COPD and asthma in patients with opioid dependency: a cross-sectional study in primary care

Increasing age and lethal opiate use

Opioid abuse is a leading cause of drug-related morbidity and mortality worldwide. It has been suggested that the age of opiate users in Australia is rising. To evaluate this further in a local population, toxicology and pathology case files from Forensic Science SA, Adelaide, South Australia, were examined for all cases with lethal opioid levels from 2000 to 2019 (n = 499; M:F 2.3:1; age range 18-91 years, median age 42 years). The median age of opiate deaths increased significantly by approximately 16 years (p = 0.007, R2 = 0.34) with a significant increase in total deaths in the 45-54 years and 55-64 years age groups (p = 0.009, R2 = 0.32) (p = < 0.001, R2 = 0.54). Deaths due to heroin overdose showed the lowest median age (39 years, n = 184), with deaths from tramadol toxicity having the highest (50.5 years, n = 32). Recent changes in the demographic profile of opioid users in cases of lethal overdose involve an aging population. Forensic and clinical practitioners should be aware of significant opioid abuse in certain individuals at older ages as this raises the possibility that this may exacerbate the effects of age-related chronic diseases in this group and/or contribute to fatalities.

Heart Rate Variability in Adults With Substance Use Disorder: A Comprehensive Narrative Review

BACKGROUND

Heart rate variability (HRV) is an indicator of autonomic abnormalities. However, little is known about the role of HRV related to substance use behavior and the association between the changes in HRV and signs of relapse in substance use.

AIM

The purpose of this study was to review the existing literature on autonomic response to substance use (i.e., opioids, cocaine, and methamphetamine) measured by HRV and its outcomes related to the risk factors of relapse.

METHODS

A systematic search of the literature was conducted using PubMed, PsychINFO, and Ovid Medline databases. The study includes full-text articles published in English from 2010 to 2020, using measures of HRV in human subjects who use substances.

RESULTS

A total of 14 studies were reviewed. Studies included outpatients with a prescription or nonprescription opioid misuse behavior with a primary diagnosis being chronic pain or substance use disorder (SUD). Significantly decreased resting HRV was found in substance users compared to healthy controls. Lower resting HRV has been significantly associated with stress, craving, and greater symptom severities in individuals with SUD and other substance dependence. HRV indices can be potential measures of homeostatic imbalance and self-regulation flexibility.

CONCLUSION

HRV may be a useful tool for monitoring early indication of relapse so that relapse prevention measures can be implemented in a timely manner. Future studies in substance use may benefit from examining HRV in relations to substance use and relapse signs and symptoms in a larger population to guide future relapse prevention strategies.

Prescriptions of opioid-containing drugs in patients with chronic cough

BACKGROUND

Chronic cough (CC) affects about 10% of adults, but opioid use in CC is not well understood.

OBJECTIVES

To determine the use of opioid-containing cough suppressant (OCCS) prescriptions in patients with CC using electronic health records.

DESIGN

Retrospective cohort study.

METHODS

Through retrospective analysis of Midwestern U.S. electronic health records, diagnoses, prescriptions, and natural language processing identified CC - at least three medical encounters with cough, with 56-120 days between first and last encounter - and a 'non-chronic cohort'. Student's t-test, Pearson's chi-square, and zero-inflated Poisson models were used.

RESULTS

About 20% of 23,210 patients with CC were prescribed OCCS; odds of an OCCS prescription were twice as great in CC. In CC, OCCS drugs were ordered in 38% with Medicaid insurance and 15% with commercial insurance.

CONCLUSION

Findings identify an important role for opioids in CC, and opportunity to learn more about the drugs' effectiveness.

[Bronchial diseases and heroin use. A systematic review]

INTRODUCTION

Heroin use can cause respiratory complications including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis (BD).

OBJECTIVES

A general review of the literature presenting the data on the relationships between heroin consumption and bronchial complications, while underlining the difficulties of diagnosis and management.

DOCUMENTARY SOURCES

Medline, 1980-2022, keywords "asthma" or "bronchospasm" or "COPD" or "bronchiectasis" and "heroin" or "opiate" or "opiates", with limits pertaining to "Title/Abstract". Concerning asthma, 26 studies were included, as were 16 for COPD and 5 for BD.

RESULTS

Asthma and COPD are more prevalent among heroin addicts, who are less compliant than other patients with their treatment. The authors found a positive association between frequency of asthma exacerbations, admission to intensive care and heroin inhalation. Late diagnosis of COPD worsens the course of the disease; emphysema and BD are poor prognostic factors.

CONCLUSION

Bronchial diseases in heroin users can be identified by means of respiratory function exploration and chest CT scans. These tests should be performed frequently in view of optimizing their care, which includes their weaning themselves from addictive substances.

Epidemiological associations of asthma status and tobacco use, substance use, and substance misuse among adults in the United States, 2015-2019

Objective: Adults with asthma have a higher prevalence of substance use. However, knowledge is scarce regarding the associations between adults with asthma and tobacco use, substance use, and substance misuse. This study aimed to use national samples of United States adults to assess the comprehensive use and misuse of substances in adults with asthma.Method: This cross-sectional study comprised data drawn from the 2015 to 2019 National Survey on Drug Use and Health. Weighted logistic regressions were used to measure the associations of asthma status (lifetime and current) with last month's tobacco use; substance use (alcohol, marijuana, cocaine, crack, heroin, hallucinogens, inhalants); and substance misuse (pain relievers, tranquilizers, stimulants, sedatives). All regression models were controlled for sociodemographic characteristics, comorbidity, last-month serious psychological distress, and co-substance use and misuse. Results: Adults with lifetime asthma (N_weighted = 115,600,887) were less likely to use cigarettes, cigars, smokeless tobacco, inhalants, and polyuse of any substance. In contrast, adults with current asthma (N_weighted = 765,096,31) were more likely to use pipe tobacco, cocaine, non-prescribed tranquilizers, and less likely to use polytobacco products. Adults with lifetime asthma were associated with fewer last-month tobacco and inhalant use than those without lifetime asthma. However, adults with current asthma were associated with greater last month's pipe tobacco, cocaine, and non-prescribed tranquilizers. Conclusion: Thus, further longitudinal studies are recommended among adults with asthma to effectively design tailored treatment and prevention interventions.

Comorbidities in older adults with opioid use disorders

BACKGROUND

There is a growing number of opioid use disorders (OUDs) and overdose deaths in older adults. In addition, older adults with OUD routinely receive lower-quality preventive and chronic care that result in poorer overall health.

PURPOSE

The purpose of this study was to identify older patients with OUD at the study site and determine the prevalence of medical and psychiatric comorbidities.

METHODOLOGY

This retrospective study used a computer algorithm employed by a network of Federally Qualified Health Center primary care clinics in lower New York state. With the approval from institutional review board, the IT department of the organization captured data about older adults with an OUD diagnosis. The IT department identified 664 patients and provided anonymized demographic and medical history data of these patients for analysis.

RESULTS

Patients with OUD had 2-3 times more medical and psychiatric co-occurring conditions than national sample of older adults with no OUD of similar age and income. The most frequent co-occurring medical conditions in the patients were heart or circulatory disorders, movement disorders, respiratory disorders, pain disorders, nutritional disorders, and metabolic disorders. The most common co-occurring psychiatric conditions were anxiety disorders, major depressive disorder, post-traumatic stress disorder (PTSD), and bipolar disorder.

CONCLUSIONS

Older adults with OUD often have complex health care needs that often include one or more chronic medical and psychiatric conditions.

IMPLICATIONS

Providers should be aware of the multiple needs of older adults with OUD so that appropriate and comprehensive care can be offered to the patients.

Integration of smoking cessation into standard treatment for patients receiving opioid agonist therapy who are smoking tobacco: protocol for a randomised controlled trial (ATLAS4LAR)

BACKGROUND

About 85% of patients receiving opioid agonist therapy (OAT) for opioid dependence are smoking tobacco. Although smoke-related pulmonary diseases are significant contributors to morbidity and mortality, few smoking cessation interventions are evaluated within this group, and few OAT patients are offered smoking cessation as an integrated part of their addiction treatment. This study protocol describes an integrated smoking cessation intervention aimed at patients receiving OAT and smoking tobacco.

METHODS

This is a multicentre, randomised controlled clinical trial that will recruit 266 daily tobacco smoking patients receiving OAT in OAT outpatient clinics in Bergen and Stavanger, Norway. The patients randomised for the intervention arm will be offered smoking cessation therapy consisting of weekly brief behavioural interventions and prescription-free nicotine replacement products. In the control arm, patients will receive standard care without any added interventions related to smoking cessation. The smoking cessation intervention includes psychoeducational techniques with components from motivational interviewing, and nicotine replacement products such as nicotine lozenges, patches, and chewing gum. The duration of the intervention is 16 weeks, with the option of extending it by a further 8 weeks. The main outcomes are measured at 16 weeks after initiation of the intervention, and sustained effects are evaluated 1 year after intervention initiation. The primary outcome is smoking cessation verified by carbon monoxide (CO) levels or at least a 50% reduction in the number of cigarettes smoked. Secondary outcomes are changes in psychological well-being, biochemical inflammation markers, changes in physical health, quality of life, and fatigue.

DISCUSSION

Integration of other treatments to standard OAT care improves adherence and completion rates providing another rationale for integrated smoking cessation treatment. Thus, if integrated smoking cessation treatment is superior to standard care, this trial provides important information on further scale-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05290025. Registered on 22 March 2022.

Healthcare utilization for somatic conditions among Swedish patients in opioid substitution treatment, with and without on-site primary healthcare

Background

Opioid substitution treatment (OST) populations are aging and have increased mortality and somatic morbidity compared to general populations internationally. While OST patients have poor self-rated physical health and unmet healthcare needs, documented healthcare utilization has been sparsely investigated. The aim of this study was to assess registered healthcare utilization for somatic conditions in a sample of Swedish OST patients, and compare healthcare utilization among OST patients with and without use of on-site primary healthcare (PHC).

Methods

Patients in OST in Malmö, Sweden, were recruited for a survey study conducted in 2017–2018. Survey data were compared with comprehensive patient records from specialized and primary care during one year prior to study inclusion (total n = 190). All patient records were examined for healthcare utilization, source of healthcare (PHC, emergency care and secondary care), and documented diagnoses and symptoms. Factors associated with healthcare utilization were analyzed by using logistic regression analysis. Patients with and without on-site PHC were compared by using descriptive statistics and Chi-2 test.

Results

A total of 88% of the sample had been in direct or indirect contact with somatic healthcare during one year (PHC 66%; emergency care 28%; secondary care 67%). The most prevalent somatic diagnoses were infectious diseases (39%) and symptom diagnoses (37%). Respiratory, dermatological and musculoskeletal diagnoses, and trauma/intoxication were documented in 21–26% of the sample, respectively. PHC utilization was associated with older age and being born in Sweden. Among patients with on-site PHC (n = 25), the number utilizing secondary care was 84%, and certain diagnostic codes were more frequent in this group.

Conclusion

OST patients are seemingly underserved as regards their physical health. Since increased OST access decreases opioid overdose fatalities, the life expectancy among OST patients is likely to increase and thereby also increases the risk of age-related conditions. Thus, easily accessible physical healthcare is of great importance in this group. On-site PHC might be a way to establish healthcare contact with OST patients, especially for non-acute conditions, although further research is needed.

Undetected Respiratory Depression in People with Opioid Use Disorder

BACKGROUND

Opioid-related deaths are increasing globally. Respiratory complications of opioid use and underlying respiratory disease in people with Opioid Use Disorder (OUD) are potential contributory factors. Individual variation in susceptibility to overdose is, however, incompletely understood. This study investigated the prevalence of respiratory depression (RD) in OUD treatment and compared this to patients with chronic obstructive pulmonary disease (COPD) of equivalent severity. We also explored the contribution of opioid agonist treatment (OAT) dosage, and type, to the prevalence of RD.

METHODS

There were four groups of participants: 1) OUD plus COPD ('OUD-COPD', n = 13); 2) OUD without COPD ('OUD', n = 7); 3) opioid-naïve COPD patients ('COPD'n = 13); 4) healthy controls ('HC'n = 7). Physiological indices, including pulse oximetry (SpO₂%), end-tidal CO₂ (ETCO₂), transcutaneous CO₂ (TcCO₂), respiratory airflow and second intercostal space parasternal muscle electromyography (EMG_para), were recorded continuously over 40 min whilst awake at rest. Significant RD was defined as: SpO₂%< 90% for > 10 s, ETCO₂ per breath > 6.6 kPa, TcCO₂ overall mean > 6 kPa, respiratory pauses > 10 s RESULTS: At least one indicator was observed in every participant with OUD (n = 20). This compared to RD episode occurrence in only 2/7 HC and 2/13 COPD participants (p < 0.05,Fisher's exact test). The occurrence of RD was similar in OUD participants prescribed methadone (n = 6) compared to those prescribed buprenorphine (n = 12).

CONCLUSIONS

Undetected RD is common in OUD cohorts receiving OAT and is significantly more severe than in opioid-naïve controls. RD can be assessed using simple objective measures. Further studies are required to determine the association between RD and overdose risk.

Is Methadone Safe for Patients With Opioid Use Disorder and Coronavirus Disease 2019 Infection?

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has led to not only increase in substance misuse, substance use disorder, and risk of overdose but also lack of access to treatment services. Due to lack of knowledge of the course and impact of COVID-19 and outcomes of it's interactions with existing treatments, the Substance Misuse Service Team initiated a safety improvement project to review the safety of opioid substitution treatment, particularly the safety of methadone. This preliminary retrospective cross-sectional audit of safety improvement intiative underscores the importance of providing treatment services to those with opioid use disorders and that methadone is safe among this population with a high burden of comorbidity, most of which leads to negative outcomes from COVID-19. The outcomes show that patients who have COVID-19 should continue with opioid substitution treatment with methadone. Although treatment with methadone is safe, symptomatic patients should be monitored. In addition, patients who take methadone at home should be educated on the risk of overdose due to, and adverse outcomes from, COVID-19 infection. Patients should monitor themselves using pulse oximeter for any signs of hypoxia.

Substance Use and Misuse among Adults with Chronic Obstructive Pulmonary Disease in the United States, 2015-2019: Prevalence, Association, and Moderation

BACKGROUND

Despite the advancements in chronic obstructive pulmonary disease (COPD) treatment, complications related to COPD exacerbation remain challenging. One associated factor is substance use/misuse among adults with COPD. Fewer studies, however, examined the prevalence and association between COPD and substance use and misuse. In addition, limited knowledge existed about the moderation effects of serious psychological distress and gender among adults with COPD and substance use/misuse. We aimed, therefore, to measure such prevalence, association, and moderation from nationally representative samples in the United States.

METHOD

Data were drawn from the 2015-2019 National Survey on Drug Use and Health. Weighted logistic regressions were used to measure the associations of last-month tobacco (cigarettes, cigars, pipe, and smokeless tobacco products), other licit and illicit substance use (alcohol, marijuana, cocaine, crack, heroin, hallucinogens, and inhalants), and substance misuse (pain relievers, tranquilizers, stimulants, and sedatives) among adults with COPD. Serious psychological distress and gender were tested as moderators in the association between COPD and substance use/misuse.

RESULTS

The findings revealed that adults with COPD [Weighted N = 53,115,718) revealed greater odds of cigarettes [adjusted odds ratio (aOR) = 2.48 (95%CI = 1.80-3.42)) and smokeless tobacco (aOR = 3.65 (95%CI = 1.75-7.65)). However, they were less likely to use alcohol (aOR = 0.61 (95%CI = 0.45-0.84)). Adults with COPD who had serious psychological distress were more likely to use pipe tobacco and alcohol; however, they were less likely to use hallucinogens and inhalants. Finally, males compared to females with COPD were less likely to use smokeless tobacco.

CONCLUSION

Adults with COPD in the United States were more likely to use tobacco products and less likely to use alcohol. In addition, serious psychological distress and gender were moderators in associations between COPD and substance use but not in substance misuse. Future studies should longitudinally assess the factors that may contribute to the initiation and progression of substance use and misuse among adults with COPD.

Transition from injecting opioids to smoking fentanyl in San Francisco, California

BACKGROUND

The introduction of illicitly made fentanyl in the United States has slowly replaced heroin. New illicit drugs are often associated with changes in frequency and modes of administration. We assessed changes in injection frequency and smoking fentanyl in the new era of fentanyl availability in San Francisco.

METHODS

We used targeted sampling to recruit 395 people who inject drugs (PWID) into an observational cohort study in San Francisco 2018-2020. We assessed changes in injection frequency, opioid injection frequency and fentanyl smoking frequency in four six-month periods. We also conducted qualitative interviews with PWID asking about motivations for injecting and smoking opioids.

RESULTS

The median number of past-month injections steadily decreased by semi-annual calendar year from 92 injections in July to December 2018 to 17 injections in January to June 2020. The rate of opioid injections reduced by half (Adjusted Incidence Rate Ratio = 0.41; 95 % Confidence Interval = 0.25, 0.70; p < 0.01). The number of days smoking fentanyl was associated with fewer number of injections (X2(2) = 11.0; p < 0.01). Qualitative interviews revealed that PWID's motivation for switching from injecting tar heroin to smoking fentanyl was related to difficulties accessing veins. After switching to smoking fentanyl, they noticed many benefits including how the drug felt, improved health, fewer financial constraints, and reduced stigma.

CONCLUSION

Between 2018 and 2020, there was a shift from injecting tar heroin to smoking fentanyl in San Francisco. Reductions in injection of illicit drugs may offer public health benefit if it reduces risk of blood-borne viruses, abscesses and soft-tissue infections, and infective endocarditis.

Query mandates in prescription drug monitoring programs reduce opioid use among commercially insured patients with cancer

BACKGROUND

Prescription drug monitoring programs (PDMPs) have been shown to reduce opioid use in the general and noncancer populations. However, evidence of PDMP impacts on patients with cancer remains limited.

OBJECTIVE

The aim of the study was to examine the impact of PDMP mandates on individual-level opioid use among patients with cancer.

METHODS

This is a retrospective cohort study of patients with newly diagnosed cancer aged 18-65 years in the IQVIA PharMetrics Plus database (IQVIA Inc; nationally representative data of the U.S. commercially insured population in 49 states) between 2013 and 2015. The primary exposure was PDMP rigor (ranked from highest to lowest rigor): provider query + registration, query only, registration only, and unexposed. The study outcomes included (1) prevalent use among all individuals; and among opioid users (2) total days supplied, (3) daily morphine equivalent dose (MED), and (4) cumulative MED.

RESULTS

Of the eligible cohort (n=28,353), 37.5% (10,656) received opioids after a cancer diagnosis. The individuals exposed to these mandates were as follows: query + registration: 3899 (13.8%); query only: 3459 (12.2%); registration only: 2764 (9.7%); and no mandates: 18,231 (64.3%). The PDMP mandates had no effect on prevalent opioid use. Compared with unexposed patients, those subject to query mandates-alone or with registration mandates-experienced 12 fewer opioid days supplied and a lower mean cumulative MED (-662 mg and -702 mg, respectively), P < 0.01. Registration-only mandates were associated with 21 days more (P < 0.01) total days supplied and lower daily MED (1.1 mg; P < 0.05) but had no statistically significant effect on cumulative MED (-46 mg, P > 0.05).

CONCLUSION

Query mandates are a stronger PDMP tool than registration mandates in reducing opioid days supplied and cumulative MED. Initiatives should target PDMP mandates toward intended patient groups to reduce high-risk opioid use without compromising adequate pain treatment.

Healthcare Contacts Regarding Circulatory Conditions among Swedish Patients in Opioid Substitution Treatment, with and without On-Site Primary Healthcare

Patients in Opioid Substitution Treatment (OST) have increased mortality and morbidity, with circulatory conditions suggested to be a contributing factor. Since OST patients tend to have unmet physical healthcare needs, a small-scale intervention providing on-site primary healthcare (PHC) in OST clinics was implemented in Malmö, Sweden in 2016. In this study, we assessed registered circulatory conditions and healthcare utilization in OST patients with and without use of on-site PHC. Patients from four OST clinics in Malmö, Sweden, were recruited to a survey study in 2017-2018. Medical records for the participants were retrieved for one year prior to study participation (n = 192), and examined for circulatory diagnoses, examinations and follow-ups. Patients with and without on-site PHC were compared through descriptive statistics and univariate analyses. Eighteen percent (n = 34) of the sample had 1≤ registered circulatory condition, and 6% (n = 12) attended any clinical physiology examination or follow-up, respectively. Among patients utilizing on-site PHC (n = 26), the numbers were 27% (n = 7) for circulatory diagnosis, 15% (n = 4) for examinations, and 12% (n = 3) for follow-up. OST patients seem underdiagnosed in regard to their circulatory health. On-site PHC might be a way to diagnose and treat circulatory conditions among OST patients, although further research is needed.

Navigating environmental constraints to injection preparation: the use of saliva and other alternatives to sterile water among unstably housed PWID in London

Background

The United Kingdom is experiencing an increase in drug-related deaths and serious bacterial infections among its most vulnerable citizens. Cuts to essential services, coupled with a growing homeless population, create a challenging environment to tackle this public health crisis. In this paper, we highlight an underexplored environmental constraint faced by people living and injecting drugs on the streets. Access to water for injection is restricted in the UK, due to legislative and financial barriers. Austerity measures, such as public toilet closures, further restrict the ability of people made homeless to access clean water and protect themselves from health harms.

Methods

We generated questionnaire (n = 455) and in-depth qualitative interview (n = 32) data with people who inject drugs in London for the Care and Prevent study. Participants provided detail on their life history; drug use, injecting and living environments; health conditions and care seeking practices.

Findings

A high proportion of the survey sample reported lifetime history of street homelessness (78%), bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts highlight unsafe, potentially dangerous, injection practices in semi-public spaces. Multiple constraints to sourcing sterile water for injection preparation were reported. Alternatives to sterile water included puddle water, toilet cistern water, whisky, cola soda and saliva. Participants who injected heroin and crack cocaine together unanimously reported adding water at two stages during injection preparation: first, adding water as a vehicle for heroin (which was then heated); second, adding cold water to the heroin mixture prior to adding the crack cocaine. This new finding of a stage addition of solvent may represent an additional risk of infection.

Conclusion

Currently, harm reduction equipment and resources for safe injecting are not meeting the needs of people who inject drugs who are street homeless or unstably housed. Preparation of injections with non-sterile water sources could precipitate bacterial and fungal infections, particularly when used without the application of heat. It is crucial that water for injection, also skin cleaning, is made available for the unstably housed and that harm reduction messaging is tailored to speak to the everyday realities of people who prepare and inject drugs in public spaces.