Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts

Evolution of an epidemic: Understanding the opioid epidemic in the United States and the impact of the COVID-19 pandemic on opioid-related mortality

We conduct this research with a two-fold aim: providing a quantitative analysis of the opioid epidemic in the United States (U.S.), and exploring the impact of the COVID-19 pandemic on opioid-related mortality. The duration and persistence of the opioid epidemic lends itself to the need for an overarching analysis with extensive scope. Additionally, studying the ramifications of these concurrent severe public health crises is vital for informing policies to avoid preventable mortality. Using data from CDC WONDER, we consider opioid-related deaths grouped by Census Region spanning January 1999 to October 2022 inclusive, and later add on a demographic component with gender-stratification. Through the lens of key events in the opioid epidemic, we build an interrupted time series model to reveal statistically significant drivers of opioid-related mortality. We then employ a counterfactual to approximate trends in the absence of COVID-19, and estimate excess opioid-related deaths (defined as observed opioid-related deaths minus projected opioid-related deaths) associated with the pandemic. According to our model, the proliferation of fentanyl contributed to sustained increases in opioid-related death rates across three of the four U.S. census regions, corroborating existing knowledge in the field. Critically, each region has an immediate increase to its opioid-related monthly death rate of at least 0.31 deaths per 100,000 persons at the start of the pandemic, highlighting the nationwide knock-on effects of COVID-19. There are consistent positive deviations from the expected monthly opioid-related death rate and a sizable burden from cumulative excess opioid-related deaths, surpassing 60,000 additional deaths nationally from March 2020 to October 2022, ∼70% of which were male. These results suggest that robust, multi-faceted measures are even more important in light of the COVID-19 pandemic to prevent overdoses and educate users on the risks associated with potent synthetic opioids such as fentanyl.

Barriers and facilitators to opioid deprescribing among Advanced Nurse Practitioners: A qualitative interview study

AIM

To explore the experiences primary care Advanced Nurse Practitioners have had in relation to deprescribing opioids in chronic non-malignant pain.

DESIGN

A qualitative interview study.

METHODS

Primary care Advanced Nurse Practitioners were recruited from across the Northern Ireland GP Federations. Data collection for this study took place between April and June 2022. In total, 10 semi-structured online interviews were conducted. Interviews were audio and visually recorded, transcribed verbatim and interpreted using a thematic analysis framework. The COREQ criteria were used to guide the reporting of this study.

RESULTS

The Advanced Nurse Practitioners experienced several challenges associated with opioid deprescribing and the implementation of current chronic pain guidelines. The main barriers identified were difficulties engaging patients in deprescribing discussions, a lack of availability of supportive therapies and poor access to secondary care services. The barriers identified directly impacted on their ability to deliver best practice which resulted in a sense of professional powerlessness.

CONCLUSION

The experiences of the Advanced Nurse Practitioners demonstrate that opioid deprescribing in patients with chronic pain is challenging, and implementation of current chronic pain guidelines is difficult.

IMPACT

This study contributes to existing literature on the topic of reducing opioid prescribing and as far as the authors are aware, is the first study to examine the experiences of primary care advanced nurse practitioners in this context. These findings will be of interest to other primary care practitioners, and prescribers involved in the management of chronic non-malignant pain.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Electronic Real-Time Monitoring Reveals Limited Adherence to Long-Term Opioid Prescriptions in Pain Patients

Background

Pain management physicians are increasingly focused on limiting prescription opioid abuse, yet existing tools for monitoring adherence have limited accuracy. Medication event monitoring system (MEMS) is an emerging technology for tracking medication usage in real-time but has not been tested in chronic pain patients on long-term opioid regimens.

Objective

We conducted a pilot clinical trial to investigate the utility of MEMS for monitoring opioid adherence and compared to traditional methods including self-report diaries, urine drug screen (UDS), and physicians' opinions.

Methods

Opioid-maintained chronic pain patients were recruited from a pain management clinic. Participants (n=28) were randomly assigned to either receive MEMS bottles containing their opioid medication for a 90-day period or to continue using standard medication bottles. MEMS bottles were configured to record and timestamp all bottle openings and the number of pills that were removed from the bottle (via measurement of weight change).

Results

Participants who received MEMS demonstrated highly heterogenous dosing patterns, with a substantial number of patients rapidly removing excessive amounts of medication and/or "stockpiling" medication. By comparison, physicians rated all participants as either "totally compliant" or "mostly compliant". UDS results did not reveal any illicit drug use, but 25% of participants (n=7) tested negative for their prescribed opioid metabolite. MEMS data did not correlate with physician-rated adherence (P=0.24) and UDS results (P=0.77). MEMS data consistently revealed greater non-adherence than self-report data (P<0.001).

Conclusion

These results highlight the limits in our understanding of naturalistic patterns of daily opioid use in chronic pain patients as well as support the use of MEMS for detecting potential misuse as compared to routine adherence monitoring methods. Future research directions include the need to determine how MEMS could be used to improve patient outcomes, minimize harm, and aid in clinical decision-making.

Trial Registration

This study was preregistered on ClinicalTrials.gov (NCT03752411).

Postoperative Opioid Use and Prescribing Patterns among Patients Undergoing Cervical Laminectomy with Instrumented Fusion versus Cervical Laminoplasty with Reconstruction

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare patterns in opioid usage and prescriptions between patients who undergo cervical laminectomy with instrumented fusion (LF) vs cervical laminoplasty with reconstruction (LP) within single surgeon and national database cohorts.

METHODS

We identified patients with cervical myelopathy undergoing primary LF or LP in both a single-surgeon series cohort (2004-2018) and a nationally representative cohort drawn from the IBM® Marketscan® database (2014-2016). We recorded opioid usage within 6 months of surgery and identified differences in unadjusted opioid use rates between LF and LP patients. Multivariable logistic regression was used to evaluate the association between procedure type and postoperative opioid use.

RESULTS

Without adjusting for covariates, LF patients had a higher rate of 6-month opioid use in the single-surgeon cohort (15.7% vs 5.1%, P = .02). After adjusting for covariates, LF patients had higher odds of 6-month postoperative opioid use (OR 2.8 [95% CI 1.0-7.7], P = .04). In the national cohort, without adjusting for covariates, there was no significant difference in 6-month opioid use between LF and LP patients. Even after adjusting for covariates, we found no significant difference in odds.

CONCLUSIONS

Findings from a single-surgeon cohort reveal that LF is associated with a higher rate of 6-month opioid use than LP. This is at odds with findings from a national database cohort, which suggested that LP and LF patients have similar rates of opioid usage at 6-months postoperatively. To prevent overuse of narcotics, surgeons must consider the distinct pain requirements associated with different procedures even in treatment of the same condition.

Predicting first use of heroin from prescription opioid use subtypes: Insights from the Monitoring the Future longitudinal panel

BACKGROUND

Only a small proportion of individuals who initiate nonmedical use of prescription opioids (NUPO) transition to heroin, suggesting that more nuanced aspects of NUPO may be better indicators of risk for escalating opioid use trajectories. This study leveraged panel data to identify NUPO typologies based on NUPO characteristics associated with opioid risk trajectories (route of administration, motives) and compared rates of heroin initiation at follow-up across typologies.

METHODS

Latent class analyses were run among respondents with no history of heroin use from the Monitoring the Future Panel Study (base year N=10,408) at modal ages 18, 19/20, 21/22, 23/24, and 25/26. Indicators included oral NUPO, nonoral NUPO, and NUPO motives to experiment, have a good time with friends, get high, escape problems, manage pain, relax, and sleep. Heroin initiation at follow-ups through modal age 29/30 was predicted from class membership.

RESULTS

No NUPO, self-medication (oral, manage pain), recreational (oral, nonoral, experiment, get high, have a good time with friends), and mixed-motive (all routes, all motives) classes emerged. Heroin initiation rates did not differ across no NUPO and self-medication classes; recreational and mixed-motives classes initiated heroin at higher rates than the other classes and comparable rates to each other. Non-NUPO drug use prior to heroin initiation was prevalent in recreational and mixed-motive classes.

CONCLUSIONS

NUPO does not uniformly or uniquely increase risk for heroin initiation. Leveraging more nuanced indicators of risk for heroin use and targeting polysubstance use in addition to opioid-specific programming may enhance the efficacy of public health efforts.

Use of Syringe Service Programs in Rural vs Urban Maine: A Harm-Reduction Study

Introduction

Syringe service programs (SSPs) reduce HIV and viral hepatitis transmission, as well as the prevalence of improperly disposed needles and needle stick injuries among first responders. Infections associated with injection drug use are rising in rural areas, including Maine, leading to concerns that SSP services are difficult to access for rural residents.

Methods

A cross-sectional survey of 101 participants hospitalized with infections associated with injection drug use at 4 hospitals in Maine was collected over a 15-month period. Descriptive analyses were performed. Statistical analyses were completed using Fisher's exact tests, Pearson's chi-squared tests, and Student's t tests.

Results

Of 101 participants, 66 (65%) lived in urban areas, and 35 (35%) lived rurally. Participants living in rural areas reported less SSP use in the past 3 months (76% urban vs 43% rural). Rural participants also had a higher prevalence of injecting buprenorphine than urban participants (6% urban vs 12% rural). Rural participants were also more likely to obtain needles from pharmacies than urban participants (40% urban vs 71% rural).

Discussion

SSP programs are underrepresented and accessed less in rural areas of Maine. Rural populations of people who inject drugs have unique health characteristics and syringe-use practices.

Conclusions

These findings highlight the need to develop rural SSP programs that address the unique needs of rural populations.

Social vulnerability predictors of drug poisoning mortality: A machine learning analysis in the United States

BACKGROUND AND OBJECTIVES

Drug poisoning is a leading cause of unintentional deaths in the United States. Despite the growing literature, there are a few recent analyses of a wide range of community-level social vulnerability features contributing to drug poisoning mortality. Current studies on this topic face three limitations: often studying a limited subset of vulnerability features, focusing on small sample sizes, or solely including local data. To address this gap, we conducted a national-level analysis to study the impacts of several social vulnerability features in predicting drug mortality rates in the United States.

METHODS

We used machine learning to investigate the role of 16 social vulnerability features in predicting drug mortality rates for US counties in 2014, 2016, and 2018-the most recent available data. We estimated each vulnerability feature's gain relative contribution in predicting drug poisoning mortality.

RESULTS

Among all social vulnerability features, the percentage of noninstitutionalized persons with a disability is the most influential predictor, with a gain relative contribution of 18.6%, followed by population density and the percentage of minority residents (13.3% and 13%, respectively). Percentages of households with no available vehicles, mobile homes, and persons without a high school diploma are the following features with gain relative contributions of 6.3%, 5.8%, and 5.1%, respectively.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

We identified social vulnerability features that are most predictive of drug poisoning mortality. Public health interventions and policies targeting vulnerable communities may increase the resilience of these communities and mitigate the overdose death and drug misuse crisis.

A Diagram of the Social-Ecological Conditions of Opioid Misuse and Overdose

The United States is experiencing a crisis of opioid misuse and overdose. To understand the underlying factors, researchers have begun looking upstream to identify social and structural determinants. However, no study has yet aggregated these into a comprehensive ecology of opioid overdose. We scoped 68 literature sources and compiled a master list of opioid misuse and overdose conditions. We grouped the conditions and used the Social Ecological Model to organize them into a diagram. We reviewed the diagram with nine subject matter experts (SMEs) who provided feedback on its content, design, and usefulness. From a literature search and SME interviews, we identified 80 unique conditions of opioid overdose and grouped them into 16 categories. In the final diagram, we incorporated 40 SME-recommended changes. In commenting on the diagram's usefulness, SMEs explained that the diagram could improve intervention planning by demonstrating the complexity of opioid overdose and highlighting structural factors. However, care is required to strike a balance between comprehensiveness and legibility. Multiple design formats may be useful, depending on the communication purpose and audience. This ecological diagram offers a visual perspective of the conditions of opioid overdose.

Identifying Prescription-Opioid-Related Risks Using Prescription Drug Monitoring Programs' Algorithms and Clinical Screening Tools

BACKGROUND

Pharmacists adopt various approaches to identifying prescription-opioid-related risks and harms, including prescription drug monitoring programs (PDMPs) and clinical screening tools. This study aims to compare 'at-risk' patients according to the published Australian PDMP algorithms with the validated Routine Opioid Outcome Monitoring (ROOM) clinical screening tool.

METHODS

Data were used from an implementation study amongst people who had been prescribed regular opioids. We examined the results from ROOM and the patients' dispensing history over the previous 90 days. A chi-squared test was used to examine the association between risk according to (i) a PDMP alert and a clinical risk per ROOM; (ii) a PDMP alert and positive screening for opioid use disorder; and (iii) a PDMP 'high-dose' alert (average of >100 mg OME/day in the past 90 days) and any ROOM-validated risk.

RESULTS

No significant associations were found between being 'at-risk' according to any of the PDMP alerts and clinical risk as identified via the ROOM tool (x2 = 0.094, p = 0.759). There was only minimal overlap between those identified as 'at-risk' via PDMP alerts and those meeting the clinical risk indicators; most patients who were 'at-risk' of clinical opioid-related risk factors were not identified as 'at-risk' based on PDMP alerts.

CONCLUSIONS

PDMP alerts were not predictive of clinical risk (as per the ROOM tool), as many people with well-established clinical risks would not receive a PDMP alert. Pharmacists should be aware that PDMPs are limited to identifying medication-related risks which are derived using algorithms; therefore, augmenting PDMP information with clinical screening tools can help create a more detailed narrative of patients' opioid-related risks.

Opioid prescriptions and patients' health services utilization and cost before and during the COVID-19 pandemic: an exploratory population-based administrative data analysis

The objective was to explore percentages of the population treated with prescribed opioids and costs of opioid-related hospitalizations and emergency department (ED) visits among individuals treated with prescription opioids and costs of all opioid-related hospitalizations and ED visits in the province (i.e., provincial costs) before and during the coronavirus disease 2019 (COVID-19) pandemic in Alberta, Canada. In administrative data, we identified individuals treated with prescription opioids and opioid-related hospitalizations and ED visits among those individuals and among all individuals in the province between 2015/16 and 2021/22 fiscal years. Services used were counted on an item-by-item basis and costed using case-mix approaches. Annually, from 9.98% (2020/21-2021/22) to 14.52% (2017/18) of the provincial population was treated with prescription opioids. Between 2015/16 and 2021/22, annual costs of opioid-related hospitalizations and ED visits among individuals treated with prescription opioids were ∼$5 and ∼$2 million, respectively. In 2020/21-2021/22, the provincial costs of opioid-related hospitalizations (∼$14 million) and ED visits (∼$7.0 million) were almost twice the costs observed in 2015/16 and immediately before the pandemic (2019/20). Our findings suggest that increases in the opioid-related utilization of inpatient and ED services between 2015/16 and 2021/22, including the drastic increases observed during the COVID-19 pandemic, were likely driven by unregulated substances.

Evaluation of Policies Limiting Opioid Exposure on Opioid Prescribing and Patient Pain in Opioid-Naive Patients Undergoing Elective Surgery in a Large American Health System

OBJECTIVES

Overprescribing to opioid-naive surgical patients substantially contributes to opioid use disorders, which have become increasingly prevalent. Opioid stewardship programs (OSPs) within healthcare settings provide an avenue for introducing interventions to regulate prescribing. This study examined the association of OSP policies limiting exposure on changes in surgery-related opioid prescriptions and patient pain.

METHODS

We evaluated policies implemented by an OSP in a large American healthcare system between 2016 and 2018: nonopioid medication during surgery, decrease of available opioid dosage vials in operating rooms, standardization of opioid in-patient practices through electronic health record alerts, and limit to postsurgery opioid supply. Generalized linear mixed effects models examined the association of interventions with outcome changes in 9262 opioid-naive patients undergoing elective surgery. Outcomes were discharge pain, morphine milligram equivalent in the first prescription postsurgery, and opioid prescription refills.

RESULTS

Decreases in all prescription outcomes and discharge pain were observed following onset of OSP interventions ( P 's < 0.001). Among individual policies, standardization of in-patient prescribing practices was associated with the strongest decrease in prescribed morphine milligram equivalent. Importantly, there was no evidence of an increase in discharge pain related to any intervention.

CONCLUSIONS

This study promotes the potential of OSP formation and policies to reduce opioid prescribing without compromising patient pain. The most effective policy, standardization of in-patient prescribing practices through alerts, suggests that reminding prescribers to re-evaluate the patient's need is effective in changing behavior. The findings offer considerations for OSP formation and policy implementation across health systems to improve quality and safety in opioid prescribing.

Demographics, Diagnoses, Drugs, and Adjuvants in Patients on Chronic Opioid Therapy vs. Intermittent Use in a Tertiary Pediatric Chronic Pain Clinic

Anywhere from 11.6% to 20% of pediatric and adolescent patients treated for chronic pain are prescribed opioids, but little is known about these patients. The purpose of this study was to determine the characteristics of patients on chronic opioid therapy (COT) and what therapies had been utilized prior to or in conjunction with COT. The study was a retrospective chart review of all chronic pain patients seen during 2020 with those patients on COT separated for analysis. A total of 346 unique patients were seen of which 257 were female (74.3%). The average age was 15.5 years. A total of 48 patients (13.9%) were identified as being on COT with an average age of 18.1 years. Of these, 23 (47.9%) were male which was significantly more than expected. The most common reason for patients to be receiving COT was palliative (13/48), and the second most common was sickle cell anemia (10/48). Patients on COT were significantly more likely to be male, be older, and to be concurrently prescribed benzodiazepines. Concurrent opioid and benzodiazepine therapy is a risk factor for respiratory depression and overdose. Further investigation into the increased proportion of males and benzodiazepine usage in patients on COT is warranted.

Contextualizing prescription opioid misuse and heroin use within dimensional models of drug involvement

Background

Prescription opioid misuse (POM) is often implicated in heroin initiation, despite evidence that POM does not predict heroin initiation any better than other drug use. Additionally, prescription misuse and illicit use behaviors tend to respectively "cluster" together. This study aimed to test a series of theory-driven factor models to explore how POM and heroin use are situated within the broader constellation of drug use that typically occurs alongside opioid (mis)use.

Methods

36,309 individuals from NESARC-III (56.31% female; mean age=45.63 [SD=17.53]) reported their lifetime (mis)use of prescription opioids, prescription stimulants, prescription sedatives, heroin, cannabis, cocaine/crack, illicit stimulants (e.g., methamphetamine), club drugs, hallucinogens, and inhalants, and were administered a DSM-5 substance use disorder (SUD) assessment. Bifactor, correlated factors, and one-factor confirmatory factor models were fit using all drug use/SUD variables and subsequently compared.

Results

POM was most strongly correlated with prescription sedative misuse; heroin use was most strongly correlated with cocaine/crack use. All factor models fit the data well. Highly correlated factors and patterns of factor loadings suggested that POM and heroin use were most parsimoniously captured within a general factor alongside all other forms of drug use. This was also the case for SUD. Additional analyses testing an alternate factor structure provided further support for unidimensionality.

Conclusions

POM and heroin use, as well as prescription- and heroin-based SUDs, were neither separable nor distinctly associated. Future research should account for other drug use more comprehensively rather than isolating POM as a primary risk factor in heroin use and use disorder.

Effect of a Multimodal Analgesic Protocol on Short-Term and Long-Term Opioid Use After Orthopaedic Trauma

OBJECTIVE

To determine whether the use of a multimodal analgesic protocol reduced short-term and long-term opioid use in patients hospitalized after orthopaedic trauma.

DESIGN

Retrospective pre-post intervention study.

SETTING

Regional, academic, Level 1 trauma center in Central Kentucky.

PATIENTS/PARTICIPANTS

Patients were hospitalized after orthopaedic injury before (n = 393) and after (n = 378) the implementation of a multimodal analgesic protocol.

INTERVENTION

The intervention involved a multimodal analgesic protocol consisting of acetaminophen, ibuprofen/ketorolac, gabapentinoids, skeletal muscle relaxants, and standardized doses of opioids plus standardized pain management education before hospital discharge.

MAIN OUTCOME MEASUREMENTS

End points included discharge opioid prescription, days' supply and daily morphine milligram equivalent (MME), and long-term opioid use after hospitalization. Opioid use in the 90 days before and after hospitalization was assessed using state prescription drug monitoring program data.

RESULTS

Discharge opioid prescription rates were similar in the intervention and control cohorts [79.9% vs. 78.4%, odds ratio (OR) 1.30 (0.83-2.03), P = 0.256]. Patients in the intervention cohort received a shorter days' supply [5.7 ± 4.1 days vs. 8.1 ± 6.2 days, rate ratio 0.70 (0.65-0.76), P < 0.001] and lower average daily MME [34.8 ± 24.9 MME vs. 51.5 ± 44.0 MME, rate ratio 0.68 (0.62-0.75), P < 0.001]. The incidence of long-term opioid use was also significantly lower in the intervention cohort [7.7% vs. 12.0%, OR 0.53 (0.28-0.98), P = 0.044].

CONCLUSIONS

Implementation of a multimodal analgesic protocol was associated with reductions in both short-term and long-term opioid use, including long-term opioid therapy, after orthopaedic trauma.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fentanyl Assay Derived from Intermolecular Interaction-Enabled Small Molecule Recognition (iMSR) with Differential Impedance Analysis for Point-of-Care Testing

Rapid and effective differentiation and quantification of a small molecule drug, such as fentanyl, in bodily fluids are major challenges for diagnosis and personal medication. However, the current toxicology methods used to measure drug concentration and metabolites require laboratory-based testing, which is not an efficient or cost-effective way to treat patients in a timely manner. Here, we show an assay for monitoring fentanyl levels by combining the intermolecular interaction-enabled small molecule recognition (iMSR) with differential impedance analysis of conjugated polymers. The differential interactions with the designed anchor interface were transduced through the perturbance of the electric status of the flexible conducting polymer. This assay showed excellent fentanyl selectivity against common interferences, as well as in variable body fluids through either testing strips or skin patches. Directly using the patient blood, the sensor provided 1%-5% of the average deviation compared to the "gold" standard method LC-MS results in the medically relevant fentanyl range of 20-90 nM. The superior sensing properties, in conjunction with mechanical flexibility and compatibility, enabled point-of-care detection and provided a promising avenue for applications beyond the scope of biomarker detection.

Management of chronic non-cancer pain: a framework

Aim: Since publication of the CDC 2016 Guideline, opioid-related mortality in the USA has doubled and a crisis has developed among the 15-20 million Americans with chronic, moderate-to-severe, noncancer pain. Our aim was to develop a comprehensive alternative approach to management of chronic pain. Methods: Analytic review of the clinical literature. Results: Published science provides a solid framework for the management of chronic non-cancer pain, detailed here, even as it leaves many knowledge gaps, which we fill with insights from clinical experience. Conclusion: There is a sufficient basis in science and in clinical experience to achieve adequate control of chronic pain in nearly all patients in a way that adequately balances benefits and potential harms.

Integration of Life Care Specialists Into Orthopaedic Trauma Care to Improve Postoperative Outcomes: A Pilot Study

BACKGROUND

  AIM: This pilot study assessed the feasibility and impact of integrating a Life Care Specialist (LCS) into orthopaedic trauma care.

DESIGN

This was a prospective feasibility single group pilot study at a level 1 trauma center.

METHOD

The LCS is a paraprofessional behavior-based "pain coach" and delivered patient-centered opioid safety education, trained participants on nonpharmacologic pain management approaches, conducted opioid risk assessments, and coordinated care. Numeric Rating Scale pain scores were assessed on admission, at discharge, and at 2-week follow-up. Daily morphine milligram equivalents (MME) during hospitalization, opioid medication use at 2-weeks, and patient satisfaction were recorded. T test compared mean morphine milligram equivalents (MME) to historical orthopaedic trauma patient population's mean dosage at discharge from the study site. Generalized linear models assessed pain scores over time.

RESULTS

Twenty-two percent of 121 total participants met criteria for moderate to severe risk of opioid misuse at initial hospitalization. On average, 2.8 LCS pain management interventions were utilized, most frequently progressive muscle relaxation (80%) and sound therapy (48%). Mean inpatient MME/day was 40.5, which was significantly lower than mean historical MME/day of 49.7 (p < .001). Pain scores improved over time from admission to 2-weeks postoperatively (p < .001). Nearly all participants agreed that the LCS was helpful in managing pain (99%).

CONCLUSIONS

The findings indicate feasibility to integrate LCS into orthopaedic trauma care, evident by participant engagement and satisfaction, and that LCS serve as valuable resources to assist with pain management and opioid education.

Digital Analgesic Comprising a Second-Generation Digital Health System: Increasing Effectiveness by Optimizing the Dosing and Minimizing Side Effects

Opioids remain an essential part of the treatment of chronic pain. However, their use and increasing rates of misuse are associated with high morbidity and mortality. The development of tolerance to opioids and analgesics further complicates dosing and the need to reduce side effects. First-generation digital systems were developed to improve analgesics but are not always capable of making clinically relevant associations and do not necessarily lead to better clinical efficacy. A lack of improved clinical outcomes makes these systems less applicable for adoption by clinicians and patients. There is a need to enhance the therapeutic regimens of opioids. In the present paper, we present the use of a digital analgesic that consists of an analgesic administered under the control of a second-generation artificial intelligence system. Second-generation systems focus on improved patient outcomes measured based on clinical response and reduced side effects in a single subject. The algorithm regulates the administration of analgesics in a personalized manner. The digital analgesic provides advantages for both users and providers. The system enables dose optimization, improving effectiveness, and minimizing side effects while increasing adherence to beneficial therapeutic regimens. The algorithm improves the clinicians’ experience and assists them in managing chronic pain. The system reduces the financial burden on healthcare providers by lowering opioid-related morbidity and provides a market disruptor for pharma companies.

Perspectives of Stakeholders of Equitable Access to Community Naloxone Programs: A Literature Review

The purpose of this review is to examine the existing literature about facilitators and barriers influencing equitable access to naloxone programs by individuals who use opioids. A total of 49 published articles were examined, which generated four overarching themes:(1) Stigma as a barrier to access; (2) Lack of a wide range of stakeholder perspectives; (3) Need for a comprehensive understanding of factors affecting equitable access to naloxone programs; (4) Facilitators to increase the access of community naloxone programs. Our review highlighted the importance of advocacy in practice, education, administration, and policy to address the health inequities that exist in naloxone distribution programs. Advocacy activities involve the need for health care professionals to engage in social justice practice through evidence-based informed research about the facts of opioid use; challenging the stigma toward victim-blaming against naloxone users; as well as promoting program development and health policy to bring about equitable access to naloxone programs by marginalized and socially disadvantaged populations.

Physician Liability for Suicide after Negligent Tapering of Opioids

The precipitous and medically contraindicated reduction or "tapering" of opioids for patients with chronic pain due to serious medical conditions has caused needless suffering and, increasingly, suicide. Physicians could be liable for wrongful death based on negligent tapering of opioids.

Faculty and dental student knowledge, attitudes, and practices concerning the prescribing of opioids: Informing curricular change

OBJECTIVES

This study aimed to assess the knowledge, attitudes, and practices surrounding the prescribing of opioids and addiction in a dental school population.

METHODS

Predoctoral dental students, residents, and dental faculty were surveyed about their beliefs, awareness, opinions about, and prior training in the prescribing of opioids, current prescribing practices, and confidence with risk mitigation strategies. Demographic information collected included gender, race/ethnicity, faculty/student role, year of birth, and year of graduation.

RESULTS

Responses were received from 220 faculty and students (n = 47 and n = 173, respectively). Both faculty and students agreed that opioids were overprescribed for the treatment of dental pain. A majority of faculty and dental students (DS)3 + DS4 and DS1 + DS2 students expressed no or limited prior training in (1) the approved state opioid guidelines (75%, 79%, and 95%, respectively), (2) the identification/assessment of substance use disorders (68%, 81%, and 92%, respectively), and (3) patient education to accompany the prescribing of opioids (71%, 80%, and 92%, respectively). A majority of faculty reported moderate or extreme confidence in their clinical skills related to the prescribing of opioids (75%), their ability to identify patients with substance use disorders (55%), and their ability to discuss addiction risk and secure storage of opioids (65%). In contrast, DS3 + DS4 and DS1 + DS2 students expressed significantly less confidence and training. Faculty and students agreed that the role of a dentist included risk mitigation, but reported actions did not match their beliefs, reportedly due to lack of time, less confidence, and the assumption that a pharmacist would assume risk mitigation conversations.

CONCLUSIONS

A cohesive curriculum across the four predoctoral years is needed focusing on factual knowledge about the prescribing of opioids, safe prescribing, and confidence with patient communication and risk mitigation strategies. In addition, a need for parallel faculty development synchronized with and reinforced by curricular content was identified.

The effect of a Life Care Specialist on pain management and opioid-related outcomes among patients with orthopedic trauma: study protocol for a randomized controlled trial

BACKGROUND

Orthopedic trauma patients face complex pain management needs and are frequently prescribed opioids, leaving them at-risk for prolonged opioid use. To date, post-trauma pain management research has placed little emphasis on individualized risk assessments for misuse and systematically implementing non-pharmacologic pain management strategies. Therefore, a community-academic partnership was formed to design a novel position in the healthcare field (Life Care Specialist (LCS)), who will educate patients on the risks of opioids, tapering usage, safe disposal practices, and harm reduction strategies. In addition, the LCS teaches patients behavior-based strategies for pain management, utilizing well-described techniques for coping and resilience. This study aims to determine the effects of LCS intervention on opioid utilization, pain control, and patient satisfaction in the aftermath of orthopedic trauma.

METHODS

In total, 200 orthopedic trauma patients will be randomized to receive an intervention (LCS) or a standard-of-care control at an urban level 1 trauma center. All patients will be assessed with comprehensive social determinants of health and substance use surveys immediately after surgery (baseline). Follow-up assessments will be performed at 2, 6, and 12 weeks postoperatively, and will include pain medication utilization (morphine milligram equivalents), pain scores, and other substance use. In addition, overall patient wellness will be evaluated with objective actigraphy measures and patient-reported outcomes. Finally, a survey of patient understanding of risks of opioid use and misuse will be collected, to assess the influence of LCS opioid education.

DISCUSSION

There is limited data on the role of individualized, multimodal, non-pharmacologic, behavioral-based pain management intervention in opioid-related risk-mitigation in high-risk populations, including the orthopedic trauma patients. The findings from this randomized controlled trial will provide scientific and clinical evidence on the efficacy and feasibility of the LCS intervention. Moreover, the final aim will provide early evidence into which patients benefit most from LCS intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04154384 . Registered on 11/6/2019 (last updated on 6/10/2021).

Association of clinical competence, specialty and physician country of origin with opioid prescribing for chronic pain: a cohort study

Background

Although little is known about why opioid prescribing practices differ between physicians, clinical competence, specialty training and country of origin may play a role. We hypothesised that physicians with stronger clinical competence and communication skills are less likely to prescribe opioids and prescribe lower doses, as do medical specialists and physicians from Asia.

Methods

Opioid prescribing practices were examined among international medical graduates (IMGs) licensed to practise in the USA who evaluated Medicare patients for chronic pain problems in 2014–2015. Clinical competence was assessed by the Educational Commission for Foreign Medical Graduates (ECFMG) Clinical Skills Assessment. Physicians in the ECFMG database were linked to the American Medical Association Masterfile. Patients evaluated for chronic pain were obtained by linkage to Medicare outpatient and prescription files. Opioid prescribing was measured within 90 days of evaluation visits. Prescribed dose was measured using morphine milligram equivalents (MMEs). Generalised estimating equation logistic and linear regression estimated the association of clinical competence, specialty, and country of origin with opioid prescribing and dose.

Results

7373 IMGs evaluated 65 012 patients for chronic pain; 15.2% received an opioid prescription. Increased clinical competence was associated with reduced opioid prescribing, but only among female physicians. For every 10% increase in the clinical competence score, the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95% CI 0.75 to 0.94) but not male physicians (OR 0.99, 95% CI 0.92 to 1.07). Country of origin was associated with prescribed opioid dose; US and Canadian citizens prescribed higher doses (adjusted MME difference +3.56). Primary care physicians were more likely to prescribe opioids, but surgical and hospital-based specialists prescribed higher doses.

Conclusions

Clinical competence at entry into US graduate training, physician gender, specialty and country of origin play a role in opioid prescribing practices.

Incidence and risk factors for prolonged postoperative opioid use following lumbar spine surgery: a cohort study

OBJECTIVE

Sustained postoperative opioid use after elective surgery is a matter of growing concern. Herein, the authors investigated incidence and predictors of long-term opioid use among patients undergoing elective lumbar spine surgery, especially as a function of opioid prescribing practices at postoperative discharge (dose in morphine milligram equivalents [MMEs] and type of opioid).

METHODS

The OptumLabs Data Warehouse (OLDW) was queried for postdischarge opioid prescriptions for patients undergoing elective lumbar decompression and discectomy (LDD) or posterior lumbar fusion (PLF) for degenerative spine disease. Only patients who received an opioid prescription at postoperative discharge and those who had a minimum of 180 days of insurance coverage prior to surgery and 180 days after surgery were included. Opioid-naive patients were defined as those who had no opioid fills in 180 days prior to surgery. The following patterns of long-term postoperative use were investigated: additional fills (at least one opioid fill 90-180 days after surgery), persistent fills (any span of opioid use starting in the 180 days after surgery and lasting at least 90 days), and Consortium to Study Opioid Risks and Trends (CONSORT) criteria for persistent use (episodes of opioid prescribing lasting longer than 90 days and 120 or more total days' supply or 10 or more prescriptions in 180 days after the index fill). Multivariable logistic regression was performed to identify predictors of long-term use.

RESULTS

A total of 25,587 patients were included, of whom 52.7% underwent PLF (n = 13,486) and 32.5% (n = 8312) were opioid-naive prior to surgery. The rates of additional fills, persistent fills, and CONSORT use were 47%, 30%, and 23%, respectively, after PLF and 35.4%, 19%, and 14.2%, respectively, after LDD. The rates among opioid-naive patients were 18.9%, 5.6%, and 2.5% respectively, after PLF and 13.3%, 2.0%, and 0.8%, respectively, after LDD. Using multivariable logistic regression, the following were identified to be significantly associated with higher risk of long-term opioid use following PLF: discharge opioid prescription ≥ 500 MMEs, prescription of a long-acting opioid, female sex, multilevel surgery, and comorbidities such as depression and drug abuse (all p < 0.05). Elderly (age ≥ 65 years) and opioid-naive patients were found to be at lower risk (all p < 0.05). Similar results were obtained on analysis for LDD with the following significant additional risk factors identified: discharge opioid prescription ≥ 400 MMEs, prescription of tramadol alone at discharge, and inpatient surgery (all p < 0.05).

CONCLUSIONS

In an analysis of pharmacy claims from a national insurance database, the authors identified incidence and predictors of long-term opioid use after elective lumbar spine surgery.

Opioids and Chronic Pain: An Analytic Review of the Clinical Evidence

We conducted an analytic review of the clinical scientific literature bearing on the use of opioids for treatment of chronic non-cancer pain in the United States. There is substantial, albeit not definitive, scientific evidence of the effectiveness of opioids in treating pain and of high variability in opioid dose requirements and side effects. The estimated risk of death from opioid treatment involving doses above 100 MMED is ~0.25%/year. Multiple large studies refute the concept that short-term use of opioids to treat acute pain predisposes to development of opioid use disorder. The prevalence of opioid use disorder associated with prescription opioids is likely &lt;3%. Morbidity, mortality, and financial costs of inadequate treatment of the 18 million Americans with moderate to severe chronic pain are high. Because of the absence of comparative effectiveness studies, there are no scientific grounds for considering alternative non-pharmacologic treatments as an adequate substitute for opioid therapy but these treatments might serve to augment opioid therapy, thereby reducing dosage. There are reasons to question the ostensible risks of co-prescription of opioids and benzodiazepines. As the causes of the opioid crisis have come into focus, it has become clear that the crisis resides predominantly in the streets and that efforts to curtail it by constraining opioid treatment in the clinic are unlikely to succeed.

Clinical Pharmacology, Toxicity, and Abuse Potential of Opioids

Opioids were the most common drug class resulting in overdose deaths in the United States in 2019. Widespread clinical use of prescription opioids for moderate to severe pain contributed to the ongoing opioid epidemic with the subsequent emergence of fentanyl-laced heroin. More potent analogues of fentanyl and structurally diverse opioid receptor agonists such as AH-7921 and MT-45 are fueling an increasingly diverse illicit opioid supply. Overdose from synthetic opioids with high binding affinities may not respond to a typical naloxone dose, thereby rendering autoinjectors less effective, requiring higher antagonist doses or resulting in a confusing clinical picture for health care providers. Nonscheduled opioid drugs such as loperamide and dextromethorphan are associated with dependence and risk of overdose as easier access makes them attractive to opioid users. Despite a common opioid-mediated pathway, several opioids present with unique pharmacodynamic properties leading to acute toxicity and dependence development. Pharmacokinetic considerations involve half-life of the parent opioid and its metabolites as well as resulting toxicity, as is established for tramadol, codeine, and oxycodone. Pharmacokinetic considerations, toxicities, and treatment approaches for notable opioids are reviewed.

A Demographic and Regional Comparison of Opioid-Related Hospital Visits within Community Type in the United States

BACKGROUND

The opioid epidemic is a complex national crisis in the United States with a 400% increase in related deaths over the past two decades with no signs of slowing. The purpose of this study was to assess the incidence of opioid use, based on the geographic and population characteristics.

METHODS

The opioid-related hospital inpatient stays and emergency department visits obtained from the 2010 to 2018 Healthcare Cost and Utilization Project and demographic confounders, including age, race, education, and income gathered from US Census data were analyzed through generalized linear mixed models and reported by community size and region.

RESULTS

Opioid use varies among population center sizes and the region analyzed. In general, opioid visits in the southwest region were greatest across the majority of population center sizes. Rural usage was greatest in the northeast, southeast, and southwest. Unemployment and diverse ethnicities were commonly associated with opioid use in the metro areas studied but these associations were not seen in rural areas.

CONCLUSION

Opioid use remains significant among diverse populations across the United States. Understanding the unique dynamics associated with opioid usage in populations within the regions studied is important in guiding future interventions to fight this crisis.

Mechanisms of Central Hypogonadism

Reproductive function depends upon an operational hypothalamo–pituitary–gonadal (HPG) axis. Due to its role in determining survival versus reproductive strategies, the HPG axis is vulnerable to a diverse plethora of signals that ultimately manifest with Central Hypogonadism (CH) in all its many guises. Acquired CH can result from any pituitary or hypothalamic lesion, including its treatment (such as surgical resection and/or radiotherapy). The HPG axis is particularly sensitive to the suppressive effects of hyperprolactinaemia that can occur for many reasons, including prolactinomas, and as a side effect of certain drug therapies. Physiologically, prolactin (combined with the suppressive effects of autonomic neural signals from suckling) plays a key role in suppressing the gonadal axis and establishing temporary CH during lactation. Leptin is a further key endocrine regulator of the HPG axis. During starvation, hypoleptinaemia (from diminished fat stores) results in activation of hypothalamic agouti-related peptide neurons that have a dual purpose to enhance appetite (important for survival) and concomitantly suppresses GnRH neurons via effects on neural kisspeptin release. Obesity is associated with hyperleptinaemia and leptin resistance that may also suppress the HPG axis. The suppressibility of the HPG axis also leaves it vulnerable to the effects of external signals that include morphine, anabolic-androgenic steroids, physical trauma and stress, all of which are relatively common causes of CH. Finally, the HPG axis is susceptible to congenital malformations, with reports of mutations within >50 genes that manifest with congenital CH, including Kallmann Syndrome associated with hyposmia or anosmia (reduction or loss of the sense of smell due to the closely associated migration of GnRH with olfactory neurons during embryogenesis). Analogous to the HPG axis itself, patients with CH are often vulnerable, and their clinical management requires both sensitivity and empathy.

Factors Predictive of Prolonged Postoperative Narcotic Usage Following Orthopaedic Surgery

BACKGROUND

The purpose of this comprehensive review was to investigate risk factors associated with prolonged opioid use after orthopaedic procedures. A comprehensive review of the opioid literature may help to better guide preoperative management of expectations as well as opioid-prescribing practices.

METHODS

A systematic review of all studies pertaining to opioid use in relation to orthopaedic procedures was conducted using the MEDLINE, Embase, and CINAHL databases. Data from studies reporting on postoperative opioid use at various time points were collected. Opioid use and risk of prolonged opioid use were subcategorized by subspecialty, and aggregate data for each category were calculated.

RESULTS

There were a total of 1,445 eligible studies, of which 45 met inclusion criteria. Subspecialties included joint arthroplasty, spine, trauma, sports, and hand surgery. A total of 458,993 patients were included, including 353,330 (77%) prolonged postoperative opioid users and 105,663 (23%) non-opioid users. Factors associated with prolonged postoperative opioid use among all evaluated studies included body mass index (BMI) of ≥40 kg/m (relative risk [RR], 1.06 to 2.32), prior substance abuse (RR, 1.08 to 3.59), prior use of other medications (RR, 1.01 to 1.46), psychiatric comorbidities (RR, 1.08 to 1.54), and chronic pain conditions including chronic back pain (RR, 1.01 to 10.90), fibromyalgia (RR, 1.01 to 2.30), and migraines (RR, 1.01 to 5.11). Age cohorts associated with a decreased risk of prolonged postoperative opioid use were those ≥31 years of age for hand procedures (RR, 0.47 to 0.94), ≥50 years of age for total hip arthroplasty (RR, 0.70 to 0.80), and ≥70 years of age for total knee arthroplasty (RR, 0.40 to 0.80). Age cohorts associated with an increased risk of prolonged postoperative opioid use were those ≥50 years of age for sports procedures (RR, 1.11 to 2.57) or total shoulder arthroplasty (RR, 1.26 to 1.40) and those ≥70 years of age for spine procedures (RR, 1.61). Identified risk factors for postoperative use were similar across subspecialties.

CONCLUSIONS

We provide a comprehensive review of the various preoperative and postoperative risk factors associated with prolonged opioid use after elective and nonelective orthopaedic procedures. Increased BMI, prior substance abuse, psychiatric comorbidities, and chronic pain conditions were most commonly associated with prolonged postoperative opioid use. Careful consideration of elective surgical intervention for painful conditions and perioperative identification of risk factors within each patient's biopsychosocial context will be essential for future modulation of physician opioid-prescribing patterns.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Variations in Postoperative Opioid Prescription Practices and Impact on Refill Prescriptions Following Lumbar Spine Surgery

OBJECTIVE

Understanding postsurgical prescribing patterns and their impact on persistent opioid use is important for establishing reasonable opioid prescribing protocols. We aimed to determine national variation in postoperative opioid prescription practices following elective lumbar spine surgery and their impact on short-term refill prescriptions.

METHODS

The OptumLabs Data Warehouse was queried from 2016 to 2017 for adults undergoing anterior lumbar fusion, posterior lumbar fusion, circumferential lumbar fusion, and lumbar decompression/discectomy for degenerative spine disease. Discharge opioid prescription fills were obtained and converted to morphine milligram equivalents (MMEs). Age- and sex-adjusted MMEs and frequency of discharge prescriptions >200 MMEs were determined for each U.S. census division and procedure type.

RESULTS

The study included 43,572 patients with 37,894 postdischarge opioid prescription fills. There was wide variation in mean filled MMEs across all census divisions (anterior lumbar fusion: 774-1147 MMEs; posterior lumbar fusion: 717-1280 MMEs; circumferential lumbar fusion: 817-1271 MMEs; lumbar decompression/discectomy: 619-787 MMEs). A significant proportion of cases were found to have filled discharge prescriptions >200 MMEs (posterior lumbar fusion: 78.6%-95%; anterior lumbar fusion: 87.5%-95.6%; circumferential lumbar fusion: 81.4%-96.5%; lumbar decompression/discectomy: 80.5%-91%). Multivariable logistic regression showed that female sex and inpatient surgery were associated with a top-quartile discharge prescription and a short-term second opioid prescription fill, while the opposite was noted for elderly and opioid-naïve patients (all P ≤ 0.05). Prescriptions with long-acting opioids were associated with higher odds of a second opioid prescription fill (reference: nontramadol short-acting opioid).

CONCLUSIONS

In analysis of filled opioid prescriptions, we observed a significant proportion of prescriptions >200 MMEs and wide regional variation in postdischarge opioid prescribing patterns following elective lumbar spine surgery.

Examining factors that shape use and access to diverted prescription opioids during an overdose crisis: A qualitative study in Vancouver, Canada

OBJECTIVE

Prescription opioid (PO) diversion is widely regarded as a driver of overdose mortality. However, less is known about the rationale for using diverted POs during an overdose epidemic and how contextual factors (e.g., poverty, drug policies) may affect this practice. Therefore, we sought to examine this phenomenon.

METHOD

We conducted qualitative interviews with 24 participants who accessed diverted POs in Vancouver, Canada. Participants were recruited from ongoing cohort studies of people who use drugs (PWUD).

RESULTS

Participants preferred a variety of POs due to their known contents and lower overdose risk compared to street drugs and used them for pain relief and pleasure. Participants reported barriers in accessing POs from physicians, with some being cut off or having insufficient prescriptions. Prices for diverted POs varied and affected access among impoverished participants. These access challenges led some to acquire fentanyl. Some participants reported concerns over the contents of counterfeit pills, while others relied on trusted sources or using visual cues to identify legitimate pills.

CONCLUSIONS

Our findings demonstrate that diverted POs are being used by PWUD with the goal of reducing opioid-related harms, although PO use comes with challenges associated with limited accessibility and risks posed by counterfeit pills. Poverty also limited PO accessibility, leading some to purchase more toxic, yet affordable, street drugs. Given the risks and barriers affecting people seeking to use diverted POs, our findings emphasize the need for the continued implementation and evaluation of safer drug supply initiatives, including those providing access to various drug types.

Impact of Opioid Prescribing Guidelines on Postoperative Opioid Prescriptions Following Elective Spine Surgery: Results From an Institutional Quality Improvement Initiative

BACKGROUND

With a dramatic rise in prescription opioid use, it is imperative to review postsurgical prescribing patterns given their contributions to the opioid epidemic.

OBJECTIVE

To evaluate the impact of departmental postoperative prescribing guidelines on opioid prescriptions following elective spine surgery.

METHODS

Patients undergoing elective cervical or lumbar spine surgery between 2017 and 2018 were identified. Procedure-specific opioid prescribing guidelines to limit postoperative prescribing following neurosurgical procedures were developed in 2017 and implemented in January 2018. Preguideline data were available from July to December 2017, and postguideline data from July to December 2018. Discharge prescriptions in morphine milliequivalents (MMEs), the proportion of patients (i) discharged with an opioid prescription, (ii) needing refills within 30 d, (iii) with guideline compliant prescriptions were compared in the 2 groups. Multivariable (MV) analyses were performed to assess the impact of guideline implementation on refill prescriptions within 30 d.

RESULTS

A total of 1193 patients were identified (cervical: 308; lumbar: 885) with 569 (47.7%) patients from the preguideline period. Following guideline implementation, fewer patients were discharged with a postoperative opioid prescription (92.5% vs 81.7%, P < .001) and median postoperative opioid prescription decreased significantly (300 MMEs vs 225 MMEs, P < .001). The 30-d refill prescription rate was not significantly different between preguideline and postguideline cohorts (pre: 24.4% vs post: 20.2%, P = .079). MV analyses did not demonstrate any impact of guideline implementation on need for 30-d refill prescriptions for both cervical (odds ratio [OR] = 0.68, confidence interval [CI] = 0.37-1.26, P = .22) and lumbar cohorts (OR = 0.95, CI = 0.66-1.36, P = .78).

CONCLUSION

Provider-aimed interventions such as implementation of procedure-specific prescribing guidelines can significantly reduce postoperative opioid prescriptions following spine surgery without increasing the need for refill prescriptions for pain control.

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.

An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients

This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.

Substances detected in used syringes of injecting drug users across 7 cities in Europe in 2017 and 2018: The European Syringe Collection and Analysis Project Enterprise (ESCAPE)

BACKGROUND AND AIMS

Injecting drug use is a matter of public health concern, associated with risks of overdoses, addiction and increased risk of bloodborne viral transmissions. Self-reported data on substances injected can be inaccurate or subject to bias or drug users might be oblivious to their injected substances or adulterations. Gathering of robust analytical information on the actual composition of substances injected might provide better information about the drugs that are being used. Therefore, this study aimed to analyse the residual content of discarded syringes collected across 7 European cities, collectively called the European Syringe Collection and Analysis Project Enterprise (ESCAPE).

METHODS

Used syringes were collected at street automatic injection kit dispensers or at harm-reduction services in Amsterdam, Budapest, Cologne, Glasgow, Helsinki, Lausanne and Paris. Two sampling periods were executed thus far, in 2017 and 2018. Qualitative chemical analysis of the content of used syringes was performed combining gas chromatographic (GC) and ultra(high)performance liquid chromatographic ((U)HPLC) analytical techniques with detection by mass spectrometry (MS).

RESULTS

Substances detected most frequently across both campaigns were cocaine, heroin, buprenorphine, amphetamines and synthetic cathinones. In Amsterdam, Cologne, Lausanne and Glasgow heroin and cocaine were the psychoactive substances most often detected, often in conjunction with each other. Helsinki showed a high presence of buprenorphine and amphetamines. In Budapest and Paris, synthetic cathinones were frequently detected. Less synthetic cathinones and cocaine was detected in 2018, whereas buprenorphine was detected almost twice as much. Inner-city variations were found, probably reflecting the types of people who inject drugs (PWID) in different areas of the city.

CONCLUSION

Overall, laboratory-confirmed local data on injected substances showed resemblance to national surveys done among PWID. However, the ESCAPE data also showed some interesting differences, showing it can be used for local interventions and complementing existing monitoring data.

Using Natural Language Processing and Machine Learning to Identify Hospitalized Patients with Opioid Use Disorder

Opioid use disorder (OUD) represents a global public health crisis that challenges classic clinical decision making. As existing hospital screening methods are resource-intensive, patients with OUD are significantly under-detected. An automated and accurate approach is needed to improve OUD identification so that appropriate care can be provided to these patients in a timely fashion. In this study, we used a large-scale clinical database from Mass General Brigham (MGB; formerly Partners HealthCare) to develop an OUD patient identification algorithm, using multiple machine learning methods. Working closely with an addiction psychiatrist, we developed a set of hand-crafted rules for identifying information suggestive of OUD from free-text clinical notes. We implemented a natural language processing (NLP)-based classification algorithm within the Medical Text Extraction, Reasoning and Mapping System (MTERMS) tool suite to automatically label patients as positive or negative for OUD based on these rules. We further used the NLP output as features to build multiple machine learning and a neural classifier. Our methods yielded robust performance for classifying hospitalized patients as positive or negative for OUD, with the best performing feature set and model combination achieving an F1 score of 0.97. These results show promise for the future development of a real-time tool for quickly and accurately identifying patients with OUD in the hospital setting.

Women, opioid use and addiction

In the midst of the current coronavirus pandemic, the United States continues to struggle with an ongoing opioid epidemic, initially fueled by widespread prescribing of opioid medications during the 1990s. The primary reason for prescribing opioids is to treat pain. Women have more acute and chronic pain and have been prescribed these drugs in significantly greater numbers than men. Comparison of women and men with chronic pain also shows that women receive the majority of prescription opioids, and the use of these prescribed medications became the major pathway to misuse and addiction for women. Yet, recognition of the extent of women's exposure to opioids and the attendant consequences has been limited. Attempts to stem the overall tide of the epidemic focused on reducing the availability of prescription opioids. However, as these medications became more difficult to obtain and treatment opportunities were limited, many turned to other synthetic opioids, such as heroin and fentanyl. Thus, the public health crisis of opioid addiction has endured. This paper highlights the importance of understanding differences among women and men in opioid use and its biological and psychosocial effects to advance the gender-based treatment approaches and effective public health policy.

Patterns of Routes of Administration and Drug Tampering for Nonmedical Opioid Consumption: Data Mining and Content Analysis of Reddit Discussions

BACKGROUND

The complex unfolding of the US opioid epidemic in the last 20 years has been the subject of a large body of medical and pharmacological research, and it has sparked a multidisciplinary discussion on how to implement interventions and policies to effectively control its impact on public health.

OBJECTIVE

This study leverages Reddit, a social media platform, as the primary data source to investigate the opioid crisis. We aimed to find a large cohort of Reddit users interested in discussing the use of opioids, trace the temporal evolution of their interest, and extensively characterize patterns of the nonmedical consumption of opioids, with a focus on routes of administration and drug tampering.

METHODS

We used a semiautomatic information retrieval algorithm to identify subreddits discussing nonmedical opioid consumption and developed a methodology based on word embedding to find alternative colloquial and nonmedical terms referring to opioid substances, routes of administration, and drug-tampering methods. We modeled the preferences of adoption of substances and routes of administration, estimating their prevalence and temporal unfolding. Ultimately, through the evaluation of odds ratios based on co-mentions, we measured the strength of association between opioid substances, routes of administration, and drug tampering.

RESULTS

We identified 32 subreddits discussing nonmedical opioid usage from 2014 to 2018 and observed the evolution of interest among over 86,000 Reddit users potentially involved in firsthand opioid usage. We learned the language model of opioid consumption and provided alternative vocabularies for opioid substances, routes of administration, and drug tampering. A data-driven taxonomy of nonmedical routes of administration was proposed. We modeled the temporal evolution of interest in opioid consumption by ranking the popularity of the adoption of opioid substances and routes of administration, observing relevant trends, such as the surge in synthetic opioids like fentanyl and an increasing interest in rectal administration. In addition, we measured the strength of association between drug tampering, routes of administration, and substance consumption, finding evidence of understudied abusive behaviors, like chewing fentanyl patches and dissolving buprenorphine sublingually.

CONCLUSIONS

This work investigated some important consumption-related aspects of the opioid epidemic using Reddit data. We believe that our approach may provide a novel perspective for a more comprehensive understanding of nonmedical abuse of opioids substances and inform the prevention, treatment, and control of the public health effects.

"I couldn't live with killing one of my friends or anybody": A rapid ethnographic study of drug sellers' use of drug checking

INTRODUCTION

Drug sellers are often represented as morally bereft actors and as being, in part, responsible for North America's overdose crisis. In Canada and the United States, drug sellers selling fentanyl and fentanyl-adulterated drugs have been charged with manslaughter when their clients fatally overdose, representing a retrenchment of drug war tactics. However, targeting drug sellers for drug checking interventions may have potential for reducing fentanyl-related harms. This study explores drug sellers' negotiation of and engagement with drug checking technologies in Vancouver, Canada.

METHODS

Rapid ethnographic fieldwork was conducted from November 2018 to January 2019, including 26 semi-structured interviews with people who tested their drugs at an overdose prevention site to examine perceptions of the efficacy of drug checking. As drug sellers were also using the drug checking services, we specifically examined their perceptions of drug checking and the market aspects of the overdose crisis. Data were analyzed using Nvivo 12 and interpreted drawing on the concept of structural vulnerability.

FINDINGS

Drug sellers accessing drug checking services were concerned about the safety of their customers, and drug checking was one way of reducing the likelihood of harm. Drug sellers were embedded in the community, thereby, enmeshing practices of community care and ethics with the selling of drugs. When they had access to drug checking knowledge, sellers were able to modify risks related to the fentanyl market, including tailoring drugs sold to clients, returning dangerous batches and modifying fentanyl in order to make it safer to consume.

CONCLUSIONS

Our findings reposition drug sellers as embedded within their communities and demonstrate their potential role in alleviating the dangers of the volatile fentanyl market. Policies that target people who sell drugs, particularly murder or manslaughter charges, are likely to make the crisis worse, and serious consideration should be put into harm reduction approaches with drug sellers.

Implications of the Opioid Crisis for the American Disability Community

Purpose

The profession of rehabilitation counseling has long been responsive to emerging disabilities. To date, however, the profession's attention and response to the ongoing opioid crisis in the United States has been incommensurate with the scope and detriment of opioids and opioid use disorder (OUD) on Americans with disabilities. The opioid crisis, including the overuse, abuse, and overdose rates associated with prescription and illegal opioids, affects people of all ages and backgrounds. However, people with disabilities are at increased risk for developing OUDs, and they experience greater barriers to OUD treatment than people without disabilities.

Method

This article describes the origins and development of this crisis, the relationship between disability and increased risk for OUD, and the barriers to treatment that exist. We then evaluate the role of rehabilitation counseling, including the need for further action in advocacy, research, education, and policy.

Results and Conclusions

Throughout this article, we encourage a more urgent and concerted response than seems to be the case presently.