Trends in the Nonmedical Use of OxyContin, United States, 2006 to 2013

Understanding Public Perceptions and Discussions on Opioids Through Twitter: Cross-Sectional Infodemiology Study

BACKGROUND

Opioids are used for the treatment of refractory pain, but their inappropriate use has detrimental consequences for health. Understanding the current experiences and perceptions of patients in a spontaneous and colloquial environment regarding the key drugs involved in the opioid crisis is of utmost significance.

OBJECTIVE

The study aims to analyze Twitter content related to opioids, with objectives including characterizing users participating in these conversations, identifying prevalent topics and gauging public perception, assessing opinions on drug efficacy and tolerability, and detecting discussions related to drug dispensing, prescription, or acquisition.

METHODS

In this cross-sectional study, we gathered public tweets concerning major opioids posted in English or Spanish between January 1, 2019, and December 31, 2020. A total of 256,218 tweets were collected. Approximately 27% (69,222/256,218) were excluded. Subsequently, 7000 tweets were subjected to manual analysis based on a codebook developed by the researchers. The remaining databases underwent analysis using machine learning classifiers. In the codebook, the type of user was the initial classification domain. We differentiated between patients, family members and friends, health care professionals, and institutions. Next, a distinction was made between medical and nonmedical content. If it was medical in nature, we classified it according to whether it referred to the drug's efficacy or adverse effects. In nonmedical content tweets, we analyzed whether the content referred to management issues (eg, pharmacy dispensation, medical appointment prescriptions, commercial advertisements, or legal aspects) or the trivialization of the drug.

RESULTS

Among the entire array of scrutinized pharmaceuticals, fentanyl emerged as the predominant subject, featuring in 27% (39,997/148,335 posts) of the tweets. Concerning user categorization, roughly 70% (101,259/148,335) were classified as patients. Nevertheless, tweets posted by health care professionals obtained the highest number of retweets (37/16,956, 0.2% of their posts received over 100 retweets). We found statistically significant differences in the distribution concerning efficacy and side effects among distinct drug categories (P<.001). Nearly 60% (84,401/148,335) of the posts were devoted to nonmedical subjects. Within this category, legal facets and recreational use surfaced as the most prevalent themes, while in the medical discourse, efficacy constituted the most frequent topic, with over 90% (45,621/48,777) of instances characterizing it as poor or null. The opioid with the greatest proportion of tweets concerning legal considerations was fentanyl. Furthermore, fentanyl was the drug most frequently offered for sale on Twitter, while methadone generated the most tweets about pharmacy delivery.

CONCLUSIONS

The opioid crisis is present on social media, where tweets discuss legal and recreational use. Opioid users are the most active participants, prioritizing medication efficacy over side effects. Surprisingly, health care professionals generate the most engagement, indicating their positive reception. Authorities must monitor web-based opioid discussions to detect illicit acquisitions and recreational use.

Evolution of doctor shopping for oxycodone in the 67 million inhabitants in France as a proxy for potential misuse or abuse

ABSTRACT

This nationwide study aimed to compare use of oxycodone and doctor shopping for oxycodone in 2010 and 2016, and to quantify doctor shopping for oxycodone by sex, age, formulation, and dosage in 2010 and 2016. This study is a cross-sectional comparative analysis of doctor shopping based on all dispensings of oxycodone in France, in 2010 and 2016. Dispensings of oxycodone were extracted from the Système national des données de santé, which covers the 67 million inhabitants in France. Quantification of doctor shopping relies on an algorithm accounting for overlapping prescriptions, which is a proxy for potential misuse or abuse. The number of subjects who received oxycodone increased by 214% from 67,838 subjects in 2010 to 212,753 subjects in 2016, and the number of subjects with doctor-shopping behavior increased by 197%, from 1066 subjects in 2010 to 3163 subjects in 2016. For 30- to 44-year-old men, the total quantity of oxycodone obtained by doctor shopping increased by 391%, from 4582 defined daily doses in 2010 to 22,517 defined daily doses in 2016. By formulation and dosage, the total quantity of oxycodone obtained by doctor shopping increased with the dosage for both immediate-release and extended-release tablets in 2010 and 2016. The widespread extent of doctor shopping and its 3-fold increase in line with population exposure is a strong signal in the French context. These results are another argument to avoid trivializing oxycodone to prevent misuse, potential abuse, and potential oxycodone-related deaths, but it requires caution to prevent compromising effective treatment of pain.

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

IMPORTANCE

Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

OBJECTIVE

To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

EVIDENCE REVIEW

Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

FINDINGS

Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

CONCLUSIONS AND RELEVANCE

These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.

The impact of the abuse-deterrent reformulation of extended-release OxyContin on prescription pain reliever misuse and heroin initiation

The introduction of abuse-deterrent OxyContin in 2010 was intended to reduce its misuse by making it more tamper resistant. However, some studies have suggested that this reformulation might have had unintended consequences, such as increases in heroin-related deaths. We used the 2005-2014 cross-sectional U.S. National Survey on Drug Use and Health to explore the impact of this reformulation on intermediate outcomes that precede heroin-related deaths for individuals with a history of OxyContin misuse. Our study sample consisted of adults who misused any prescription pain reliever prior to the reformulation of OxyContin (n = 81,400). Those who misused OxyContin prior to the reformulation were considered the exposed group and those who misused other prescription pain relievers prior to the reformulation were considered the unexposed group. We employed multivariate logistic regression under a difference-in-differences framework to examine the effect of the reformulation on five dichotomous outcomes: prescription pain reliever misuse; prescription pain reliever use disorder; heroin use; heroin use disorder; and heroin initiation. We found a net reduction in the odds of prescription pain reliever misuse (OR:0.791, p < 0.001) and heroin initiation (OR:0.422, p = 0.011) after the reformulation for the exposed group relative to the unexposed group. We found no statistically significant effects of the reformulation on prescription pain reliever use disorder (OR: 0.934, p = 0.524), heroin use (OR: 1.014p = 0.941), and heroin use disorder (OR: 1.063, p = 0.804). Thus, the reformulation of OxyContin appears to have reduced prescription pain reliever misuse without contributing to relatively greater new heroin use among those who misused OxyContin prior to the reformulation.

Targeting the Orexin System for Prescription Opioid Use Disorder

Prescription opioids are potent analgesics that are used for clinical pain management. However, the nonmedical use of these medications has emerged as a major concern because of dramatic increases in abuse and overdose. Therefore, effective strategies to prevent prescription opioid use disorder are urgently needed. The orexin system has been implicated in the regulation of motivation, arousal, and stress, making this system a promising target for the treatment of substance use disorder. This review discusses recent preclinical studies that suggest that orexin receptor blockade could be beneficial for the treatment of prescription opioid use disorder.

Pharmacokinetic and pharmacodynamic considerations in developing a response to the opioid epidemic

Introduction: Opioids continue to be used widely for pain management. Widespread availability of prescription opioids has led to opioid abuse and addiction. Besides steps to reduce inappropriate prescribing, exploiting opioid pharmacology to make their use safer is important.Areas covered: This article discusses the pathology and factors underlying opioid abuse. Pharmacokinetic and pharmacodynamic properties affecting abuse liability of commonly abused opioids have been highlighted. These properties inform the development of ideal abuse deterrent products. Mechanisms and cost-effectiveness of available abuse deterrent products have been reviewed in addition to the pharmacology of medications used to treat addiction.Expert opinion: The opioid crisis presents unique challenges to managing pain effectively given the limited repertoire of strong analgesics. The 5-point strategy to combat the opioid crisis calls for better preventive, treatment, and recovery services, better data, better pain management, better availability of overdose-reversing drugs and better research. There is an urgent need to decrease the cost of abuse deterrent opioids which deters their cost-effectiveness. In addition, discovery of novel analgesics, further insight into central and peripheral pain mechanisms, understanding genomic risk profiles for efficient targeted efforts, and education will be key to winning this fight against the opioid crisis.

Targeting the orexin system for prescription opioid use disorder: Orexin-1 receptor blockade prevents oxycodone taking and seeking in rats

Prescription opioids, such as oxycodone, are potent analgesics that are used to treat and manage pain. However, oxycodone is one of the most commonly abused prescription drugs. Finding an effective strategy to prevent prescription opioid use disorder is urgent. Orexin receptors (OrxR1 and OrxR2) have been implicated in the regulation of motivation, arousal, and stress, making them possible targets for the treatment of substance use disorder. To study the significance of environmental stimuli in maintaining the vulnerability to relapse to oxycodone use, resistance to the extinction of oxycodone-seeking behavior that was elicited by an oxycodone-related stimulus was examined. Rats were trained to self-administer oxycodone in the presence of a contextual/discriminative stimulus (S^D). Using this procedure, the rats readily acquired oxycodone self-administration and exhibited increases in physical signs of opioid withdrawal. Following extinction, response-reinstating effects of re-exposure to the S^D perseverated. We then tested whether OrxR blockade prevents oxycodone intake and relapse. The effects of the OrxR1 antagonist SB334867 and OrxR2 antagonist TCSOX229 on oxycodone self-administration were tested. SB334867 significantly decreased oxycodone self-administration, whereas TCSOX229 did not produce any effect. To investigate whether OrxR1 and OrxR2 blockade prevents oxycodone seeking, the rats were tested for the ability of SB334867 and TCSOX229 to prevent the S^D-induced conditioned reinstatement of oxycodone-seeking behavior. SB334867 decreased oxycodone-seeking behavior, whereas TCSOX229 was ineffective. These results suggest that OrxR1 antagonism prevents excessive prescription opioid use and relapse and might be beneficial for the treatment of prescription opioid use disorder.

Post-marketing studies of pharmaceutical opioid abuse-deterrent formulations: a framework for research design and reporting

BACKGROUND AND AIMS

Opioid formulations with properties to deter abuse (abuse-deterrent formulations; ADFs) have been developed as one response to the prescription opioid 'epidemic'. As for all medicines, ADFs undergo evaluation of safety and efficacy prior to registration for marketing. However, reduced extra-medical use (the primary intended outcome of ADFs and reason for their introduction) can only be established in post-marketing observational studies, comparing them to opioid formulations without abuse-deterrent properties. This has implications for various features of study design and analysis. We discuss proposals for the design, conduct, governance and reporting of post-marketing studies on the effectiveness of pharmaceutical and opioid ADFs.

METHODS

A review of current guidance documents, public work-shops and forums and our own experience with post-marketing studies of ADFs.

RESULTS AND CONCLUSIONS

Research questions for post-marketing studies on ADFs of opioids should reasonably be framed around detecting any probable intended or unintended clinical and/or meaningful changes in specific aspects of extra-medical use (e.g. injection use) and harms. Outcomes reported by prevalence and frequency of occurrence and disaggregated by specific product and route of administration can illustrate the magnitude of ADF impact. We argue that a multi-faceted approach is required, using data from both general population and sentinel high-risk cohorts and from primary and secondary data sources. The comparator (historical non-ADF formulation of that opioid, equivalent current generic or similar opioid product), duration of monitoring and analytical approach require justification and should be sufficient to add weight to conclusions of causality. To maximize transparency, we recommend explicit declarations of funding and conflict of interest, establishment of an advisory committee, publication of study protocol and access to study results.

Incidence of nonmedical use of OxyContin and other prescription opioid pain relievers before and after the introduction of OxyContin with abuse deterrent properties

OBJECTIVES

There is an epidemic of nonmedical and extra-medical use opioid abuse, addiction, and overdose. Extended-release oxycodone (OxyContin®), a prescription opioid pain reliever, was reformulated in 2010 to deter its abuse. The aim of this study was to assess changes in the onset of abuse of OxyContin and other opioids among young people and adults after reformulation of OxyContin with abuse-deterrent properties.

METHODS

The study population was U.S. residents ≥ 12 years sampled in National Surveys on Drug Use and Health (NSDUH), 2004 to 2015, with subsample of 12-21-year-olds. Nonmedical and extra-medical use is the NSDUH proxy for abuse. Confidential audio-computer-assisted self-interviews were assessed. Age-specific incidence of nonmedical and extra-medical use of OxyContin and other prescription opioids were estimated year by year. Interrupted-time-series and age-period-cohort analyses were analyzed.

RESULTS

Interrupted-time-series analysis showed a lower incidence of OxyContin nonmedical and extra-medical use after 2010 reformulation compared to the counterfactual predicted by the trend before 2010. No such difference was seen for other prescription opioids for all ages, although a lower incidence was also observed for other prescription opioids among 12-21-year-olds. Among 12-21-year-olds, a robustly lower incidence was found in 2012 compared to 2010 for OxyContin after holding constant age and cohort effects, whereas no robust difference was observed for other prescription opioids. The results showed 137,500 fewer newly incident cases of OxyContin nonmedical and extra-medical use per year.

CONCLUSIONS

This study provides evidence supporting the role of OxyContin reformulation in the reduction of onset of OxyContin nonmedical and extra-medical use.

Abuse-deterrent opioids: an update on current approaches and considerations

OBJECTIVE

Abuse and misuse of prescription opioids is a significant public health concern. This review examines the strategies used to confer abuse-deterrent properties on opioid abuse-deterrent formulations (ADFs), the characteristics and supporting data for each of the available ADFs, and the role of opioid ADFs as part of a comprehensive opioid risk management plan.

METHODS

A PubMed search was performed for articles published within the last 10 years using the search terms "abuse deterrent opioids". Articles were limited to clinical studies and reviews focusing on United States (US) Food and Drug Administration (FDA)-approved opioid ADFs in the US.

RESULTS

There are currently nine extended-release and one immediate-release opioid pain medications with US FDA-approved ADF labelling. All use either physical and chemical barriers or agonist/antagonist combinations to deter manipulation and abuse. Evidence is mounting that introduction of opioid ADFs has been associated with decreased rates of abuse and diversion of opioids in the US.

CONCLUSIONS

Although not sufficient by themselves to prevent prescription opioid abuse and misuse, opioid ADFs are an important component of a healthcare provider's comprehensive opioid risk management plan (along with utilization of prescription drug monitoring programs, clinical assessment tools, urine tests, co-prescribing of naloxone to patients at risk of an overdose, access to non-pharmacological treatments and addiction/mental health resources, among others). Adoption of opioid ADFs should be considered as part of an overall public health opioid risk management plan involving all stakeholders to balance legitimate safe and effective use of opioids against misuse and abuse.