The FDA and the Next Wave of Drug Abuse - Proactive Pharmacovigilance

Management of Persistent Post-Endodontic Pain With a Standardized Gabapentin Pyramid Protocol: A Case Series and Clinical Guidelines

INTRODUCTION

Persistent postendodontic pain following endodontic therapy is a rare but substantial clinical challenge. Mechanisms that mediate peripheral neuropathy and/or central sensitization likely play a pivotal role in its development and chronification. The objective of this case series is to describe a management plan for persistent postendodontic pain and provide prescription guidelines using a standardized "Gabapentin Pyramid Protocol" for clinical practice.

METHODS

Four cases of persistent postendodontic pain are presented. A peripheral etiology for pain was eliminated in all 4 cases. All patients were also refractory to conventional analgesics. Patients received the "Gabapentin Pyramid Protocol."

RESULTS

Three of the 4 cases experienced complete resolution of symptoms within the prescribed treatment period. In 1 case, symptoms were greatly reduced but recurred upon discontinuation of the drug.

CONCLUSIONS

The "Gabapentin Pyramid Protocol" represents an effective treatment option for persistent postendodontic pain, demonstrating significant symptom relief and potential for complete resolution.

Unveiling the roadblocks: exploring substance use disorder treatment policies in Iran through a qualitative lens

BACKGROUND

Different countries, including Iran, have implemented various policies to address substance use disorder. This study aims to describe the policies related to substance use disorder treatment and identify challenges related to these policies in Iran since the beginning of the Iranian Revolution in 1979.

METHODS

This qualitative study utilized document analysis and interviews with policymakers and implementers. We reviewed a total of 22 documents related to substance use disorder treatment and harm reduction. The results from document analysis complemented and validated the interview data. The research population comprised policymakers and implementers, including individuals directly involved in formulating and implementing substance use disorder treatment policies. Purposive sampling was employed, with a snowball strategy utilized to maximize diversity. Data saturation was achieved after conducting 32 semi-structured interviews. Conventional content analysis was used for data analysis.

RESULTS

In general, the policy landscape for substance use disorder treatment in the Islamic Republic of Iran can be divided into two periods: the "Moral Model" era (1979-1993) and the "Disease Model" era (1993-present). Challenges within the content of substance use disorder treatment policies in Iran encompass the lack of law revisions, existence of contradictions in laws and nature of disease, the absence of evidence-based policymaking, and an inadequate comprehensive perspective on the phenomenon of substance use disorder.

CONCLUSIONS

The presence of multiple authorities with different perspectives on substance use disorder and its treatment, coupled with the application of personal preferences in policymaking and the absence of evidence-based policymaking, have contributed to weaknesses in decision-making and policy formulation. The true philosophy of Disease Model appears not to have been fully grasped by health policymakers in Iran, as all Disease Model policies have been pursued with an emphasis on abstinence and quitting. Iran and other nations facing similar challenges should place more reliance on evidence-based approaches and shift away from the "Moral Model" paradigm to develop more effective substance use disorder treatment policies.

Gabapentin and pregabalin exposures reported to United States poison centers, 2012-2022

BACKGROUND

Gabapentin and pregabalin were originally introduced as anticonvulsant medications but are now also prescribed on- and off-label for multiple medical disorders, especially for pain management. The national opioid crisis has led to increased use of non-opioid pain medications, including gabapentinoids, which has been associated with changing patterns of adverse events associated with these medications. This study investigated the characteristics and trends of gabapentin and pregabalin exposures reported to US poison centers from 2012 to 2022.

METHODS

National Poison Data System data involving gabapentin and pregabalin exposures for 2012 to 2022 were analyzed.

RESULTS

There were 124,161 exposures involving gabapentin and pregabalin as the primary substance reported to US poison centers during the study period. Most exposures involved gabapentin (85.9%), females (59.4%), single-substance exposures (62.9%), or occurred at a residence (97.2%). Suspected suicides accounted for 45.2% of exposures. Most exposures were associated with a minor effect (27.4%) or no effect (34.0%), while 22.1% experienced a serious medical outcome, including 96 fatalities. The rate of gabapentin and pregabalin exposures per one million US population increased by 236.1% from 22.7 in 2012 to 76.5 in 2019 (P < 0.001), followed by a non-significant decrease to 68.5 in 2022 (P = 0.068).

CONCLUSIONS

The rate of gabapentin and pregabalin exposures reported to US poison centers increased by more than 230% from 2012 to 2019 before plateauing from 2019 to 2022. The observed rate trend was driven primarily by gabapentin exposures and by cases associated with suspected suicide. Although most exposures were associated with a minor or no effect, 22% of individuals experienced a serious medical outcome, including 96 fatalities. These findings contribute to the discussion of rescheduling gabapentin as a federally controlled substance, which is the current status of pregabalin. Prevention of suicide associated with gabapentin and pregabalin merits special attention.

Inputs of pharmacoepidemiology in addictovigilance: How do they fit together?

The French Addictovigilance Network has been using data from the French Heath insurance since the late 1990s to assess prescription drug abuse. In this narrative review, we illustrate the inputs of pharmacoepidemiology in addictovigilance based on the experience of the French Addictovigilance Network. The review focuses on pharmacoepidemiology using the French National Health Data System. We propose three examples: the MEGADOSE study, which aimed to conduct the first nation-wide, systematic, repeated assessment of doctor shopping; the DANTE study, which aimed to assess trends in analgesic use, focusing on the prevalence of use and the demographic profiles of analgesic users by age and sex; and the ZORRO study, which aimed to assess the impact of secure prescription forms on the use of zolpidem and other sedatives. These examples show how pharmacoepidemiology fits in the multifaceted monitoring conducted by the French Addictovigilance Network and complements the other data sources of this framework. This approach improves signal detection, confirmation, and quantification. It also makes it possible to overcome the limitations of each data source taken individually.

Systematic assessment of non-medical use of prescription drugs using doctor-shopping indicators: A nation-wide, repeated cross-sectional study

AIMS

The aim of this study was to present the first nation-wide, systematic, repeated assessment of doctor-shopping (i.e. visiting multiple physicians to be prescribed the same drug) during 10 years for more than 200 psychoactive prescription drugs in the 67 million inhabitants in France.

DESIGN

This was a nation-wide, repeated cross-sectional study.

SETTING AND PARTICIPANTS

Data are from the French National Health Data System in 2010, 2015 and 2019 for 214 psychoactive prescription drugs (i.e. anaesthetics, analgesics, antiepileptics, anti-Parkinson drugs, psycholeptics, psychoanaleptics, other nervous system drugs and antihistamines for systemic use).

MEASUREMENTS

The detection and quantification of doctor-shopping relied upon an algorithm that detects overlapping prescriptions from repeated visits to different physicians. We used two doctor-shopping indicators aggregated at population level for each drug dispensed to more than 5000 patients: (i) the quantity doctor-shopped, expressed in defined daily doses (DDD), which measures the total quantity doctor-shopped by the study population for a given drug; and (ii) the proportion doctor-shopped, expressed as a percentage, which standardizes the quantity doctor-shopped according to the use level of the drug.

FINDINGS

The analyses included approximately 200 million dispensings to approximately 30 million patients each year. Opioids (e.g. buprenorphine, methadone, morphine, oxycodone and fentanyl), benzodiazepines and non-benzodiazepine hypnotics (Z-drugs) (e.g. diazepam, oxazepam, zolpidem and clonazepam) had the highest proportions doctor-shopped during the study period. In most cases, the proportion and the quantity doctor-shopped increased for opioids and decreased for benzodiazepines and Z-drugs. Pregabalin had the sharpest increase in the proportion doctor-shopped (from 0.28 to 1.40%), in parallel with a sharp increase in the quantity doctor-shopped (+843%, from 0.7 to 6.6 DDD/100 000 inhabitants/day). Oxycodone had the sharpest increase in the quantity doctor-shopped (+1000%, from 0.1 to 1.1 DDD/100 000 inhabitants/day), in parallel with a sharp increase in the proportion doctor-shopped (from 0.71 to 1.41%). Detailed results for all drugs during the study period can be explored interactively at: https://soeiro.gitlab.io/megadose/.

CONCLUSIONS

In France, doctor-shopping occurs for many drugs from many pharmacological classes, and mainly involves opioid maintenance drugs, some opioids analgesics, some benzodiazepines and Z-drugs and pregabalin.

Oxycodone withdrawal induces HDAC1/HDAC2-dependent transcriptional maladaptations in the reward pathway in a mouse model of peripheral nerve injury

The development of physical dependence and addiction disorders due to misuse of opioid analgesics is a major concern with pain therapeutics. We developed a mouse model of oxycodone exposure and subsequent withdrawal in the presence or absence of chronic neuropathic pain. Oxycodone withdrawal alone triggered robust gene expression adaptations in the nucleus accumbens, medial prefrontal cortex and ventral tegmental area, with numerous genes and pathways selectively affected by oxycodone withdrawal in mice with peripheral nerve injury. Pathway analysis predicted that histone deacetylase (HDAC) 1 is a top upstream regulator in opioid withdrawal in nucleus accumbens and medial prefrontal cortex. The novel HDAC1/HDAC2 inhibitor, Regenacy Brain Class I HDAC Inhibitor (RBC1HI), attenuated behavioral manifestations of oxycodone withdrawal, especially in mice with neuropathic pain. These findings suggest that inhibition of HDAC1/HDAC2 may provide an avenue for patients with chronic pain who are dependent on opioids to transition to non-opioid analgesics.

Using GPT-3 to Build a Lexicon of Drugs of Abuse Synonyms for Social Media Pharmacovigilance

Drug abuse is a serious problem in the United States, with over 90,000 drug overdose deaths nationally in 2020. A key step in combating drug abuse is detecting, monitoring, and characterizing its trends over time and location, also known as pharmacovigilance. While federal reporting systems accomplish this to a degree, they often have high latency and incomplete coverage. Social-media-based pharmacovigilance has zero latency, is easily accessible and unfiltered, and benefits from drug users being willing to share their experiences online pseudo-anonymously. However, unlike highly structured official data sources, social media text is rife with misspellings and slang, making automated analysis difficult. Generative Pretrained Transformer 3 (GPT-3) is a large autoregressive language model specialized for few-shot learning that was trained on text from the entire internet. We demonstrate that GPT-3 can be used to generate slang and common misspellings of terms for drugs of abuse. We repeatedly queried GPT-3 for synonyms of drugs of abuse and filtered the generated terms using automated Google searches and cross-references to known drug names. When generated terms for alprazolam were manually labeled, we found that our method produced 269 synonyms for alprazolam, 221 of which were new discoveries not included in an existing drug lexicon for social media. We repeated this process for 98 drugs of abuse, of which 22 are widely-discussed drugs of abuse, building a lexicon of colloquial drug synonyms that can be used for pharmacovigilance on social media.

Establishment and application value of a novel prescription medication abuse monitoring model for psychiatric hospitals

Objective

To construct a prescription medication abuse (PMA) monitoring model for psychiatric hospitals and to assess its applicability.

Methods

A PMA monitoring working group was established to guide the formulation of a PMA monitoring system, which included three active real-time monitoring modes and one retrospective analysis monitoring mode. The effect of the established system was analyzed.

Results

In 2021, 35 cases of effective PMA were reported, which was a significant increase compared to two cases identified through passive monitoring mode in the preceding year. Most of the reported cases were based on active real-time monitoring mode. Among them, 21 cases (60.00%) were identified during the diagnosis and treatment of medicine and nursing; 3 cases (8.57%) were reported based on drug concentration detection technology; and 5 cases (14.29%) were reported by the laboratory department during PMA screening. Besides, 6 cases (17.14%) were reported according to the retrospective analysis of the hospital information system. The majority of prescription medication abusers were adolescents under the age of 18 (12 cases, 34.29%). Overall, there were 27 cases of class II psychotropic prescription medications, accounting for 77.14%.

Conclusion

The combined PMA monitoring model can effectively improve the quality of PMA monitoring and provide a basis for the supervision of higher-level regulatory authorities.

Gabapentinoids for Pain: A Review of Published Comparative Effectiveness Trials and Data Submitted to the FDA for Approval

Use of the gabapentinoids for pain continues to increase. In 2018, the US Food and Drug Administration (FDA) strengthened the warnings for both gabapentin and pregabalin to emphasize the central nervous system side effects and the risk of respiratory depression, especially when combined with other centrally acting drugs. We reviewed the published comparative effectiveness literature for gabapentinoids for pain as well as all trials (published and unpublished) used by the FDA for the approval of the five pain indications for these agents (one for gabapentin, four for pregabalin). Among the findings of interest are the fact that the FDA rejected the application for gabapentin for diabetic peripheral neuropathy based on the risk versus benefit profile of that drug in the clinical trials that were submitted by the manufacturer. Additionally, both the comparative effectiveness trials as well as the studies used by the FDA tend to be short in duration and show only modest pain benefits for the gabapentinoids. The placebo response in these trials was frequently one-third to one-half as great as the pain benefit demonstrated by the gabapentinoid. Based on the available clinical trial evidence, we feel prescribers should be cautious when using gabapentinoids for pain, particularly when using these agents for a prolonged period or when combined with other, centrally acting agents.

Association of State-Imposed Restrictions on Gabapentin with Changes in Prescribing in Medicare

BACKGROUND

Between August 2016 and July 2018, three states classified gabapentin as a Schedule V drug and nine states implemented prescription drug monitoring program (PDMP) regulation for gabapentin. It is highly unusual for states to take drug regulation into their own hands. The impact of these changes on gabapentin prescribing is unclear.

OBJECTIVE

To determine the effect of state-imposed regulation on gabapentin prescribing for Medicare Part D enrollees from 2013 to 2018.

DESIGN

Population-based difference-in-difference(DID) analysis study utilizing the Medicare Part D Prescriber Public Use File.

PARTICIPANTS

All eligible Medicare Part D prescribers excluding those outside of the fifty states and the District of Columbia were included in our analysis. Prescriber data and key sociodemographic variables were organized by state and year. States with a gabapentin schedule change or PDMP regulation enacted before 2019 were included in the intervention group. For the Schedule V DID analysis, a control group of the ten highest opioid-prescribing states was used.

INTERVENTIONS

States with gabapentin schedule changes or PDMP regulation before January 1, 2019, were included and compared to control states that did not implement these policies.

MAIN MEASURES

Total days' supply of gabapentin per enrollee per year was the primary outcome variable.

KEY RESULTS

The mean total days' supply of gabapentin per enrollee increased 41% from 19.71 to 27.81 total days' supply per enrollee per year between 2013 and 2018. After adjustment, Schedule V gabapentin regulation resulted in a reduction of 8.37 total days of gabapentin prescribed per enrollee (95% confidence interval of - 10.34 to - 6.39). In contrast, PDMP regulation resulted in a reduction of 1.01 total days of gabapentin prescribed per enrollee (95% confidence interval of - 1.74 to - 0.29).

CONCLUSIONS

Classifying gabapentin as a Schedule V drug results in substantial reduction in total days prescribed whereas PDMP regulation results in modest reduction.

Using a multi-module web-app to prevent substance use among students at a Hispanic Serving Institution: development and evaluation design

BACKGROUND

Despite effective strategies to prevent substance use and substance use disorders among college students, challenges remain. As young adults' preference for and comfortability with web-based technology continues to increase, leveraging innovative approaches to rapidly evolving mHealth technology is critical for the success of lowering the risk for substance use and related consequences in college populations, and especially those at Hispanic Serving Institutions. Therefore, the present study describes the rationale, development, and design of iSTART, a novel web-app to prevent substance use among students.

METHODS

The web-app was developed following the intervention mapping protocol, and in collaboration with numerous stakeholders, including a community-based partner specializing in substance abuse prevention and treatment. A 30-day multi-module web-app intervention was developed based on key theoretical constructs, behavior change strategies, and practical module components: attitudes (knowledge), perceived susceptibility (risk perceptions), subjective norms (normative re-education), and self-efficacy (refusal skills). This intervention will be evaluated via a time series design using a sample of 600 students randomly assigned to either the intervention, comparison, or control condition at a public institution in southern California.

DISCUSSION

The iSTART web-app is an innovative and sustainable program ideal for college campuses with diverse student populations. If this prevention web-app is successful, it will significantly contribute to the evidence of effective substance use interventions in the college setting, and identify the benefits of mHealth programs to prevent future substance use.

TRIAL REGISTRATION

NCT05362357 retrospectively registered on May 4, 2022 on clinicaltrials.gov .

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.

Increase of high-risk tramadol use and harmful consequences in France from 2013-2018: evidence from the triangulation of addictovigilance data

Aims

The aim of this paper is to assess recent developments in non‐medical tramadol use, tramadol use disorder, illegal procurement and deaths.

Methods

This study used repeated cross‐sectional analysis of data collected nationwide from 2013 to 2018. Analysis was conducted through multisource monitoring of the French Addictovigilance Network of: (1) validated reports of high‐risk tramadol use, (2) record systems collecting information from toxicology experts investigating analgesic‐related deaths (DTA) and deaths related to substance abuse (DRAMES), and pharmacists for forged prescriptions (OSIAP), and (3) survey of drug users, with investigation of patterns of use while visiting addiction‐specialised institutions (OPPIDUM).

Results

Despite a plateauing level of tramadol exposure in the French population, the proportion of tramadol reports increased 1.7‐fold (187 cases in 2018, 3.2% (95% confidence interval [CI]: 2.74–3.63%), versus 1.9% (95% CI: 1.49–2.42% in 2013). Trends were similar in OSIAP: 11.9% of forged prescriptions in 2018 (95% CI: 10.56–13.45%); 1.7‐fold increase; in OPPIDUM: 0.76% (95% CI: 0.55–1.02); 2.2‐fold increase; and DRAMES: 3.2% of drug abuse‐related deaths in 2018 (95% CI: 1.89–5.16) versus 1.7% in 2013 (95% CI: 0.65–3.84). Tramadol was the primary opioid in analgesic‐related deaths in DTA (45% in 2018). Two profiles of high‐risk tramadol users were identified: (1) patients treated for pain or with tramadol persistence when pain disappeared (mainly women; mean age 44 years), and (2) individuals with non‐medical use for psychoactive effects (mainly men; mean age 36 years).

Conclusion

The triangulation of the data obtained through addictovigilance monitoring evidenced a recent increase in high‐risk tramadol use. These findings have a practical impact on the limitation of the maximal duration of tramadol prescriptions.

Setting the policy agenda for the treatment of substance use disorders in Iran

Background

Drug use is one of the most common public health problems globally. This study was done to analyze the agenda-setting of policies related to substance use disorder treatment in Iran since 1979.

Methods

The current qualitative study was done through document review and interviews with policymakers and executives. Purposive sampling with snowball strategy was considered for sampling. Semi-structured interviews were done. A total of 22 documents were examined, and the data were saturated with 32 interviews. Kingdon's Multiple Streams Framework was used to analyze the data.

Results

The results indicated the intersection of problem stream, policy stream, political stream, and opening the opportunity window. In the problem stream, the rapid growth of AIDS among people who inject drugs (PWID), the decrease in the average age of first drug use, the increase in the prevalence of substance use disorder in women, the ineffectiveness of compulsive treatment, and criminological perspectives played key roles. The policy stream included criminological perspective and war on drugs, and harm reduction. The political stream included announcing general anti-narcotics policies by the Supreme Leader of Iran and understanding the need for treatment, rehabilitation, harm reduction, and social support for substance use disorder by officials and policymakers.

Conclusions

For a long time in Iran, policies based on the war on drugs were the dominant approach, and then, policies based on harm reduction and patient-centeredness were considered. The ideology and political parties influenced the executive apparatus's policy stream in this area. In countries with an ideological approach, the political stream plays a critical role in setting issues on the agenda. Therefore, policy entrepreneurs can put the points on the agenda by attracting the attention of political forces to the issue.

Chronic Pain in the Elderly: Mechanisms and Perspectives

Chronic pain affects a large part of the population causing functional disability, being often associated with coexisting psychological disorders, such as depression and anxiety, besides cognitive deficits, and sleep disturbance. The world elderly population has been growing over the last decades and the negative consequences of chronic pain for these individuals represent a current clinical challenge. The main painful complaints in the elderly are related to neurodegenerative and musculoskeletal conditions, peripheral vascular diseases, arthritis, and osteoarthritis, contributing toward poorly life quality, social isolation, impaired physical activity, and dependence to carry out daily activities. Organ dysfunction and other existing diseases can significantly affect the perception and responses to chronic pain in this group. It has been proposed that elderly people have an altered pain experience, with changes in pain processing mechanisms, which might be associated with the degeneration of circuits that modulate the descending inhibitory pathways of pain. Aging has also been linked to an increase in the pain threshold, a decline of painful sensations, and a decrease in pain tolerance. Still, elderly patients with chronic pain show an increased risk for dementia and cognitive impairment. The present review article is aimed to provide the state-of-art of pre-clinical and clinical research about chronic pain in elderly, emphasizing the altered mechanisms, comorbidities, challenges, and potential therapeutic alternatives.

The Impact of Regulatory Restrictions on Pregabalin use in Saudi Arabia: An Interrupted Time series Analysis

PURPOSE

The Saudi Food and Drug Authority (SFDA) added pregabalin to the list of controlled substances in December 2017 to minimize the risk of its possible abuse and misuse. This study was aimed at assessing the impact of this decision on the overall use of pregabalin in Saudi Arabia and in comparison, with drugs prescribed to treat neuropathic pain therapy (i.e. vs. gabapentin, tramadol, duloxetine, and amitriptyline).

METHODS

This was an interrupted time-series analysis of the Saudi quarterly sale data of the study drugs from October/2015 to September/2020. These data were obtained from IQVIA and were converted into use estimates (defined daily dose per 1000 inhabitant-days [DDD/TID]). Segmented regression models were conducted to assess the direct (level) and prolonged (trend) changes in use data after the decision. All analyses were completed using RStudio Version 1.4.1103.

RESULTS

Before the SFDA's decision, there was an increased quarter-to-quarter use of pregabalin (DDD/TID: 0.16; 95% confidence interval [CI] 0.04 to 0.28). Pregabalin overall use dropped sharply by -1.85 DDD/TID (95%CI -2.71 to -0.99) directly after the decision with a prolonged quarter-to-quarter declining effect (DDD/TID: -0.22, CI to -0.37 to -0.05). The decision was associated with a direct increase in the use of gabapentin by 0.62 DDD/TID (95%CI 0.52 to 0.72) without any impact on the use of other drugs.

CONCLUSIONS

The results of our study showed that the SFDA decision was associated with a decrease in the overall use of pregabalin, which may help minimize the risk of its abuse and misuse. This article is protected by copyright. All rights reserved.

Central nervous system polytherapy among veterans with posttraumatic stress disorder: changes across a decade

OBJECTIVE

The study objectives were to investigate rates and patterns of polytherapy among veterans with PTSD across time (in 2009 and 2019), describe features of polytherapy prescribing, and identify demographic and clinical factors associated with polytherapy.

METHODS

Veterans Affairs (VA) administrative data were used to build cohorts of all VA-served veterans with PTSD in 2009 (N = 458,620) and 2019 (N = 877,785). Frequency of CNS active drug classes, rates of polytherapy (≥5 concurrent CNS drugs), clinical features associated with polytherapy, number of prescribers, and patterns of co-prescribed medications were examined.

RESULTS

The 12-month period prevalence of CNS polytherapy declined from 12.1% in 2009 to 6.9% in 2019. However, polytherapy rates increased from 3.3% in 2009 to 4.1% in 2019, when opioids and benzodiazepines were excluded. In multivariable regression analysis, CNS polytherapy was more common among women, White people, middle-age veterans (45-64 years), rural residents, veterans receiving care at a medical center, and those with psychiatric comorbidities. CNS polytherapy regimens involved a mean of 2.3 prescribers and the majority (86.6%) included at least one medication commonly prescribed for pain management.

CONCLUSIONS

CNS polytherapy declined among veterans with PTSD from 2009 to 2019 and was wholly attributable to decreases in opioid and benzodiazepine prescribing.

Kinetics and Mechanism of Fentanyl Dissociation from the μ-Opioid Receptor

Driven by illicit fentanyl, opioid related deaths have reached the highest level in 2020. Currently, an opioid overdose is resuscitated by the use of naloxone, which competitively binds and antagonizes the μ-opioid receptor (mOR). Thus, knowledge of the residence times of opioids at mOR and the unbinding mechanisms is valuable for assessing the effectiveness of naloxone. In the present study, we calculate the fentanyl-mOR dissociation time and elucidate the mechanism by applying an enhanced sampling molecular dynamics (MD) technique. Two sets of metadynamics simulations with different initial structures were performed while accounting for the protonation state of the conserved H297^6.52, which has been suggested to modulate the ligand-mOR affinity and binding mode. Surprisingly, with the Nδ-protonated H297^6.52, fentanyl can descend as much as 10 Å below the level of the conserved D147^3.32 before escaping the receptor and has a calculated residence time τ of 38 s. In contrast, with the Nϵ- and doubly protonated H297^6.52, the calculated τ are 2.6 and 0.9 s, respectively. Analysis suggests that formation of the piperidine-Hid297 hydrogen bond strengthens the hydrophobic contacts with the transmembrane helix (TM) 6, allowing fentanyl to explore a deep pocket. Considering the experimental τ of ∼4 min for fentanyl and the role of TM6 in mOR activation, the deep insertion mechanism may be biologically relevant. The work paves the way for large-scale computational predictions of opioid dissociation rates to inform evaluation of strategies for opioid overdose reversal. The profound role of the histidine protonation state found here may shift the paradigm in computational studies of ligand-receptor kinetics.

Safety concerns on the abuse potential of esketamine: Multidimensional analysis of a new anti-depressive drug on the market

Prominent features of esketamine (e.g., similar mechanism of action as ketamine and target population) require to be vigilant regarding its benefits/risks balance and its risks of abuse in real-life settings. The aim of this study was to review all available pharmacological and clinical data to assess the abuse potential of esketamine shortly after its marketing. This multidimensional study is a quantitative and qualitative analysis of complementary data sources, ranging from preauthorization data (i.e., fundamental pharmacology and clinical trials) to real-life settings data (i.e., pharmacovigilance databases and web forums). According to esketamine pharmacology, its psychoactive effects play a role both in its therapeutic effect and its abuse potential. Only one out of the three short-term efficacy trials found a significant difference between esketamine and placebo in treatment-resistant depression. Beside adverse events that may be sought for abuse purpose (e.g., dissociation, sedation, euphoric mood, hallucination, feeling drunk, and derealization), clinical signs related to substance use disorder (e.g., tolerance, withdrawal syndrome, and drug dependence) and misuse (e.g., off-label use) were also identified in pharmacovigilance databases. Analysis of pharmacovigilance narratives and web forums showed that esketamine psychoactive effects are appreciated by some patients, while they are badly experienced by others. Strict compliance with the market authorization, close monitoring of patients by psychiatrists, and surveillance of any signs of misuse, abuse, or dependence must be part of any treatment course.

Is gabapentin a safe and effective treatment for nonneuropathic pain?

ABSTRACT

A review of the recent literature found that compared with placebo or other pain medications, gabapentin did not significantly reduce nonneuropathic pain. The drug also is associated with an increased risk of adverse reactions, including somnolence, dizziness, and nausea. Given the lack of efficacy and risk of adverse reactions, gabapentin should not be used for nonneuropathic pain.

Antidepressants abuse in subjects with opioid use disorders: A 10-year study in the French OPPIDUM program

Accumulating evidence shows that some antidepressants are abused for their psychostimulant effects, but the extent of antidepressants abuse is unknown in subjects with opioid use disorders (OUD). The objective of this work is to assess the prevalence of antidepressant abuse and its correlates in subjects with OUD. Subjects ≥18 year-old in an opiate maintenance treatment (OMT) program who reported using an antidepressant were selected from the OPPIDUM program from 2011 to 2020. The outcome was antidepressant abuse. Antidepressant abusers were identified as subjects reporting at least one of the following behaviors: "drug abuse," "concomitant use of alcohol," "illegal obtaining," and "dose higher than recommended in the Summary of Product Characteristics." Among the 83 040 observations of subjects ≥18 year-old in an OMT program included in the OPPIDUM program from 2011 to 2020, 2708 (3.3%) subjects reported using an antidepressant in monotherapy. Among them, there were 385 (14.2%) abusers. The proportion of abusers was the highest for amitriptyline (n = 31, 25.0%). In multivariate analysis, antidepressant abuse was positively associated with amitriptyline (OR 2.07, 95% CI [1.16, 3.73]; p = 0.015), unemployment (OR 1.52, 95% CI [1.16, 2.01]; p = 0.003), the use of intravenous route of administration (OR 1.77, 95% CI [1.12, 2.80]; p = 0.014), and the use of benzodiazepines (OR 1.53, 95% CI [1.21, 1.94]; p < 0.001). Clinicians should be aware of the risk of antidepressant abuse when prescribing in subjects with OUD, accounting for their heterogeneous pharmacological properties that may account for their abuse potential.

Gabapentinoid Pharmacology in the Context of Emerging Misuse Liability

This article will review the epidemiology and pharmacology of gabapentinoids (gabapentin and pregabalin) relevant to their emerging misuse potential and provide guidance for clinical and regulatory management. Gabapentinoids are γ-aminobutyric acid analogues that produce their therapeutic effects by inhibiting voltage-gated calcium channels and decreasing neurotransmitter release. Recently gabapentinoid prescribing and use have increased tremendously. Although traditionally thought to possess a favorable safety profile, gabapentinoid misuse has also risen significantly. Gabapentinoid misuse generally occurs in combination with other substances, most notably opioids, and may be for purposes of eliciting euphoric effects, enhancing the effects of other substances, or self-treating conditions such as withdrawal, pain, anxiety, or insomnia. Given its faster onset, increased bioavailability and potency, and nonsaturable absorption, pregabalin's pharmacokinetics theoretically enhance its misuse liability versus gabapentin. However, gabapentin can produce similar euphoric effects, and epidemiologic studies have identified higher rates of gabapentin misuse in the United States, likely because of greater availability and less regulated prescribing. Although adverse events of gabapentinoid-only ingestion are relatively benign, a growing body of evidence indicates that gabapentinoids significantly increase opioid-related morbidity and mortality when used concomitantly. In addition, significant withdrawal effects may occur on abrupt discontinuation. As a result of these trends, several US states have begun to further regulate gabapentinoid prescribing, reclassifying it as a controlled substance or mandating reporting to local prescription drug-monitoring programs. Although increased regulation of gabapentin prescribing may be warranted, harm reduction efforts and increased patient and provider education are necessary to mitigate this concerning gabapentinoid misuse trend.

Association between preoperative administration of gabapentinoids and 30-day hospital readmission: A retrospective hospital registry study

STUDY OBJECTIVE

To evaluate the effectiveness of preoperative gabapentinoid administration.

DESIGN

Retrospective hospital registry study.

SETTING

Tertiary referral center (Boston, MA).

PATIENTS

111,008 adult non-emergency, non-cardiac surgical patients between 2014 and 2018.

INTERVENTIONS

Preoperative administration of gabapentinoids (gabapentin or pregabalin).

MEASUREMENTS

We tested the primary hypothesis that preoperative gabapentinoid use was associated with lower odds of hospital readmission within 30 days. Contingent on this hypothesis, we examined whether lower intraoperative opioid utilization mediated this effect. Secondary outcome was postoperative respiratory complications.

MAIN RESULTS

Gabapentinoid administration was associated with lower odds of readmission (adjusted odds ratio [OR_adj] 0.80 [95% CI, 0.75-0.85]; p < 0.001). This effect was in part mediated by lower intraoperative opioid utilization in patients receiving gabapentinoids (8.2% [2.4-11.5%]; p = 0.012). Readmissions for gastrointestinal disorders (OR_adj 0.74 [0.60-0.90]; p = 0.003), neuro-psychiatric complications (OR_adj 0.66 [0.49-0.87]; p = 0.004), non-surgical site infections (OR_adj 0.68 [0.52-0.88; p = 0.004) and trauma or poisoning (OR_adj 0.25 [0.16-0.41]; p < 0.001) occurred less frequently in patients receiving gabapentinoids. The risk of postoperative respiratory complications was lower in patients receiving gabapentinoids (OR_adj 0.77 [0.70-0.85]; p < 0.001). Lower doses of pregabalin (< 75 mg) and gabapentin (< 300 mg) compared to both, no and high-dose administration of gabapentinoids, were associated with a lower risk of postoperative respiratory complications (OR_adj 0.61 [0.50-0.75]; p < 0.001 and OR_adj 0.70 [0.53-0.92]; p = 0.012, respectively). These lower gabapentinoid doses prevented 30-day readmission (OR_adj 0.74 [0.65-0.85]; p < 0.001). The results were robust in several sensitivity analyses including surgical procedure defined subgroups and patients undergoing ambulatory surgery.

CONCLUSIONS

The preoperative use of pregabalin and gabapentin, up to doses of 75 and 300 mg respectively, mitigates the risks of hospital readmission and postoperative respiratory complications which can in part be explained by lower intraoperative opioid use. Further research is warranted to elucidate mechanisms of the preventive action.

Beyond the 'purple drank': Study of promethazine abuse according to the European Medicines Agency adverse drug reaction reports

BACKGROUND

Promethazine is a medicinal product, available on its own or in combination with other ingredients including dextromethorphan, paracetamol and/or expectorants. Anecdotal reports have however indicated that promethazine may have a misuse potential, especially in adolescents.

OBJECTIVE

We here aimed at studying how this phenomenon has been reported to the European Monitoring Agency Adverse Drug Reactions database.

METHODS

After a formal request to the European Monitoring Agency, the promethazine-specific dataset has been studied, performing a descriptive analysis of misuse/abuse/dependence-related adverse drug reaction reports. The study was approved by the University of Hertfordshire (LMS/PGR/UH/03234).

RESULTS

The analysis of promethazine data showed increasing levels of misuse/abuse/ dependence issues over time (2003-2019). Out of a total number of 1543 cases of adverse drug reactions, the abuse/misuse/dependence-related cases reported were 557, with 'drug abuse' (300/557: 53.8%) and 'intentional product misuse' (117/557: 21.0%). being the most represented adverse drug reactions. A high number of fatalities were described (310/557: 55.6%), mostly recorded as 'drug toxicity/drug abuse' cases, with opiates/opioids having been the most commonly reported concomitant drugs used.

CONCLUSION

Anecdotal promethazine misuse/abuse reports have been confirmed by European Monitoring Agency data. Promethazine misuse/abuse appears to be an alarming issue, being associated with drug-related fatalities. Thus, healthcare professionals should be warned about a possible misuse of promethazine and be vigilant, as in some countries medicinal products containing promethazine can be purchased over the counter. Since promethazine is often available in association with opioids, its abuse may be considered a public health issue, with huge implications for clinical practice.

Early Detection of Prescription Drug Abuse Using Doctor Shopping Monitoring From Claims Databases: Illustration From the Experience of the French Addictovigilance Network

Opioid analgesics and maintenance treatments, benzodiazepines and z-drugs, and other sedatives and stimulants are increasingly being abused to induce psychoactive effects or alter the effects of other drugs, eventually leading to dependence. Awareness of prescription drug abuse has been increasing in the last two decades, and organizations such as the International Narcotics Control Board has predicted that, worldwide, prescription drug abuse may exceed the use of illicit drugs. Assessment of prescription drug abuse tackles an issue that is hidden by nature, which therefore requires a specific monitoring. The current best practice is to use multiple detection systems to assess prescription drug abuse by various populations in a timely, sensitive, and specific manner. In the early 2000's, we designed a method to detect and quantify doctor shopping for prescription drugs from the French National Health Data System, which is one of the world's largest claims database, and a first-class data source for pharmacoepidemiological studies. Doctor shopping is a well-known behavior that involves overlapping prescriptions from multiple prescribers for the same drug, to obtain higher doses than those prescribed by each prescriber on an individual basis. In addition, doctor shopping may play an important role in supplying the black market. The paper aims to review how doctor shopping monitoring can improve the early detection of prescription drug abuse within a multidimensional monitoring. The paper provides an in-depth overview of two decades of development and validation of the method as a complementary component of the multidimensional monitoring conducted by the French Addictovigilance Network. The process accounted for the relevant determinants of prescription drug abuse, such as pharmacological data (e.g., formulations and doses), chronological and geographical data (e.g., impact of measures and comparison between regions), and epidemiological and outcome data (e.g., profiles of patients and trajectories of care) for several pharmacological classes (e.g., opioids, benzodiazepines, antidepressants, and methylphenidate).

Refined Prediction of Pharmacokinetic Kratom-Drug Interactions: Time-Dependent Inhibition Considerations

Preparations from the leaves of the kratom plant (Mitragyna speciosa) are consumed for their opioid-like effects. Several deaths have been associated with kratom used concomitantly with some drugs. Pharmacokinetic interactions are potential underlying mechanisms of these fatalities. Accumulating in vitro evidence has demonstrated select kratom alkaloids, including the abundant indole alkaloid mitragynine, as reversible inhibitors of several cytochromes P450 (CYPs). The objective of this work was to refine the mechanistic understanding of potential kratom-drug interactions by considering both reversible and time-dependent inhibition (TDI) of CYPs in the liver and intestine. Mitragynine was tested against CYP2C9 (diclofenac 4'-hydroxylation), CYP2D6 (dextromethorphan O-demethylation), and CYP3A (midazolam 1'-hydroxylation) activities in human liver microsomes (HLMs) and CYP3A activity in human intestinal microsomes (HIMs). Comparing the absence to presence of NADPH during preincubation of mitragynine with HLMs or HIMs, an ∼7-fold leftward shift in IC50 (∼20 to 3 μM) toward CYP3A resulted, prompting determination of TDI parameters (HLMs: K I , 4.1 ± 0.9 μM; k inact , 0.068 ± 0.01 min-1; HIMs: K I , 4.2 ± 2.5 μM; k inact , 0.079 ± 0.02 min-1). Mitragynine caused no leftward shift in IC50 toward CYP2C9 (∼40 μM) and CYP2D6 (∼1 μM) but was a strong competitive inhibitor of CYP2D6 (K i , 1.17 ± 0.07 μM). Using a recommended mechanistic static model, mitragynine (2-g kratom dose) was predicted to increase dextromethorphan and midazolam area under the plasma concentration-time curve by 1.06- and 5.69-fold, respectively. The predicted midazolam area under the plasma concentration-time curve ratio exceeded the recommended cutoff (1.25), which would have been missed if TDI was not considered. SIGNIFICANCE STATEMENT: Kratom, a botanical natural product increasingly consumed for its opioid-like effects, may precipitate potentially serious pharmacokinetic interactions with drugs. The abundant kratom indole alkaloid mitragynine was shown to be a time-dependent inhibitor of hepatic and intestinal cytochrome P450 3A activity. A mechanistic static model predicted mitragynine to increase systemic exposure to the probe drug substrate midazolam by 5.7-fold, necessitating further evaluation via dynamic models and clinical assessment to advance the understanding of consumer safety associated with kratom use.

What about "Pharming"? Issues Regarding the Misuse of Prescription and Over-the-Counter Drugs

Recently, a range of prescription and over-the-counter (OTC) drugs have emerged as being used recreationally, either on their own or in combination with other substances, both licit and illicit, including new psychoactive substances (NPS). Among them, the misuse of prescription drugs involves not only traditionally recorded substances, such as benzodiazepines and opioid pain relievers, but also gabapentinoids (e.g., pregabalin and gabapentin); some antidepressants, e.g., bupropion and venlafaxine; some second-generation antipsychotics, e.g., quetiapine and olanzapine. Moreover, the use of some OTC for recreational purposes appears on the increase, especially in vulnerable categories such as young people/youths, including the use of high dosages of the antidiarrheal loperamide; first-generation antihistamines, e.g., promethazine, cyclizine, and diphenhydramine; cough and cold preparations containing dextromethorphan and/or codeine. In this context, the role of the Internet has rapidly increased, playing a significant role both in the diffusion of emerging trends of drug misuse among users and experimenters, and the marketing, sale, and distribution of drugs through online pharmacies. This phenomenon within the context of a rapidly modifying drug scenario is a globally recognized health problem, determining severe adverse consequences, including fatalities, and represents a challenge for clinicians in general, psychiatrists, public health, and drug-control policies.

Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain

Background

Widely used for acute pain management, the clinical benefit from perioperative use of gabapentinoids is uncertain. The aim of this systematic review was to assess the analgesic effect and adverse events with the perioperative use of gabapentinoids in adult patients.

Methods

Randomized controlled trials studying the use of gabapentinoids in adult patients undergoing surgery were included. The primary outcome was the intensity of postoperative acute pain. Secondary outcomes included the intensity of postoperative subacute pain, incidence of postoperative chronic pain, cumulative opioid use, persistent opioid use, lengths of stay, and adverse events. The clinical significance of the summary estimates was assessed based on established thresholds for minimally important differences.

Results

In total, 281 trials (N = 24,682 participants) were included in this meta-analysis. Compared with controls, gabapentinoids were associated with a lower postoperative pain intensity (100-point scale) at 6 h (mean difference, −10; 95% CI, −12 to −9), 12 h (mean difference, −9; 95% CI, −10 to −7), 24 h (mean difference, −7; 95% CI, −8 to −6), and 48 h (mean difference, −3; 95% CI, −5 to −1). This effect was not clinically significant ranging below the minimally important difference (10 points out of 100) for each time point. These results were consistent regardless of the type of drug (gabapentin or pregabalin). No effect was observed on pain intensity at 72 h, subacute and chronic pain. The use of gabapentinoids was associated with a lower risk of postoperative nausea and vomiting but with more dizziness and visual disturbance.

Conclusions

No clinically significant analgesic effect for the perioperative use of gabapentinoids was observed. There was also no effect on the prevention of postoperative chronic pain and a greater risk of adverse events. These results do not support the routine use of pregabalin or gabapentin for the management of postoperative pain in adult patients.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Prescribed and non-prescribed gabapentin use among persons seeking inpatient opioid detoxification

BACKGROUND

Persons with opioid use disorder (OUD) are at increased risk for gabapentin misuse. Rising rates of concomitant gabapentin-opioid use in the U.S. are concerning given heightened risk of fatal overdose.

OBJECTIVE

To examine predictors of ever using gabapentin among persons seeking treatment for opioid use and to assess if reasons for gabapentin use differed by gender and how gabapentin was procured (prescribed, non-prescribed, or both).

METHOD

Persons with OUD were recruited from a managed withdrawal program. t-Tests and Pearson χ2 tests of independence were used to compare reasons for gabapentin use by gender and source of acquisition.

RESULTS

Among participants (n = 401; 69.1% male, 84.5% White, 86.8% sought treatment for heroin use, 90.0% insured), female gender, higher educational attainment, injection drug use (IDU), history of overdose, and chronic pain were associated with gabapentin use. Overall, reasons for use were similar across genders among those reporting a history of gabapentin use (65.8%), although males were more likely to use to get high than females. About half (47.0%) reported only using gabapentin that was not prescribed, 20.5% had only used prescribed gabapentin, and 32.5% reported prescribed and non-prescribed use. Persons prescribed gabapentin were most likely to use it to control pain (81.5%); for those using diverted gabapentin only and those reporting both prescribed and non-prescribed gabapentin use, the most common reasons for intake were to: get high, increase effects of heroin, substitute for opioids, and help with opioid withdrawal.

CONCLUSIONS

In this sample of people with OUD entering inpatient detoxification program, a majority reported a history of gabapentin use, with most using diverted gabapentin. The range of reasons for gabapentin use point to the need to better understand why co-use is common.

Long-term use of hydrocodone vs. oxycodone in primary care

BACKGROUND

Hydrocodone and oxycodone are the Schedule II opioids most often prescribed in primary care. Notwithstanding the dangers of prescription opioid use, the likelihood of long-term use with either drug is presently unknown.

METHODS

Using a retrospective cohort design and data from a commerical healthcare claims repository, we compared the likelihood of long-term use of hydrocodone and oxycodone in primary care patients presenting with acute back pain. Treatment was categorized as long-term if the prescription dates spanned ≥90 days from initial prescription to the run-out date of the last prescription, and included ≥120 days' supply or ≥10 fills. Instrumental variable methods and probit regression were used to model the effect of drug choice on long-term use, estimate the average treatment effect, and correct for confounding by indication.

RESULTS

A total of 3,983 patients who were prescribed only hydrocodone or only oxycodone were followed for 270 days in 2016. Long-term opioid use was observed in 320 patients (8%). Controlling for potential confounders including morphine milligram equivalents and dosage, an estimated 12% (95 CI, 10%-14%) treated with hydrocodone transitioned to long-term use vs. 2% (95 CI, 1%-3%) on oxycodone. Among patients who received more than one prescription (n = 1,866), an estimated 23% (95 CI, 19%-26%) treated with hydrocodone transitioned to long-term use vs. 5% (95 CI, 3%-7%) on oxycodone. The difference between drugs was supported in sensitivity and subgroup analyses. Sample selection bias was not detected.

CONCLUSIONS

Long-term use was substantially greater for patients treated with hydrocodone than oxycodone, despite equianalgesia.

Trends in prior receipt of prescription opioid or adjuvant analgesics among patients with incident opioid use disorder or opioid-related overdose from 2006 to 2016

BACKGROUND

With increasing efforts to scrutinize and reduce opioid prescribing, limited data exist on the recent trend in receipt of prescription pain medications before diagnosis of opioid use disorder (OUD) or opioid-related overdose (OD).

METHODS

Using 2005-2016 Truven MarketScan Commercial Claims databases, we assessed trends in annual 1) incidence of OUD or OD and 2) prevalence of receipt of prescription opioids or four commonly-prescribed adjuvant analgesics among patients newly diagnosed with OUD/OD. Trends were examined in the overall sample and by 3 age groups, including youths (≤18 years), adults (19-64 years), and older adults (≥65 years).

RESULTS

The incidence of diagnosed OUD or OD increased more than 3-fold from 4.99 to 23.81 per 10,000 persons from 2006 to 2016, with the highest increase (14.18-fold) seen in older adults, followed by adults (3.53-fold), and youths (0.16-fold). Between 2006 and 2016, the proportion of patients with incident OUD/OD who received anticonvulsant adjuvant analgesics in the year before diagnosis increased (from 23.4% to 34.3% [P-trend = .005]) whereas the proportion receiving high-dose prescriptions opioids decreased (from 45.5% to 34.8% [P-trend =< .001]). A decreasing trend was observed in general for tricyclic antidepressants and serotonin and norepinephrine reuptake inhibitors.

DISCUSSION

In US commercially insured patients newly diagnosed with OUD/OD, receipt of high-dose opioid prescriptions preceding the diagnosis decreased over time, paralleled by increased use of anticonvulsants commonly prescribed for pain conditions. Further investigations are warranted to understand how prescribed and anticonvulsants contribute to the development of OUD/OD.

Home induction and outpatient treatment of kratom use disorder with buprenorphine-naloxone: A case report in a young adult

Background: The use of the natural product, kratom, has increased significantly in recent years. The active compounds in kratom have been shown to produce both opioid and stimulant-like effects. While kratom is marketed as a safe, non-addictive method to treat pain and opioid withdrawal, there have been reports demonstrating that kratom is physiologically addictive and linked to overdose deaths. A limited number of case-reports are available describing treatment of kratom use disorder in middle-aged adults, generally in the context of chronic pain and in inpatient settings. Our case is unique in that we describe outpatient treatment of kratom use disorder in a young adult with comorbid attention deficit hyperactivity disorder (ADHD) and in the absence of chronic pain. Case: A 20-year-old college student with ADHD presented to an office-based opioid agonist treatment clinic (OBOT) for treatment of kratom use disorder. He was unable to attend inpatient or residential substance use treatment due to work and school obligations. Additionally, he had stopped taking his prescribed stimulant due to cardiac side effects. The OBOT team successfully initiated buprenorphine-naloxone (BUP/NAL) sublingual films via home induction to treat his kratom use disorder. The patient is being monitored monthly with plans to slowly taper his BUP/NAL dose as tolerated. Discussion: We present a case of a young adult male with kratom use disorder, complicated by a diagnosis of ADHD, successfully treated with BUP/NAL via home induction. The patient is currently kratom-free, reports improved mood and sleep patterns since initiating BUP/NAL, and is able to once again tolerate his ADHD stimulant medication. Healthcare providers should be aware of the use of kratom and consider utilizing BUP/NAL to treat dependence to this botanical drug.

Assessment of public and patient online comments in social media and food and drug administration archival data

OBJECTIVES

To refine a method of collecting the data from various patient generated data sources to explore themes with high repeatability. FDA will acquire new insight into understanding the perspectives of patients and caregivers through analyses of multiple sources.

DESIGN

Qualitative analysis of FDA archival data and social media data.

SETTING

Two pilot studies assessing methodologies on differing unstructured data sources. Study 1: Opioid Use Disorder (OUD), analyzing OUD public docket comments and social media data. STUDY 2: Pulmonary Arterial Hypertension (PAH), utilizing FDA's PAH PFDD meeting transcripts and 1813 Online User Generated Content (UGC) posts.

RESULTS

Through triangulation of data, FDA identified data overlaps (thus increasing confidence of data) and located information found only in certain sources.

CONCLUSIONS

and Relevance: For research to be patient centric, leveraging technological advances and multiple patient experience data sources captures the patient perspective beyond clinical delivery and provides additional information and aids in understanding the picture of medical product functioning beyond controlled randomized clinical trials.

The use of new psychoactive substances (NPS) in young people and their role in mental health care: a systematic review

Introduction: Over the past 10 years, a large number of New Psychoactive Substances (NPS) have entered the recreational drug scenario. NPS intake has been associated with health-related risks, and especially so for vulnerable populations such as the youngsters. Currently, most knowledge on the NPS health effects is learnt from both a range of users' reports, made available through the psychonauts' web fora, and from the few published, related toxicity, clinical observations.Areas covered: This paper aims at providing an overview of NPS effects on youngsters' mental health, whilst performing a systematic review of the current related knowledge.Expert opinion: NPS consumption poses serious health risks, due to both a range of unpredictable clinical pharmacological properties and the typical concomitant use of other psychoactive molecules; overall, this can lead to near misses and fatalities. In comparison with adults, the central nervous system of children/adolescents may be more vulnerable to the activity of these molecules, hence raising even further the levels of health-related concerns. More research is needed to provide evidence of both short- and long-term effects of NPS, related health risks, and their addiction potential.

Comment on: An Insight Into Z-Drug Abuse and Dependence: An Examination of Reports to the European Medicines Agency Database of Suspected Adverse Drug Reactions

After the publication of an article discussing the methodological options to detect the diversion potential of prescription drugs, this letter presents the multidimensional functioning of the French Addictovigilance System. This system aims at monitoring all substances with abuse potential, relying on a network of experts specialized in clinical and fundamental pharmacology. For more than 25 years, we have created collaborations with partners at the interface with field data related to substance use and the potential related disorders. When relevant depending on the context, these data sources are explored and crossed to analyze the abuse potential of one given substance. This organizational approach is useful to detect early Addictovigilance warning signals and to take appropriate measures. Generalizing such a multidimensional approach outside France appears an appealing option to move towards more effective Addictovigilance systems at the international level.

Radiographic dose-dependency study of loperamide effects on gastrointestinal motor function in the rat. Temporal relationship with nausea-like behavior

BACKGROUND

Loperamide is a potent mu opioid receptor agonist available over the counter to treat diarrhea. Although at therapeutic doses loperamide is devoid of central effects, it may exert them if used at high doses or combined with drugs that increase its systemic and/or central bioavailability. Recently, public health and scientific interest on loperamide has increased due to a growing trend of misuse and abuse, and consequent reports on its toxicity. Our aim was to evaluate in the rat the effects of increasing loperamide doses, with increasing likelihood to induce central effects, on gastrointestinal motor function (including gastric dysmotility and nausea-like behavior).

METHODS

Male Wistar rats received an intraperitoneal injection of vehicle or loperamide (0.1, 1, or 10 mg kg^-1 ). Three sets of experiments were performed to evaluate: (a) central effects (somatic nociceptive thresholds, immobility time, core temperature, spontaneous locomotor activity); (b) general gastrointestinal motility (serial X-rays were taken 0-8 hours after intragastric barium administration and analyzed semiquantitatively, morphometrically, and densitometrically); and (c) bedding intake (a rodent indirect marker of nausea). Animals from sets 1 and 3 were used to evaluate gastric dysmotility ex vivo at 2 and 4 hours after administration, respectively.

KEY RESULTS

Loperamide significantly induced antinociception, hypothermia, and hypolocomotion (but not catalepsy) at high doses and dose-dependently reduced gastrointestinal motor function, with the intestine exhibiting higher sensitivity than the stomach. Whereas bedding intake occurred early and transiently, gastric dysmotility was much more persistent.

CONCLUSIONS AND INFERENCES

Our results suggest that loperamide-induced nausea and gastric dysmotility might be temporally dissociated.

Pain therapy - Are there new options on the horizon?

This article reviews the role of analgesic drugs with a particular emphasis on opioids. Opioids are the oldest and most potent drugs for the treatment of severe pain, but they are burdened by detrimental side effects such as respiratory depression, addiction, sedation, nausea, and constipation. Their clinical application is undisputed in acute (e.g., perioperative) and cancer pain, but their long-term use in chronic pain has met increasing scrutiny and has contributed to the current opioid crisis. We discuss epidemiological data, pharmacological principles, clinical applications, and research strategies aiming at novel opioids with reduced side effects.

Assessing the Structural and Pharmacological Similarity of Newly Identified Drugs of Abuse to Controlled Substances Using Public Health Assessment via Structural Evaluation

The US Food and Drug Administration's Center for Drug Evaluation and Research (CDER) developed an investigational Public Health Assessment via Structural Evaluation (PHASE) methodology to provide a structure-based evaluation of a newly identified opioid's risk to public safety. PHASE utilizes molecular structure to predict biological function. First, a similarity metric quantifies the structural similarity of a new drug relative to drugs currently controlled in the Controlled Substances Act (CSA). Next, software predictions provide the primary and secondary biological targets of the new drug. Finally, molecular docking estimates the binding affinity at the identified biological targets. The multicomponent computational approach coupled with expert review provides a rapid, systematic evaluation of a new drug in the absence of in vitro or in vivo data. The information provided by PHASE has the potential to inform law enforcement agencies with vital information regarding newly emerging illicit opioids.

Chronic Pain Management in the Elderly

Chronic pain is extremely prevalent in older adults and is associated with significant morbidity, including limited mobility, social isolation, and depressed mood. Pain is defined by a biopsychosocial model highlighting the importance of a multidisciplinary approach to treatment, including multimodal medications, selected interventions, physical therapy and rehabilitation, and psychological treatments. In this narrative review, the authors highlight the use of these approaches in older adults with specific attention paid to considerations unique to aging, including alterations in drug metabolism, avoidance of polypharmacy, and physiologic changes predisposing to painful conditions.

U.S. Emergency Department Visits Resulting From Nonmedical Use of Pharmaceuticals, 2016

INTRODUCTION

National data on morbidity from nonmedical use of pharmaceuticals are limited. This study used nationally representative, public health surveillance data to characterize U.S. emergency department visits for acute harms from nonmedical use of pharmaceuticals and to guide prevention efforts.

METHODS

Data collected in 2016 from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project were analyzed in 2018 to calculate national estimates of emergency department visits for harms from nonmedical use of pharmaceuticals.

RESULTS

Based on 5,130 surveillance cases, there were an estimated 358,247 emergency department visits (95% CI=280,675, 435,819) in 2016 for harms from nonmedical use of pharmaceuticals and 41.1% resulted in hospitalization (95% CI=32.3%, 49.8%). One half (50.9%, 95% CI=46.6%, 55.3%) of estimated visits involved patients aged ≤34 years; more than one half of estimated visits also involved non-pharmaceutical substances (52.9%, 95% CI=49.7%, 56.1%), including illicit drugs in 34.1% (95% CI=30.9%, 37.2%) and alcohol in 21.8% (95% CI=19.8%, 23.9%). Overall, benzodiazepines were implicated in 46.9% (95% CI=42.5%, 51.2%) of estimated emergency department visits for nonmedical use of pharmaceuticals but were the only substance implicated in just 6.5% (95% CI=5.1%, 7.9%). Prescription opioids were implicated in 36.2% (95% CI=30.8%, 41.7%) of estimated emergency department visits and were the only substance implicated in 11.3% (95% CI=8.6%, 14.0%).

CONCLUSIONS

Although prescription opioids or benzodiazepines are frequently implicated in emergency department visits for nonmedical use, because other substances and additional pharmaceuticals are most often involved, prescribing clinicians should consider implementing specific screening to address polysubstance use and, when warranted, treatment interventions.

Comparison of Quetiapine Abuse and Misuse Reports to the FDA Adverse Event Reporting System With Other Second-Generation Antipsychotics

BACKGROUND

Second-generation antipsychotics (SGAs) are assumed to have little abuse potential. However, reports of quetiapine abuse have emerged as prescribing has increased in recent years. The US Food and Drug Administration's (FDA) Adverse Event Reporting System (FAERS) provides postmarketing information regarding adverse drug events (ADEs). This is the first study to analyze quetiapine abuse-related ADEs reported to FAERS to determine whether a disproportionate rate of such events have been reported when compared with other commonly used SGAs.

METHODS

A cross-sectional analysis of FAERS data from January 1, 2015, to December 31, 2017, was performed. The total number of all-cause and abuse-related ADEs reported to FAERS regarding quetiapine, olanzapine, aripiprazole, and risperidone were identified, along with demographic and mortality data. The proportional reporting ratio (PRR) was calculated to assess disproportionate reporting of abuse-related adverse drug reactions between quetiapine and each of three alternative SGA medications.

RESULTS

Abuse-related ADEs represented 11% (3144/27 962) of total ADEs reported for quetiapine, 8% for olanzapine (1548/19 228), 5% (1380/29 699) for aripiprazole, and 3% (1168/45 518) for risperidone. The PRRs (95% confidence interval) for quetiapine versus olanzapine, aripiprazole, and risperidone were 1.40 (1.32-1.48), 2.42 (2.28-2.57), and 4.38 (4.10-4.68), respectively, indicating that abuse-related events were significantly more likely to be reported with quetiapine than each comparator drug. In addition, more deaths were reported among the abuse-related events regarding quetiapine (673) than olanzapine (200), aripiprazole (88), and risperidone (143).

CONCLUSION

This study corroborates recent evidence indicating that quetiapine might possess a significantly higher abuse potential than other commonly used SGAs. Although prospective studies are needed to better understand the abuse potential of quetiapine, increased vigilance in monitoring for signs of substance abuse might be warranted when prescribing quetiapine.

A Clinical Overview of Off-label Use of Gabapentinoid Drugs

BACKGROUND

The gabapentinoid drugs gabapentin and pregabalin were originally developed as antiseizure drugs but now are prescribed mainly for treatment of pain. For gabapentin, the only pain-related indication approved by the US Food and Drug Administration (FDA) is postherpetic neuralgia. For pregabalin, FDA-approved indications related to pain are limited to postherpetic neuralgia, neuropathic pain associated with diabetic neuropathy or spinal cord injury, and fibromyalgia. Despite these limited indications, gabapentin and pregabalin are widely prescribed off-label for various other pain syndromes. Such use is growing, possibly because clinicians are searching increasingly for alternatives to opioids.

OBSERVATIONS

This report summarizes the limited published evidence to support off-label gabapentinoid uses, describes clinical cases in which off-label use is problematic, and notes how review articles and guidelines tend to overstate gabapentinoid effectiveness.

CONCLUSIONS

Clinicians who prescribe gabapentinoids off-label for pain should be aware of the limited evidence and should acknowledge to patients that potential benefits are uncertain for most off-label uses.

Characterization of intentional-abuse venlafaxine exposures reported to poison control centers in the United States

Background: Venlafaxine use to achieve an amphetamine-like high has been described but data regarding the epidemiology and clinical effects are sparse. Objectives: Describe the prevalence and toxicity of venlafaxine abuse reported to US poison control centers. Methods: This was a retrospective review of venlafaxine exposures reported to the National Poison Data System (NPDS) from 2000 to 2016. Inclusion criteria were: age 12 years and older, reason for exposure intentional-abuse, and either single-substance exposure or venlafaxine was the first substance. The primary outcome was prevalence of intentional-abuse of venlafaxine. Secondary outcomes characterized demographics, geographic distribution, toxicity, and outcomes. Results: Intentional-abuse accounted for 752 of 85,621 venlafaxine exposures. Overall prevalence was 87.8 intentional-abuse exposures/10,000 venlafaxine exposures reported to NPDS (range, 59.3-117.6/10,000). Prevalence decreased from 107/10,000 in 2000 to 59.3/10,000 in 2016. Median age was 23 years and 50% were female. Primary route was ingestion (90.8%) with 4.7% using venlafaxine via inhalation/intranasal insufflation, and 3.7% both routes. There were 227 venlafaxine-only exposures; 54.0% were treated/released from the emergency department, 20% were admitted for medical management, 9.0% to a psychiatric facility, and 17.0% managed at home. Known medical outcomes for single-substance exposures were: no effect (24.0%), minor (39.0%), moderate (33.0%), and major (4.0%); no deaths occurred. Most frequent clinical effects were tachycardia (33.9%), drowsiness (20.7%), and agitation (11.5%). Conclusion: The prevalence of venlafaxine abuse reported to poison control centers has decreased. Medical outcomes are usually not serious. Clinicians should be aware that non-medical use is possible but infrequently reported to poison control centers.