with moderate-risk drug users, but the potential for under-identification of low-frequency use suggests that researchers should consider employing low detection cut-offs and using hair testing in conjunction with self-report.

Opioids induce dissociable forms of long-term depression of excitatory inputs to the dorsal striatum

As prescription opioid analgesic abuse rates rise, so does the need to understand the long-term effects of opioid exposure on brain function. The dorsal striatum is an important site for drug-induced neuronal plasticity. We found that exogenously applied and endogenously released opioids induced long-term depression (OP-LTD) of excitatory inputs to the dorsal striatum in mice and rats. Mu and delta OP-LTD, although both being presynaptically expressed, were dissociable in that they summated, differentially occluded endocannabinoid-LTD and inhibited different striatal inputs. Kappa OP-LTD showed a unique subregional expression in striatum. A single in vivo exposure to the opioid analgesic oxycodone disrupted mu OP-LTD and endocannabinoid-LTD, but not delta or kappa OP-LTD. These data reveal previously unknown opioid-mediated forms of long-term striatal plasticity that are differentially affected by opioid analgesic exposure and are likely important mediators of striatum-dependent learning and behavior.

The prevalence of diagnosed opioid abuse in commercial and Medicare managed care populations

PURPOSE

To measure the prevalence of diagnosed opioid abuse and prescription opioid use in a multistate managed care organization.

METHODS

This retrospective claims data analysis reviewed the prevalence of diagnosed opioid abuse and the parallel prevalence of prescription opioid use in half-year intervals for commercial and Medicare members enrolled with Humana Inc., from January 1, 2008 to June 30, 2010. Diagnosis of opioid abuse was defined by ≥ 1 medical claim with any of the following ICD-9-CM codes: 304.0 ×, 304.7 ×, 305.5 ×, 965.0 ×, excluding 965.01, and opioid use was defined by ≥ 1 filled prescription for an opioid. The prevalence of opioid abuse was defined by the number of members with an opioid abuse diagnosis, divided by the number of members enrolled in each 6-month interval.

RESULTS

The 6-month prevalence of diagnosed opioid abuse increased from 0.84 to 1.15 among commercial and from 3.17 to 6.35 among Medicare members, per 1,000. In contrast, there was no marked increase in prescription opioid use during the same time period (118.0 to 114.8 for commercial members, 240.6 to 256.9 for Medicare members, per 1,000). The prevalence of diagnosed opioid abuse was highest among members younger than 65 years for both genders in commercial (18- to 34-year-olds) and Medicare (35- to 54-year-olds) populations.

CONCLUSIONS

Despite a stable rate of prescription opioid use among the observed population, the prevalence of diagnosed opioid abuse is increasing, particularly in the Medicare population.

Lessons learned in the abuse of pain-relief medication: a focus on healthcare costs

The increasing prevalence of chronic pain with its major societal impact and the escalating use of opioids in managing it, along with their misuse, abuse, associated fatalities and costs, are epidemics in modern medicine. Over the past two decades, multiple lessons have been learned addressing various issues of abuse. Multiple measures have already been incorporated and more are expected to be incorporated in the future, which in turn may curtail the abuse of drugs and reduce healthcare costs, but these measures may also jeopardize access to appropriate pain treatment. This manuscript describes the lessons learned from the misuse, abuse and diversion of opioids, escalating healthcare costs and the means to control this epidemic.

Comparison of a drug versus money and drug versus drug self-administration choice procedure with oxycodone and morphine in opioid addicts

This double-blind, placebo-controlled study investigated the effects of oral morphine (0, 45, 135 mg/70 kg) and oral oxycodone (0, 15, 45 mg/70 kg) on buprenorphine-maintained opioid addicts. As a 3: 1 morphine : oxycodone oral dose ratio yielded equivalent subjective and physiological effects in nondependent individuals, this ratio was used in the present study. Two self-administration laboratory procedures - that is, a drug versus money and a drug versus drug procedure - were assessed. Study participants (N=12) lived in the hospital and were maintained on 4 mg/day sublingual buprenorphine. When participants chose between drug and money, money was preferred over all drug doses; only high-dose oxycodone was self-administered more than placebo. When participants chose between drug and drug, both drugs were chosen more than placebo, high doses of each drug were chosen over low doses, and high-dose oxycodone was preferred over high-dose morphine. The subjective, performance-impairing, and miotic effects of high-dose oxycodone were generally greater than those of high-dose morphine. The study demonstrated that a 3: 1 oral dose ratio of morphine : oxycodone was not equipotent in buprenorphine-dependent individuals. Both self-administration procedures were effective for assessing the relative reinforcing effects of drugs; preference for one procedure should be driven by the specific research question of interest.

The downward spiral of chronic pain, prescription opioid misuse, and addiction: cognitive, affective, and neuropsychopharmacologic pathways

Prescription opioid misuse and addiction among chronic pain patients are emerging public health concerns of considerable significance. Estimates suggest that more than 10% of chronic pain patients misuse opioid analgesics, and the number of fatalities related to nonmedical or inappropriate use of prescription opioids is climbing. Because the prevalence and adverse consequences of this threat are increasing, there is a pressing need for research that identifies the biobehavioral risk chain linking chronic pain, opioid analgesia, and addictive behaviors. To that end, the current manuscript draws upon current neuropsychopharmacologic research to provide a conceptual framework of the downward spiral leading to prescription opioid misuse and addiction among chronic pain patients receiving opioid analgesic pharmacotherapy. Addictive use of opioids is described as the outcome of a cycle initiated by chronic pain and negative affect and reinforced by opioidergic-dopamingeric interactions, leading to attentional hypervigilance for pain and drug cues, dysfunctional connectivity between self-referential and cognitive control networks in the brain, and allostatic dysregulation of stress and reward circuitry. Implications for clinical practice are discussed; multimodal, mindfulness-oriented treatment is introduced as a potentially effective approach to disrupting the downward spiral and facilitating recovery from chronic pain and opioid addiction.

Long-term opioid treatment of chronic nonmalignant pain: unproven efficacy and neglected safety?

BACKGROUND

For the past 30 years, opioids have been used to treat chronic nonmalignant pain. This study tests the following hypotheses: (1) there is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective; and (2) the main problem associated with the safety of such treatment - assessment of the risk of addiction - has been neglected.

METHODS

Scientometric analysis of the articles representing clinical research in this area was performed to assess (1) the quality of presented evidence (type of study); and (2) the duration of the treatment phase. The sufficiency of representation of addiction was assessed by counting the number of articles that represent (1) editorials; (2) articles in the top specialty journals; and (3) articles with titles clearly indicating that the addiction-related safety is involved (topic-in-title articles).

RESULTS

Not a single randomized controlled trial with opioid treatment lasting >3 months was found. All studies with a duration of opioid treatment ≥6 months (n = 16) were conducted without a proper control group. Such studies cannot provide the consistent good-quality evidence necessary for a strong clinical recommendation. There were profound differences in the number of addiction articles related specifically to chronic nonmalignant pain patients and to opioid addiction in general. An inadequate number of chronic pain-related publications were observed with all three types of counted articles: editorials, articles in the top specialty journals, and topic-in-title articles.

CONCLUSION

There is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective. The above identified signs indicating neglect of addiction associated with the opioid treatment of chronic nonmalignant pain were present.

Buprenorphine—Clinically useful but often misunderstood

Background

There are a number of false myths about buprenorphine based on unconfirmed animal data, even from isolated animal organs, and early clinical research. These myths came into textbooks on pharmacology and pain about 30 years ago and have been difficult to eradicate. Animal models of pain and pain relief are notoriously unreliable as predictors of human clinical effects. The fact is that in clinical practice there is NO bell-shaped dose-response curve, there is NO plateau on the dose-response curve, and there is NO antagonist effect from buprenorphine on other mu-opioid agonists.

Methods

This narrative, topical review of relevant research publications evaluates new knowledge on the pharmacodynamics and pharmacokinetics of buprenorphine of importance in clinical practice.

Results

Buprenorphine is a potent opioid analgesic acting on all four opioid receptors: it is an agonist on the mu-, the delta, and the ORL-1 receptors. It is an antagonist at the kappa-receptor. Buprenorphine has a number of active metabolites with different effects on the four opioid receptors; all except the norbup-3-glu are analgesic. Buprenorphine itself is not a respiratory depressant or sedative, but some of its active metabolites are. Buprenorphine and its active metabolites are not excreted by the kidney. Therefore buprenorphine may be used in patients with advanced renal failure.

Buprenorphine has a slow onset and a long offset. These properties are advantageous, except sometimes when treating severe acute pain. Its agonist effect on the ORL-1 receptor reduces reward-effects and slows the development of tolerance to the analgesic effects.

Buprenorphine inhibits voltage-gated sodium-channels and enhances and prolongs peripheral nerve blocks. Its ORL-1 -effect at the spinal cord may do the same.

Buprenorphine is well suited for treatment of chronic pain, especially chronic neuropathic pain and cancer pain. The beneficial effects as a co-medication during treatment of the opioid-abuse disease are due to its slow onset (less “kick-effect”). Its prolonged offset-time reduces the likelihood of acute withdrawal problems and reduces the “craving” of opioids.

Adverse effects

Buprenorphine, being a mu-agonist, may induce or maintain opioid addiction. Illegally obtained high-dose transmucosal buprenorphine, intended for treatment of addiction, is dissolved and injected by opioid abusers. This is an increasing problem in some countries.

Conclusions

Buprenorphine’s unusual pharmacodynamics and pharmacokinetics make it an ideal opioid for treatment of most chronic pain conditions where opioid therapy is indicated.

Implications

Buprenorphine is a well studied and often misunderstood analgesic opioid drug. The evidence base predicts that it will be an increasingly important alternative for treatment of chronic pain conditions caused by cancer and non-cancer diseases. It will continue to be an attractive alternative to methadone for opioid abuse rehabilitation.

Topical analgesics in the management of acute and chronic pain

Oral analgesics are commonly prescribed for the treatment of acute and chronic pain, but these agents often produce adverse systemic effects, which sometimes are severe. Topical analgesics offer the potential to provide the same analgesic relief provided by oral analgesics but with minimal adverse systemic effects. This article describes the results of a systematic review of the efficacy of topical analgesics in the management of acute and chronic pain conditions. A literature search of MEDLINE/PubMed was conducted using the keywords topical analgesic AND chronic pain OR acute pain OR neuropathic pain and focused only on individual clinical trials published in English-language journals. The search identified 92 articles, of which 65 were eligible for inclusion in the review. The most commonly studied topical analgesics were nonsteroidal anti-inflammatory drugs (n=27), followed by lidocaine (n=9), capsaicin (n=6), amitriptyline (n=5), glyceryl trinitrate (n=3), opioids (n=2), menthol (n=2), pimecrolimus (n=2), and phenytoin (n=2). The most common indications were acute soft tissue injuries (n=18), followed by neuropathic pain (n=17), experimental pain (n=6), osteoarthritis and other chronic joint-related conditions (n=5), skin or leg ulcers (n=5), and chronic knee pain (n=2). Strong evidence was identified for the use of topical diclofenac and topical ibuprofen in the treatment of acute soft tissue injuries or chronic joint-related conditions, such as osteoarthritis. Evidence also supports the use of topical lidocaine in the treatment of postherpetic neuralgia and diabetic neuropathy. Currently, limited evidence is available to support the use of other topical analgesics in acute and chronic pain.

Do initial responses to drugs predict future use or abuse?

Individuals vary in their initial reactions to drugs of abuse in ways that may contribute to the likelihood of subsequent drug use. In humans, most drugs of abuse produce positive subjective states such as euphoria and feelings of well-being, which may facilitate repeated use. In nonhumans, many drugs initially increase locomotor activity and produce discriminative stimulus effects, both of which have been considered to be models of human stimulant and subjective states. Both humans and nonhumans vary in their sensitivity to early acute drug effects in ways that may predict future use or self-administration, and some of these variations appear to be genetic in origin. However, it is not known exactly how the initial responses to drugs in either humans or nonhumans relate to subsequent use or abuse. In humans, positive effects of drugs facilitate continued use of a drug while negative effects discourage use, and in nonhumans, greater genetic risk for drug intake is predicted by reduced sensitivity to drug aversive effects; but whether these initial responses affect escalation of drug use, and the development of dependence is currently unknown. Although early use of a drug is a necessary step in the progression to abuse and dependence, other variables may be of greater importance in the transition from use to abuse. Alternatively, the same variables that predict initial acute drug effects and early use may significantly contribute to continued use, escalation and dependence. Here we review the existing evidence for relations between initial direct drug effects, early use, and continued use. Ultimately, these relations can only be determined from systematic longitudinal studies with comprehensive assessments from early drug responses to progression of problem drug use. In parallel, additional investigation of initial responses in animal models as predictors of drug use will shed light on the underlying mechanisms.