Gender differences in prescription opioid use and misuse: Implications for men's health and the opioid epidemic

Sex Disparities in Opioid Prescription and Administration on a Hospital Medicine Service

INTRODUCTION

Decisions to prescribe opioids to patients depend on many factors, including illness severity, pain assessment, and patient age, race, ethnicity, and gender. Gender and sex disparities have been documented in many healthcare settings, but are understudied in inpatient general medicine hospital settings.

OBJECTIVE

We assessed for differences in opioid administration and prescription patterns by legal sex in adult patient hospitalizations from the general medicine service at a large urban academic center.

DESIGNS, SETTING, AND PARTICIPANTS

This study included all adult patient hospitalizations discharged from the acute care inpatient general medicine services at the University of California, San Francisco (UCSF) Helen Diller Medical Center at Parnassus Heights from 1/1/2013 to 9/30/2021.

MAIN OUTCOME AND MEASURES

The primary outcomes were (1) average daily inpatient opioids received and (2) days of opioids prescribed on discharge. For both outcomes, we first performed logistic regression to assess differences in whether or not any opioids were administered or prescribed. Then, we performed negative binomial regression to assess differences in the amount of opioids given. We also performed all analyses on a subgroup of hospitalizations with pain-related diagnoses.

RESULTS

Our study cohort included 48,745 hospitalizations involving 27,777 patients. Of these, 24,398 (50.1%) hospitalizations were female patients and 24,347 (49.9%) were male. Controlling for demographic, clinical, and hospitalization-level variables, female patients were less likely to receive inpatient opioids compared to male patents (adjusted OR 0.87; 95% CI 0.82, 0.92) and received 27.5 fewer morphine milligram equivalents per day on average (95% CI - 39.0, - 16.0). When considering discharge opioids, no significant differences were found between sexes. In the subgroup analysis of pain-related diagnoses, female patients received fewer inpatient opioids.

CONCLUSIONS

Female patients were less likely to receive inpatient opioids and received fewer opioids when prescribed. Future work to promote equity should identify strategies to ensure all patients receive adequate pain management.

Opioid prescribing in the Netherlands during the COVID-19 pandemic: a national register-based study

OBJECTIVES

The COVID-19 pandemic and related lockdown measures disrupted global healthcare provision, including opioid prescribing. In North America, opioid sales declined while opioid-related deaths increased. In Europe, the effect of the pandemic on prescribing is not yet known. Given the ongoing increase in opioid-related harm and mortality, it is crucial to analyse the impact of the COVID-19 crisis and lockdown measures on opioid prescribing. Therefore, the objective of this study was to characterise opioid prescribing in the Netherlands during the COVID-19 pandemic.

DESIGN

A nationwide register-based study characterising opioid prescribing using aggregated insurance reimbursement data.

SETTING

Dutch healthcare during the first 2 years of the COVID lockdown.

PARTICIPANTS

The whole Dutch population.

PRIMARY AND SECONDARY OUTCOME MEASURES

Comparing the number of opioid prescriptions during the pandemic with a prepandemic period using a risk ratio (RR), with separate analysis on the prescription type (first-time or repeat prescription), patients' sex, age and socioeconomic status. We also explored lockdown effects.

RESULTS

During the first lockdown, the total number of new opioid prescriptions and prescriptions to young patients (briefly) decreased (RR 0.88, 95% CI 0.88 to 0.89 and RR 0.73, 95% CI 0.70 to 0.75, respectively), but the overall number of opioid prescriptions remained stable throughout the pandemic compared with prepandemic. Women, older patients and patients living in lower socioeconomic areas received more opioids per capita, but the pandemic did not amplify these differences.

CONCLUSIONS

The pandemic appears to have had a limited impact on opioid prescribing in the Netherlands. Yet, chronic use of opioids remains an important public health issue.

Concurrent and lagged associations among pain medication use, pain, and negative affect: a daily diary study of people with chronic low back pain

ABSTRACT

People with chronic pain often attempt to manage pain and concurrent emotional distress with analgesic substances. Habitual use of such substances-even when not opioid-based-can pose side effect risks. A negative reinforcement model has been proposed whereby relief of pain and emotional distress following medication consumption increases the likelihood that the experience of elevated pain and distress will spur further medication use. People with chronic low back pain (N = 105) completed electronic diary assessments 5 times/day for 14 consecutive days. Lagged and cross-lagged analyses focused on links between time 1 pain and negative affect (NA) and time 2 analgesic medication use and vice versa. Sex differences were also explored. Primary results were as follows: (1) participants on average reported taking analgesic medication during 41.3% of the 3-hour reporting epochs (29 times over 14 days); (2) time 1 within-person increases in pain and NA predicted time 2 increases in the likelihood of ingesting analgesic medications; (3) time 1 within-person increases in medication use predicted time 2 decreases in pain and NA; and (4) lagged associations between time 1 pain/NA and time 2 medication use were strongest among women. Findings suggest that the use of analgesic medications for many people with chronic pain occurs frequently throughout the day. Results support the validity of a negative reinforcement model where pain and distress lead to pain medication use, which in turn leads to relief from pain and distress.

Associations between cannabis use, opioid misuse and severe psychological distress in adolescents: A cross-sectional school-based study

BACKGROUND

Cannabis use and nonmedical use of prescription opioids are consumed by a small to moderate number of adolescents. However, little is known about their combined influence on mental health in this age group. This study examined the association between cannabis use, nonmedical use of prescription opioids, or both with serious psychological distress among adolescents and tested if sex could moderate these associations.

METHODS

We based our analyses on cross-sectional data from the 2019 Ontario Student Drug Use and Health Survey, a provincially representative sample of students in grades 7 through 12 (aged 11-20 years or older) across Ontario, Canada (n= 7097; mean age: 15.2 ± 1.2 years). Logistic regression analyses were adjusted for important covariates.

RESULTS

We found that 20.5% reported cannabis use only, 5.8% reported opioid use only, and 5% reported both cannabis and opioid use. Cannabis use only (odds ratio [OR]:1.91; 95% confidence interval [CI]:1.53-2.37), opioid use only (OR: 2.21; 95% CI: 1.63-3.00), and both cannabis and opioid use (OR: 3.24; 95% CI: 2.25-4.66) were associated with greater odds of serious psychological distress after adjustment for covariates. Associations were similar for males and females.

CONCLUSION

The use of both cannabis and opioids is significantly associated with serious psychological distress among adolescents. Adolescents who use both cannabis and opioids represent a small and vulnerable group that should be targeted in future interventions against mental health problems. Health professionals should consider screening for polysubstance use, especially when working with adolescents who use cannabis.

Cigarette and e-cigarette use trajectories and prospective prescription psychotherapeutic drug misuse among adolescents and young adults

OBJECTIVE

This study aimed to determine the potential longitudinal impact of different cigarette and e-cigarette use trajectories among people aged 10-24 on prescription drug misuse of psychotherapeutic drugs.

METHODS

Data came from waves 1-5 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2019; n = 14,454). Group-based trajectory modeling identified groups of adolescents and young adults based on cigarette and e-cigarette use across the five waves. Weighted logistic regression models were fit to examine the association of group membership with two outcomes at all waves: 1) misuse of opioids, sedatives, and/or tranquilizers, and 2) misuse of Ritalin and/or Adderall, adjusting for background characteristics.

RESULTS

Five trajectory groups emerged: (1) non-use (77.7 %); (2) early-onset cigarette use with reducing use (4.6 %); (3) ever-increasing e-cigarette use (6.1 %); (4) stable dual use of cigarettes and e-cigarettes (3.2 %); and (5) accelerating dual use of cigarettes and e-cigarettes (8.4 %). In comparison to the non-use group, all other groups had significantly higher odds of misuse of opioids, tranquilizers, and/or sedatives and all but the early-onset cigarette use with reducing use group had significantly higher odds of misuse of Ritalin and/or Adderall by the end of wave 5.

DISCUSSION

Patterns of cigarette and e-cigarette use in adolescent and young adult populations may serve as important indicators for concurrent and prospective prescription psychotherapeutic drug misuse. Findings highlight the need for cigarette and e-cigarette use prevention, harm reduction, and/or cessation efforts among adolescents and young adults.

Morphine-context associative memory and locomotor sensitization in mice are modulated by sex and context in a dose-dependent manner

Sex differences in opioid use, development of opioid used disorder, and relapse behaviors indicate potential variations in opioid effects between men and women. The locomotor and interoceptive effects of opioids play essential roles in opioid addiction, and uncovering the neural mechanisms underlying these effects remain crucial for developing effective treatments. In this study, we examined the dose-dependent effects of morphine on locomotor sensitization and the strength and stability of morphine-context associations in the conditioned place preference (CPP) paradigm in male and female mice, as well as the relationships between these measures. We observed that while CPP is similar between sexes, the locomotor effects of repeated morphine administration and withdrawal differentially contributed to the strength and stability of morphine-context associations. Specifically, females exhibited higher morphine-induced hyperlocomotion than males regardless of the context in which morphine was experienced. Greater locomotor sensitization to morphine in females than males emerged in a dose-dependent manner only when there was sufficient context information for CPP to be established. Additionally, the relationships between the locomotor effects of morphine and the strength and stability of CPP were different in males and females. In females, positive acute and sensitizing locomotor effects of morphine were correlated with a higher CPP score, while the opposite direction of this relationship was found in males. These results suggest that different aspects of the subjective experience of morphine intoxication and withdrawal are important for morphine abuse-related behaviors and highlight the importance of sex-specific responses in the context of opioid addiction.

Indicators of publicly funded prescription opioid use among persons with traumatic spinal cord injury in Ontario, Canada

OBJECTIVE

To describe the proportion and identify predictors of community-dwelling individuals with traumatic spinal cord injury (TSCI) who were dispensed ≥1 publicly funded opioid in the year after injury using a retrospective cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS, INTERVENTIONS, OUTCOME MEASURES

We used administrative data to identify predictors of receiving publicly funded prescription opioids during the year after injury for individuals who were injured between April 2004 and March 2015. Our outcome was modeled using robust Poisson multivariable regression and we reported adjusted relative risks (aRR) with 95% confidence intervals.

RESULTS

In our retrospective cohort of 934 individuals with TSCI who were eligible for the provincial drug program, 510 (55%) received ≥1 prescription opioid in the year after their injury. Most individuals were male (71%) and the median age was 63 years (interquartile range: 42-72). Being male (aRR 1.15, 95% confidence interval [CI] 1.01-1.31), having chronic obstructive pulmonary disease (aRR 1.25, 95% CI 1.05-1.50), and using prescription opioids before injury (aRR 1.46, 95% CI 1.29-1.66) were significantly associated with receiving opioids in the year after TSCI. Short durations of hospital stay after injury were also identified as being a significant risk factor of outpatient opioid use (aRR = 1.28, 95% CI = 1.08-1.51) when compared to longer hospital stays.

CONCLUSION

This study presented evidence showing that most individuals eligible for Ontario's public drug program who experienced a TSCI used opioids in the year following their injury. Due to the paucity of research on this population and their potential for elevated risks of adverse events, it is important for additional studies to be conducted on opioid use in this population to understand short-term and long-term risks and benefits.

Patients Undergoing Primary, Cementless TKA had Similar Pain, Opioid Utilization, and Functional Outcomes Compared to Matched Patients With Cemented Fixation

BACKGROUND

Despite renewed interest in cementless fixation of total knee implants, many surgeons have anecdotal concerns about slower recovery and higher early pain scores. We sought to analyze 90-day opioid utilizations, inhospital pain scores, and patient-reported outcome measures (PROMs) in patients undergoing primary cemented versus cementless total knee arthroplasty (TKA).

METHODS

We retrospectively identified a cohort of opioid naïve patients undergoing primary TKA for osteoarthritis. There were 186 patients who had cementless TKAs matched 1:6 with 1,116 who received a cemented TKAs based on age (±6 years), body mass index (BMI) (±5), and sex. We compared inhospital pain scores, 90-day opioid utilizations in morphine milligram equivalents (MMEs), and early postoperative PROMs.

RESULTS

The cemented and cementless cohorts had similar lowest (0.09 versus 0.08), highest (7.36 versus 7.34), and average (3.26 versus 3.27) pain scores using numeric rating scale (P > .05). They received similar inhospital (90 versus 102, P = .176), discharge (315 versus 315, P = .483), and total (687 versus 720, P = .547) MMEs. They had similar average inpatient hourly opioid consumption (2.5 versus 2.5 MMEs/hour, P = .965). Average refills 90 days postoperatively were similar in both cohorts (1.5 versus 1.4 refills, P = .893). Also, preoperative, 6-week, 3-month, delta 6-week, and delta 3-month PROMs scores were similar between cemented and cementless cohorts (P > .05) CONCLUSION: This matched study demonstrated similar in-hospital pain scores and opioid utilization, total MMEs prescribed within 90 days, and PROMs at 6 weeks and 3 months postoperatively between cemented and cementless TKAs.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Sense of control and likelihood of prescription drug misuse 10-years later among middle-aged and older adults

Objectives: Sense of control (i.e. one's beliefs about their ability to influence life circumstances) has been linked to various psychological outcomes. However, it is unknown if sense of control is protective against prescription drug misuse (PDM). The present study sought to evaluate if sense of control is associated with reduced odds of PDM 9 to 10 years later among a sample of middle-aged and older adults.Methods: Data were evaluated from participants (M = 54 years, SD = 10.86; N = 2,108) of the second and third waves of the Midlife in the United States study. Logistic regression models were used to assess whether baseline sense of control (Wave 2) predicted odds of PDM 9 to 10 years later (Wave 3).Results: Findings revealed that greater sense of control at baseline was related to reduced odds of subsequent PDM (OR = 0.78; 95% CI: 0.64, 0.95), adjusting for baseline PDM, sociodemographic characteristics, health behaviors, psychological factors, number of prescription medications, and health. When assessing the subscales of sense of control separately, constraints (OR = 1.19; 95% CI: 1.00, 1.42), but not mastery (OR = 0.96; 95% CI: 0.80, 1.12), was predictive of odds of subsequent PDM. Further, being female was associated with greater odds of PDM (OR = 1.46; 95% CI: 1.02, 2.09), but did not moderate the association between sense of control and PDM.Conclusions: Sense of control may be a novel and viable target for interventions (e.g. using mobile phone apps) aimed at mitigating prescription drug misuse.

Intergenerational consequences of adolescent morphine exposure on learning and memory

Drug addiction is a worldwide social and medical disorder. More than 50 percent of drug abusers start their substance abuse in adolescence between the ages of 15-19. Adolescence is a sensitive and crucial period for the development and maturity of the brain. Chronic exposure to morphine, particularly during this period, lead to long-lasting effects, including effects that extend to the next generation. The current study examined the intergenerational effects of paternal morphine exposure during adolescence on learning and memory. In this study, male Wistar rats were exposed to increasing doses of morphine (5-25 mg/kg, s.c.) or saline for 10 days at postnatal days (PND) 30-39 during adolescence. Following a 20-day drug-free period, the treated male rats were mated with naïve females. Adult male offspring (PND 60-80) were tested for working memory, novel object recognition memory, spatial memory, and passive avoidance memory using the Y-Maze, novel object recognition, Morris water maze, and shuttle box tests, respectively. The spontaneous alternation (as measured in the Y-Maze test) was significantly less in the morphine-sired group compared to the saline-sired one. The offspring showed significantly less discrimination index in the novel object recognition test when compared to the control group. Morphine-sired offspring tended to spend significantly more time in the target quadrant and less escape latency in the Morris water maze on probe day when compared to the saline-sired ones. The offspring showed significantly less step-through latency to enter the dark compartment compared to the control group when measured in the shuttle box test. Paternal exposure to morphine during adolescence impaired working, novel object recognition, and passive avoidance memory in male offspring. Spatial memory changed in the morphine-sired group compared to the saline-sired one.

Sex differences in the associations of non-medical use of prescription drugs with depressive and anxiety symptoms among undergraduates in China

BACKGROUND

Non-medical use of prescription drugs (NMUPD) and their association with depression and anxiety are becoming global concerns. Biological sex may introduce differential exposure to NMUPD or depressive/anxiety symptoms. However, few studies have investigated the potential sex differences in the associations of NMUPD with depressive/anxiety symptoms.

METHODS

Data were drawn from the 2019 School-based Chinese College Students Health Survey. A total of 30,039 undergraduates (mean age: 19.8 [SD: 1.3] years) from sixty universities/colleges in China completed standard questionnaires and were included in the study (response rate: 97.7 %).

RESULTS

In the final adjusted model, non-medical use of opioids (experimenters: β = 1.10, [95 % CI, 0.62 to 1.57]) or sedatives (frequent users: β = 2.98, [95 % CI, 0.70 to 5.26]) was associated with depressive symptoms, while non-medical use of opioids (frequent users: β = 1.37, [95 % CI, 0.32 to 2.42]) or sedatives (frequent users: β = 1.19, [95 % CI, 0.35 to 2.03]) was also associated with anxiety symptoms. Sex-stratified analyses indicated that lifetime opioids misuse was associated with depressive symptoms in both sexes but with anxiety symptoms only in males (β = 0.39, [95 % CI, 0.09 to 0.70]). The association of lifetime sedative misuse with depressive symptoms was greater in males, while the significant association with anxiety symptoms remained only in female (β = 0.52, [95 % CI, 0.14 to 0.91]).

LIMITATIONS

Causal inference cannot be made due to the cross-sectional nature of the data.

CONCLUSIONS

Our study suggests NMUPD is associated with depressive and anxiety symptoms among Chinese undergraduates, and the associations may differ by sex.

Assessing Opioid Abuse in Chronic Pain Patients: Further Validation of the Prescription Opioid Misuse Index (POMI) Using Item Response Theory

Due the limitations of the previous validations, the purpose of this study was to further validate the Prescription Opioid Misuse Index (POMI) in a larger sample of chronic non-cancer pain (CNCP) patients and to examine differential item functioning (DIF) across sex. Participants (n=225 CNCP patients under long-term opioid therapy) completed patient characteristics, self-reported POMI and DSM-5 prescription opioid use disorder measurements. Reliability and factor structure were assessed using both item response theory and classical test theory. ROC curve analysis was used to establish the optimum cut-off score for detecting the presence of DSM-5 prescription opioid-use disorder. Concurrent validity was also tested. The POMI showed a unidimensional factor structure and acceptable internal consistency (ωcat =0.62). DIF analysis showed that males and females respond similarly to each item of the POMI, supporting unbiased measurement of the latent trait across both groups. A cut-off point of 2 is suggested in order to maximize the accuracy of the instrument as a first-screening tool for opioid misuse (AUC=0.78; p<0.001; CI 95%: 0.72–0.85). Concurrent validity of the POMI was high with DSM-5 moderate to severe opioid-use disorder criteria (OR=7.824, p<0.001). These results indicate that the POMI is a valid and clinically feasible screening instrument for detecting CNCP patients who misuse opioid medications. The short length of the scale could meet the needs of clinical practice as it allows clinicians to precisely identify and monitor prescription opioid misuse in both male and female patients.

Sex-specific inflammatory and white matter effects of prenatal opioid exposure: a pilot study

BACKGROUND

Preclinical data demonstrate that opioids modulate brain reward signaling through an inflammatory cascade, but this relationship has yet to be studied in opioid-exposed neonates.

METHODS

Saliva samples of 54 opioid-exposed and sex- and age-matched non-exposed neonates underwent transcriptomic analysis of inflammatory and reward genes. A subset of 22 neonates underwent brain magnetic resonance imaging (MRI) to evaluate white matter injury commonly associated with inflammatory response. Gene expression and brain MRI were compared between opioid- and non-exposed neonates and further stratified by sex and pharmacotherapy need.

RESULTS

Opioid-exposed females regardless of pharmacotherapy need had higher expression of inflammatory genes than their male counterparts, with notable differences in the expression of CCL2 and CXCL1 in females requiring pharmacotherapy (p = 0.01 and 0.06, respectively). Opioid-exposed males requiring pharmacotherapy had higher expression of DRD2 than exposed females (p = 0.07), validating our prior research. Higher expression of IL1β, IL6, TNFα, and IL10 was seen in opioid-exposed neonates with T1 white matter hyperintensity (WMH) compared to exposed neonates without WMH (p < 0.05).

CONCLUSION

Prenatal opioid exposure may promote inflammation resulting in changes in reward signaling and white matter injury in the developing brain, with unique sex-specific effects. The actions of opioids through non-neuronal pathways need further investigation.

IMPACT

Opioid-exposed neonates are at risk for punctate T1 white matter hyperintensity (WMH). Females carry a greater propensity for WMH. Salivary transcriptomic data showed significantly higher expression of inflammatory genes in opioid-exposed neonates with WMH than those without WMH, irrespective of pharmacotherapy need. Adding to prior studies, our findings suggest that prenatal opioid exposure may modulate white matter injury and reward signaling through a pro-inflammatory process that is sex specific. This novel study highlights the short-term molecular and structural effects of prenatal opioids and the need to elucidate the long-term impact of prenatal opioid exposure.

The endocannabinoid system and breathing

Recent changes in cannabis accessibility have provided adjunct therapies for patients across numerous disease states and highlights the urgency in understanding how cannabinoids and the endocannabinoid (EC) system interact with other physiological structures. The EC system plays a critical and modulatory role in respiratory homeostasis and pulmonary functionality. Respiratory control begins in the brainstem without peripheral input, and coordinates the preBötzinger complex, a component of the ventral respiratory group that interacts with the dorsal respiratory group to synchronize burstlet activity and drive inspiration. An additional rhythm generator: the retrotrapezoid nucleus/parafacial respiratory group drives active expiration during conditions of exercise or high CO₂. Combined with the feedback information from the periphery: through chemo- and baroreceptors including the carotid bodies, the cranial nerves, stretch of the diaphragm and intercostal muscles, lung tissue, and immune cells, and the cranial nerves, our respiratory system can fine tune motor outputs that ensure we have the oxygen necessary to survive and can expel the CO₂ waste we produce, and every aspect of this process can be influenced by the EC system. The expansion in cannabis access and potential therapeutic benefits, it is essential that investigations continue to uncover the underpinnings and mechanistic workings of the EC system. It is imperative to understand the impact cannabis, and exogenous cannabinoids have on these physiological systems, and how some of these compounds can mitigate respiratory depression when combined with opioids or other medicinal therapies. This review highlights the respiratory system from the perspective of central versus peripheral respiratory functionality and how these behaviors can be influenced by the EC system. This review will summarize the literature available on organic and synthetic cannabinoids in breathing and how that has shaped our understanding of the role of the EC system in respiratory homeostasis. Finally, we look at some potential future therapeutic applications the EC system has to offer for the treatment of respiratory diseases and a possible role in expanding the safety profile of opioid therapies while preventing future opioid overdose fatalities that result from respiratory arrest or persistent apnea.

Association between psychological pain and suicidal ideation among men with substance use disorder: a moderated mediation model

Previous studies have found that people with substance use disorder are associated with significantly higher odds of suicidal ideation than the general population. Psychological pain and emotional regulation are considered protective factors for suicidal ideation, but the interaction process is not clear. In this study, we investigated the effects of psychological pain on suicidal ideation and constructed a moderated mediation model. 445 men with substance use disorder in China were recruited to complete the Chinese version of the Psychological Pain Scale, Regulatory Emotional Self-efficacy Scale, Suicidal Ideation Scale, and Intolerance of Uncertainty Scale. The results demonstrated that psychological pain significantly and positively predicted suicidal ideation among people with substance use disorder, and that regulatory emotional self-efficacy played a mediating role between psychological pain and suicidal ideation. Intolerance of uncertainty moderated the top and bottom halves of the intermediate process paths. This study suggests that intolerance of uncertainty and regulatory emotional self-efficacy can be improved by interventions among people with substance use disorder, which in turn can reduce their suicidal ideation and improve quality of life.

Development of anxiety-like behaviors during adolescence: Persistent effects of adolescent morphine exposure in male rats

Epidemiological studies show the prevalence of opioid use, misuse and abuse in adolescents, which imposes social and economic accountability worldwide. Chronic opioid exposure, especially in adolescents, may have lasting effects on emotional behaviors that persist into adulthood. The current experiments were therefore designed to study the effects of sustained opioid exposure during adolescence on anxiety-like behaviors. Adolescent male Wistar rats underwent increasing doses of morphine for 10 days (PNDs 31-40). After that the open field test (OFT) and elevated plus maze (EPM) test were performed over a 4-week postmorphine treatment from adolescence to adulthood. Moreover, the weight of the animals was measured at these time points. We found that chronic adolescent morphine exposure reduces the weight gain during the period of morphine treatment and 4 weeks after that. It had no significant effect on the locomotor activity in the animals. Moreover, anxiolytic-like behavior was observed in the rats exposed to morphine during adolescence evaluated by OFT and EPM test. Thus, long-term exposure to morphine during adolescence has the profound potential of altering the anxiety-like behavior profile in the period from adolescence to adulthood. The maturation of the nervous system can be affected by drug abuse during the developmental window of adolescence and these effects may lead to behaviorally stable alterations.

Trajectories and correlates of opioid prescription receipt among patients experiencing interpersonal violence

Interpersonal violence increases vulnerability to the deleterious effects of opioid use. Increased opioid prescription receipt is a major contributor to the opioid crisis; however, our understanding of prescription patterns and risk factors among those with a history of interpersonal violence remains elusive. This study sought to identify 5-year longitudinal patterns of opioid prescription receipt among patients experiencing interpersonal violence within a large healthcare system and sociodemographic and clinical characteristics associated with prescription patterns. This secondary analysis examined electronic health record data from January 2004–August 2019 for a cohort of patients (N = 1,587) referred for interpersonal violence services. Latent class growth analysis was used to estimate trajectories of opioid prescription receipt over a 5-year period. Standardized differences were calculated to assess variation in sociodemographic and clinical characteristics between classes. Our cohort had a high prevalence of prescription opioid receipt (73.3%) and underlying co-morbidities, including chronic pain (54.6%), substance use disorders (39.0%), and mental health diagnoses (76.9%). Six prescription opioid receipt classes emerged, characterized by probability of any prescription opioid receipt at the start and end of the study period (high, medium, low, never) and change in probability over time (increasing, decreasing, stable). Classes with the highest probability of prescription opioids also had the highest proportions of males, chronic pain diagnoses, substance use disorders, and mental health diagnoses. Black, non-Hispanic and Hispanic patients were more likely to be in low or no prescription opioid receipt classes. These findings highlight the importance of monitoring for synergistic co-morbidities when providing pain management and offering treatment that is trauma-informed, destigmatizing, and integrated into routine care.

How Patients Dispose of Unused Prescription Opioids: A Survey of over 300 Postoperative Patients

Introduction

Diversion of unused prescription opioids is a common source of opioid sensitization in the community. Educating patients about safe opioid use has been shown to be effective in decreasing opioid use. However, decreasing diversion will also require educating patients on proper opioid disposal. A survey was administered to better understand patients’ habits with opioid disposal for opioids prescribed after orthopedic surgery.

Methods

A cross-sectional survey study of 469 patients who had undergone orthopedic surgery was conducted to learn their preferences and habits regarding the disposal of unused prescription opioids received after orthopedic surgery.

Results

The survey respondents consisted of 48.8% female and 51.2% male patients. Ninety-four point two percent (94.2%) of those receiving opioid prescriptions reported having leftover unused opioids. In terms of voluntary disposal, 68.8% claimed to dispose of their prescription opioids while 31.2% did not. Gender, but not age, had a significant effect on plans for opioid disposal and how seriously respondents viewed issues of opioid misuse. When asked their preferred location for prescription opioid disposal, the most common preference was a local pharmacy.

Discussion

This survey identified that most patients do not store their prescription opioids in a locked location, claim to dispose of their unused prescription opioids, and would prefer to dispose of them at a pharmacy if possible. This information points to the need for close prescriber-to-pharmacy collaboration to promote the safe disposal of prescription opioids and mitigate drug diversion.

Trajectories and Individual Differences in Pain, Emotional Distress, and Prescription Opioid Misuse During the COVID-19 Pandemic: A One-Year Longitudinal Study

Recent studies suggest that the COVID-19 pandemic can serve as a unique psychosocial stressor that can negatively impact individuals with chronic pain. Using a large online sample in the U.S., the present study sought to investigate the impact of the pandemic on the trajectories of pain severity and interference, emotional distress (ie, anxiety and depressive symptoms), and opioid misuse behaviors across one year. Potential moderating effects of socio-demographic factors and individual differences in pain catastrophizing, pain acceptance, and sleep disturbance on outcome trajectories were also examined. Adults with chronic pain were surveyed three times across 1 year (April/May 2020 [N = 1,453]; June/July 2020 [N = 878], and May 2021 [N = 813]) via Amazon's Mechanical Turk online crowdsourcing platform. Mixed-effects growth models revealed that pain severity and interference, emotional distress, and opioid misuse behaviors did not significantly deteriorate across one year during the pandemic. None of the socio-demographic factors, pain catastrophizing, or sleep disturbance moderated outcome trajectories. However, individuals with higher pain acceptance reported greater improvement in pain severity (P< .008, 95% CI: -.0002, -.00004) and depressive symptoms (P< .001, 95% CI: -.001, -.0004) over time. Our findings suggest that the negative impact of the pandemic on pain, emotional distress, and opioid misuse behaviors is quite small overall. The outcome trajectories were also stable across different socio-demographic factors, as well as individual differences in pain catastrophizing and sleep disturbance. Nevertheless, interventions that target improvement of pain acceptance may help individuals with chronic pain be resilient during the pandemic. PERSPECTIVE: Individuals with chronic pain overall did not experience significant exacerbation of pain, emotional distress, and opioid misuse across one year during the COVID-19 pandemic. Individuals with higher pain acceptance showed greater improvement in pain severity and depressive symptoms over time during the pandemic.

Perceptions of prescription opioid use among rural farming and ranching communities: Preliminary implications for outreach and treatment

Background: In 2017, 45% of rural adults reported being directly impacted by the opioid epidemic. While research on the experiences of those using prescription opioids in rural communities is increasing, less is known about a unique sub-population who may have high rates of exposure: rural agricultural workers. The purpose of this study was to explore the prevalence and perceptions related to prescription opioids among rural producers and farmworkers. Methods: A questionnaire was mailed in spring 2019 and spring 2020 to rural residents living in one of two agricultural-based states in the Upper Midwest. Individuals were eligible to participate if any member of their family was involved in the agricultural industry. A total of 1116 questionnaires were returned for a 27.9% response rate. Results: Participants were 68.1 years old on average. The majority identified as white, male, and married. Prescription opioid use was found in 8.2% of households currently, and 15.7% in the past year. There were no gender differences in prevalence of use, but women and older individuals reported significantly more perceived risk than men and younger individuals. Nearly half used alternative pain management, and received most information about prescription opioids from the radio (65.5%) and newsletters (13.5%). Conclusions. Despite their elevated age and working in an occupation at high risk of injury and chronic pain, study participants reported few opioid prescriptions and moderate use of alternative pain management. Perceived risk of prescription opioids may explain low prevalence. Outreach efforts that increase access to healthcare services and alternative pain management treatments for agricultural workers may mitigate the experience of chronic pain that can interfere with their overall quality of life.

Sex, gender, and the opioid epidemic: Crucial implications for acute care

Introduction

The opioid epidemic continues to escalate in the United States, exacerbated significantly by the COVID-19 pandemic. Necessary steps in acute care medicine to expand efforts to combat this epidemic involve increased emergency department engagement of patients with opioid use disorder (OUD) and an incorporation of evolving sex- and gender-based factors that affect this disease presentation and management course.

Methods & Aims

An ever-increasing amount of peer-reviewed, evidence-based literature has shed light on the important biologic and sociocultural variables, specifically sex and gender, which impact OUD trajectory and outcomes. As a collaborative effort of the Sex and Gender in Emergency Medicine (SGEM) Interest Group, a community within the Society for Academic Emergency Medicine (SAEM), we sought to consider, review, and summarize clinically pertinent information as a comprehensive introduction to this topic for the emergency medicine (EM) clinician and educator.

Results

A selected overview of current evidence-based data and publications, to include current epidemiologic trends, opioid-based physiology and pathophysiology, as well as opioid use disorder management and outcomes, through a sex- and gender-based lens, was reviewed and included in this summary. Also discussed are implications and recommendations for EM educators seeking insight and resources for continuing, graduate, and/or undergraduate education on this topic.

Conclusion

Incorporation of emerging sex- and gender-specific scientific knowledge into clinical context represents a critical link to effective management of the OUD patient in the ED. Similarly, integration of this information into EM education represents an essential step for both sex- and gender-based medicine and opioid-specific training.

Pharmacovigilance Signals of the Opioid Epidemic over 10 Years: Data Mining Methods in the Analysis of Pharmacovigilance Datasets Collecting Adverse Drug Reactions (ADRs) Reported to EudraVigilance (EV) and the FDA Adverse Event Reporting System (FAERS)

In the past twenty years, the consumption of opioid medications has reached significant proportions, leading to a rise in drug misuse and abuse and increased opioid dependence and related fatalities. Thus, the purpose of this study was to determine whether there are pharmacovigilance signals of abuse, misuse, and dependence and their nature for the following prescription opioids: codeine, dihydrocodeine, fentanyl, oxycodone, pentazocine, and tramadol. Both the pharmacovigilance datasets EudraVigilance (EV) and the FDA Adverse Events Reporting System (FAERS) were analyzed to identify and describe possible misuse-/abuse-/dependence-related issues. A descriptive analysis of the selected Adverse Drug Reactions (ADRs) was performed, and pharmacovigilance signal measures (i.e., reporting odds ratio, proportional reporting ratio, information component, and empirical Bayesian geometric mean) were computed for preferred terms (PTs) of abuse, misuse, dependence, and withdrawal, as well as PTs eventually related to them (e.g., aggression). From 2003 to 2018, there was an increase in ADR reports for the selected opioids in both datasets. Overall, 16,506 and 130,293 individual ADRs for the selected opioids were submitted to EV and FAERS, respectively. Compared with other opioids, abuse concerns were mostly recorded in relation to fentanyl and oxycodone, while tramadol and oxycodone were more strongly associated with drug dependence and withdrawal. Benzodiazepines, antidepressants, other opioids, antihistamines, recreational drugs (e.g., cocaine and alcohol), and several new psychoactive substances, including mitragynine and cathinones, were the most commonly reported concomitant drugs. ADRs reports in pharmacovigilance databases confirmed the availability of data on the abuse and dependence of prescription opioids and should be considered a resource for monitoring and preventing such issues. Psychiatrists and clinicians prescribing opioids should be aware of their misuse and dependence liability and effects that may accompany their use, especially together with concomitant drugs.

The association between the availability of over the counter codeine and the prevalence of non-medical use

PURPOSE

To investigate the prevalence of non-medical use (NMU) of codeine in Germany, Italy, Spain and the UK and whether availability of OTC codeine has any association with NMU of the drug.

METHODS

Data collected in the online Survey of Non-Medical Use of Prescription Drugs, in surveys launched in the second half of 2018 from (Germany (n = 14,969), Italy, (n = 9974), Spain (n = 9912) and the UK (n = 9819) were analysed. For each survey, the estimated prevalence and 95% confidence interval (CI) of respondents reporting NMU of prescription and/or OTC codeine within the last 12 months were calculated and compared.

RESULTS

The prevalence of last 12-month NMU in Spain was 12.6% (95% CI 11.7-13.6) for prescription codeine, 6.3% (5.6-7.0) for OTC codeine and 16.1% (15.1-17.3) for any codeine (prescription and/or OTC). The prevalence of last 12-month NMU in the UK was 5.4% (4.9-5.8) for prescription codeine, 4.5% (4.1-5.0) for OTC codeine and 8.3% (7.8-8.9) for any codeine (prescription and/or OTC). The prevalence of last 12-month NMU for prescription codeine was 2.1% (1.9-2.4) in Germany and 1.9% (1.7-2.2) in Italy.

CONCLUSION

The prevalence of last 12-month NMU of any codeine product is approximately eight times greater in Spain and four times greater in the UK compared to Germany and Italy where the drug is only available by prescription. While other factors may contribute, these findings suggest that availability of codeine OTC is associated with greater NMU.

Prevalence and distribution of high-risk prescription opioid use in the United States, 2011-2016

PURPOSE

Despite the efforts of many stakeholders to reduce the risk of opioid overdose, there is limited information on the prevalence of high-risk prescription opioid use in the US.

METHODS

Descriptive analysis of a nationally representative 5% random sample of anonymized, longitudinal, individual-level prescription claims from IQVIA LRx between January 1, 2011 and December 31, 2016 among individuals ages 18 years or older that used a retail pharmacy. High-risk opioid use was defined as ≥50 morphine milligram equivalents per day and/or having concurrent dispensing of a benzodiazepine based on overlapping days of coverage.

RESULTS

The prevalence of high-risk opioid use among adults in the US decreased from 12.0% in 2011 to 9.4% in 2016 (p < 0.01). Declines were most pronounced among individuals ages 18-35 years (10.9%-7.0%, 36.2% decline; p < 0.01) compared to individuals age 65 years or greater (10.5%-9.8%, 6.7% decline; p < 0.01). Declines in high-risk use prevalence were observed across 49 states, with only South Dakota experiencing an increase (+13.7% relative increase). Similar to earlier years, in 2016 50.9% of all high-risk use opioid users received all their opioid prescriptions from a single prescriber, and 71.1% used a single pharmacy to fill them.

CONCLUSION

Despite clinically significant declines in high-risk opioid use, in 2016 nearly 1 in 10 adult retail pharmacy users remained at high-risk for opioid overdose in the US. Future clinical and policy interventions should consider targeting older adults with Medicare Part-D, including those using a single pharmacy to fill their opioid prescriptions.

Transgenerational effects on anxiety-like behavior following adolescent morphine exposure in female rats

Global opioid use and misuse remains high, despite efforts to decrease rates of prescribing and diversion. Chronic exposure to opioids, particularly during critical periods of development, can lead to long-lasting effects, including effects that may extend to future generations. Using a rodent model, we have demonstrated significant transgenerational effects of female adolescent morphine exposure, despite the absence of in utero drug exposure. While these effects have been observed in both sexes, effects on anxiety-like behavior were only observed in F1 females. The current study was designed to examine both inter- and transgenerational effects of adolescent morphine exposure on anxiety-like behavior. Female Sprague Dawley rats were administered increasing doses of morphine (5-25 mg/kg s.c.) or saline for 10 days during adolescence (PND30-39). Adult diestrous female offspring (MORF1 or SALF1) and grand offspring (F2) were tested for anxiety-like behavior using the elevated plus maze (EPM). F1 females cross-fostered to donor mothers were also examined. The results show that MORF1 and MORF2 females spend significantly more time on the open arms of the EPM compared to SALF1 controls, an effect that persisted in cross-fostered females. Additional studies demonstrate that this effect is estrous cycle dependent, as decreased anxiety-like behavior was observed in diestrus, while increased anxiety-like behavior was observed in estrus. These behavioral effects were not associated with any differences in circulating corticosterone either at baseline or following EPM testing. Thus, female adolescent morphine exposure alters the regulation of anxiety-like behavior in an estrous-dependent manner and this effect persists in the F2 generation.

National Trends in Opioid Prescriptions Following Outpatient Otologic Surgery, 2005-2017

OBJECTIVE

To describe opioid stewardship in ambulatory otologic surgery from 2005 to 2017.

STUDY DESIGN

Descriptive study of US private insurance claims.

SETTING

Nationwide deidentified private insurance claims database (Clinformatics DataMart; Optum).

METHODS

A total of 17,431 adult opioid-naïve outpatients were included in the study. Patients were identified from CPT-4 codes (Current Procedural Terminology, Fourth Edition) as having undergone middle ear or mastoid surgery. Multiple regression was used to determine sociodemographic and geographic predictors of postoperative morphine milligram equivalents (MMEs) prescribed, including procedure type, year of procedure, age, sex, education, income level, and geographic region of the United States.

RESULTS

The mean prescribed perioperative dose over the examined period was 203.03 MMEs (95% CI, 200.27-205.79; 5-mg hydrocodone pill equivalents, 40.61). In multivariate analysis, patients undergoing mastoid surgery were prescribed more opioids than those undergoing middle ear surgery (mean difference, 39.89 MME [95% CI, 34.37-45.41], P < .01; 5-mg hydrocodone pill equivalents, 8.0). Men were prescribed higher doses than women (mean difference, 15.39 [95% CI, 9.87-20.90], P < .01; 5-mg hydrocodone pill equivalents, 3.1). Overall MMEs prescribed by year demonstrates a sharp drop in MMEs from 2015 to 2017.

CONCLUSION

While the amount of opioids prescribed perioperatively has declined in recent years, otologists should continue to be cognizant of potential overprescribing in light of previous studies of patients' relatively low opioid intake.

Prevalence and minority-stress correlates of past 12-month prescription drug misuse in a national sample of transgender and gender nonbinary adults: Results from the U.S. Transgender Survey

BACKGROUND

Prescription drug (PD) misuse, particularly opioid misuse, is a major US public health concern. While transgender and gender nonbinary (TGNB) individuals experience numerous health disparities, including substance use disparities, little research has focused on PD misuse in this population.

METHODS

Data for this secondary analysis come from the US Transgender Survey (N = 26,689). First, we examined bivariate differences in past 12-month PD misuse among binary transgender women, binary transgender men, nonbinary individuals assigned-female-at-birth (AFAB), and nonbinary individuals assigned-male-at-birth (AMAB). We then used multivariable logistic regression (separately based on sex-assigned-at-birth) to examine the relationship between gender-identity related discrimination and PD misuse.

RESULTS

PD misuse was significantly more common among binary transgender men (17.3 %), nonbinary AFAB individuals (18.7 %), and nonbinary AMAB individuals (18.0 %); compared to binary transgender women (13.5 %). In multivariable analyses, nonbinary identity was associated with higher odds of PD misuse among TGNB AFAB individuals (OR = 1.121; 95 %CI 1.021-1.232) and AMAB individuals (OR = 1.315; 95 % CI 1.133-1.527). Controlling for overall health status and psychological distress, public accommodations discrimination was associated with PD misuse among TGNB AMAB individuals (OR = 1.578, 95 %CI 1.354-1.839). Among both groups, healthcare discrimination was associated with PD misuse (AFAB OR = 1.388, 95 %CI 1.255-1.534; AMAB OR = 1.227, 95 %CI 1.073-1.404).

CONCLUSION

In this national sample of TGNB individuals, nonbinary individuals were at greater risk for PD misuse than binary individuals, possibly due to less societal affirmation. Similar to other TGNB health disparities, discrimination based on gender identity/expression was associated with PD misuse. This highlights the importance of interventions to reduce discrimination against TGNB individuals.

Perceived vulnerability to COVID-19 infection from event attendance: results from Louisiana, USA, two weeks preceding the national emergency declaration

Background

Individual perceptions of personal and national threats posed by COVID-19 shaped initial response to the pandemic. The aim of this study was to investigate the changes in residents’ awareness about COVID-19 and to characterize those who were more aware and responsive during the early stages of the pandemic in Louisiana.

Methods

In response to the mounting threat of COVID-19, we added questions to an ongoing food preference study held at Louisiana State University from March 3rd through March 12th, 2020. We asked how likely it was that the spread of the coronavirus will cause a national public health crisis and participants’ level of concern about contracting COVID-19 by attending campus events. We used regression and classification tree analysis to identify correlations between these responses and (a) national and local COVID case counts; (b) personal characteristics and (c) randomly assigned information treatments provided as part of the food preference study.

Results

We found participants expressed a higher likelihood of an impending national crisis as the number of national and local confirmed cases increased. However, concerns about contracting COVID-19 by attending campus events rose more slowly in response to the increasing national and local confirmed case count. By the end of this study on March 12th, 2020 although 89% of participants agreed that COVID-19 would likely cause a public health crisis, only 65% of the participants expressed concerns about contracting COVID-19 from event attendance. These participants were significantly more likely to be younger students, in the highest income group, and to have participated in the study by responding to same-day, in-person flyer distribution.

Conclusions

These results provide initial insights about the perceptions of the COVID-19 public health crisis during its early stages in Louisiana. We concluded with suggestions for universities and similar institutions as in-person activities resume in the absence of widespread vaccination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10035-6.