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Abstract
Management of acute pain in children is fundamental to our practice. Its myriad benefits include reduced suffering, improved patient satisfaction, more rapid recovery, and a reduced risk of developing postsurgical chronic pain. Although a multimodal analgesic approach is now routinely used, informed and judicious use of opioid receptor agonists remains crucial in this treatment paradigm, as long as the benefits and risks are fully understood. Further, an ongoing public health response to the current opioid crisis is required to help prevent new cases of opioid addiction, identify opioid-addicted individuals, and ensure access to effective opioid addiction treatment, while at the same time continuing to safely meet the needs of patients experiencing pain.
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Lam T, Kuhn L, Hayman J, Middleton M, Wilson J, Scott D, Lubman DI, Smith K, Nielsen S. Recent trends in heroin and pharmaceutical opioid-related harms in Victoria, Australia up to 2018. Addiction 2020; 115:261-269. [PMID: 31465131 DOI: 10.1111/add.14784] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/20/2019] [Accepted: 08/08/2019] [Indexed: 12/14/2022]
Abstract
AIMS To characterize the trajectory in the years leading up to 2018 in pharmaceutical opioid and heroin morbidity in Victoria, Australia, and to assess the effect on that trajectory of reformulation of oxycodone to a form that could not be easily snorted or injected. DESIGN Interrupted time-series analyses of population-level data before versus after reformulation of oxycodone, stratified by sex. SETTING Victoria, Australia. PARTICIPANTS The population of Victoria aged 12+ years. MEASUREMENTS Ambulance patient care and emergency department (ED) records were examined using both fixed-code and free-text fields, with each record manually cleaned and checked by trained coders. These were used to derive the output variables providing an index of harm: rates of opioid-related ambulance attendances and ED attendances for pharmaceutical opioids and heroin. The input variable was pre- versus post-oxycodone reformulation. FINDINGS There were 30 045 opioid-related ambulance attendances from January 2012 to October 2018 (54% heroin-related), and 10 113 ED attendances from July 2008 to June 2018 (39% heroin-related). There was an increase in the rate (events per 100 000 people per year) of all opioid ED attendances from 2008 to 2018 [increase = 0.063; 95% confidence interval (CI) = 0.049, 0.078]. Pharmaceutical opioid ED attendances decreased from 2014 onwards (slope change = -0.083; 95% CI = -0.108, -0.059). Heroin-related ED attendances increased from 2014 to 2018; 11 324 heroin-related ambulance attendances and 1980 ED attendances were observed from April 2014 to June 2018, compared with the respective estimates of 8176, and 1661 had the pre-April 2014 trend continued (ambulance slope change = 0.296, 95% CI = 0.104, 0.489; ED slope change = 0.026, 95% CI = 0.005, 0.046). The inflection point of 2014 coincided with the re-formulation of oxycodone. CONCLUSION In Victoria, Australia, there appears to have been a trend starting around mid-2014 of increasing heroin-related harm, and a flattening of the increase or a decrease of harms relating to pharmaceutical opioids. These changes may, in part, reflect reformulation of oxycodone to reduce the extent to which it can be injected or snorted.
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Affiliation(s)
- Tina Lam
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia
| | - Lisa Kuhn
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia.,Monash Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
| | - Jane Hayman
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia.,Victorian Injury Surveillance Unit, Monash University Accident Research Centre, Monash University, Clayton, Victoria, Australia
| | - Melissa Middleton
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia
| | - James Wilson
- Turning Point, Eastern Health & Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
| | - Debbie Scott
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia.,Turning Point, Eastern Health & Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
| | - Dan I Lubman
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia.,Turning Point, Eastern Health & Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
| | - Karen Smith
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Ambulance Victoria, Victoria, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia
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Nielsen S, Crossin R, Middleton M, Martin C, Wilson J, Lam T, Scott D, Smith K, Lubman D. Comparing rates and characteristics of ambulance attendances related to extramedical use of pharmaceutical opioids in Australia: a protocol for a retrospective observational study. BMJ Open 2019; 9:e029170. [PMID: 31138584 PMCID: PMC6549600 DOI: 10.1136/bmjopen-2019-029170] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION AND AIMS Extramedical use of, and associated harms with pharmaceutical opioids are common. Analysis of coded ambulance clinical records provides a unique opportunity to examine a national population-level indicator of relative harms. This protocol describes an observational study with three aims: (1) to compare supply adjusted rates of pharmaceutical opioid-related ambulance attendances for buprenorphine, codeine, fentanyl, oxycodone, oxycodone-naloxone, morphine, pethidine, tramadol and tapentadol; (2) to compare presentation characteristics for these commonly used pharmaceutical opioids and (3) to describe the context surrounding ambulance presentations related to oxycodone, a widely used opioid with an established abuse liability, and tapentadol, a more recent 'atypical' opioid on the Australian market, with fewer studies that have directly examined signals of extramedical use. METHOD Trained coders extract data from clinical records for ambulance presentations relating to extramedical use of commonly used pharmaceutical opioids. These data form the basis of a large, national database that captures alcohol-related and drug-related harms. Supply adjusted rates of presentations will be examined using Poisson regression. Multinomial logistic regression will be used to compare severity and other characteristics of attendances relating to different pharmaceutical opioids. Tapentadol-related and oxycodone-related cases will be qualitatively examined to understand the situationally specific contexts of the ambulance attendances outside of the characteristics captured in routinely coded variables. ETHICS AND DISSEMINATION Ethics approval related to analysis of ambulance attendance data was obtained from the Eastern Health Human Research Ethics Committee (E122 08-09), with an amendment specific to the qualitative analysis. Findings will be submitted for peer review in 2019. The understanding of risk profiles in real-world settings is of international public health importance. The analysis and publication of findings from this national dataset of clinical records will provide one of the most nuanced analyses to date of relative harms across nine pharmaceutical opioids over a 6-year period.
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Affiliation(s)
- Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- National Drug and Alcohol Research Centre, UNSW Sydney, Randwick, New South Wales, Australia
- Turning Point, Monash University Eastern Health Clinical School, North Richmond, Victoria, Australia
| | - Rose Crossin
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Turning Point, Monash University Eastern Health Clinical School, North Richmond, Victoria, Australia
| | - Melissa Middleton
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Catherine Martin
- Biostatistics Unit, Public Health and Preventative Medicine, Monash University, Melbourne, New South Wales, Australia
| | - James Wilson
- Turning Point, Monash University Eastern Health Clinical School, North Richmond, Victoria, Australia
| | - Tina Lam
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Debbie Scott
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Turning Point, Monash University Eastern Health Clinical School, North Richmond, Victoria, Australia
| | - Karen Smith
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia
| | - Dan Lubman
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Turning Point, Monash University Eastern Health Clinical School, North Richmond, Victoria, Australia
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Peacock A, Larance B, Bruno R, Pearson SA, Buckley NA, Farrell M, Degenhardt L. Post-marketing studies of pharmaceutical opioid abuse-deterrent formulations: a framework for research design and reporting. Addiction 2019; 114:389-399. [PMID: 29989247 PMCID: PMC6599581 DOI: 10.1111/add.14380] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 02/12/2018] [Accepted: 07/04/2018] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Amy Peacock
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney NSW 2052 Australia,School of Medicine, University of Tasmania, TAS 7001, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney NSW 2052 Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney NSW 2052 Australia,School of Medicine, University of Tasmania, TAS 7001, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Australia
| | | | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney NSW 2052 Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney NSW 2052 Australia
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Larance B, Dobbins T, Peacock A, Ali R, Bruno R, Lintzeris N, Farrell M, Degenhardt L. The effect of a potentially tamper-resistant oxycodone formulation on opioid use and harm: main findings of the National Opioid Medications Abuse Deterrence (NOMAD) study. Lancet Psychiatry 2018; 5:155-166. [PMID: 29336948 DOI: 10.1016/s2215-0366(18)30003-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/20/2017] [Accepted: 11/22/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Escalation of pharmaceutical opioid use and harm in North America is well-documented, with similar issues emerging in Australia. One response is the development of tamper-resistant formulations of opioids. A potentially tamper-resistant formulation of controlled-release oxycodone was introduced in Australia in April, 2014, rapidly replacing the non-tamper-resistant formulation. Our study is the most systematic and comprehensive examination of the impact of a new opioid formulation to date, assessing the effect of tamper-resistant formulation of controlled-release oxycodone on population-level opioid use and opioid-related harm (ie, overdose, help-seeking, and treatment-seeking); and opioid use, tampering, and preference for the tamper-resistant formulation of controlled-release oxycodone compared with other drugs or formulations among sentinel populations likely to tamper with pharmaceutical opioids. METHODS We conducted interrupted time-series analyses of opioid sales data and multiple routinely collected health datasets, followed up a cohort of people who tamper with pharmaceutical opioids before and after the introduction of the tamper-resistant formulation of controlled-release oxycodone, and analysed annual surveys of people who inject drugs. Data were collected from several Australian states: New South Wales, South Australia, and Tasmania. Meta-analyses (weighted Z tests) were conducted to synthesise across data sources providing evidence for a given indicator. FINDINGS At the population level, we found reduced sales of higher strengths of controlled-release oxycodone and increased sales of other oxycodone formulations. No significant effect was observed among population-level indicators of opioid overdose, or help or treatment-seeking. Mortality data were not available for inclusion at the time of our study. Meta-analyses across sentinel populations (ie, prospective cohort, surveys of people who inject drugs, and clients of supervised injecting facilities or needle and syringe programmes) indicated reduced controlled-release oxycodone use via tampering (mainly injection), with no evidence of switching to heroin or other drug use. INTERPRETATION This formulation of controlled-release oxycodone reduced tampering with pharmaceutical opioids among people who inject drugs, but did not affect population-level opioid use or harm. FUNDING Mundipharma Australia, the Australian Government, and the National Health and Medical Research Council.
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Affiliation(s)
- Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.
| | - Timothy Dobbins
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Robert Ali
- Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia; School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Nicholas Lintzeris
- Sydney Medical School, Sydney University, Sydney, NSW, Australia; The Langton Centre, South East Sydney Local Health District Drug and Alcohol Services, Sydney, NSW, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia; School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Global Health, School of Public Health, University of Washington, Washington, DC, USA
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6
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Dasgupta N. Evaluating difficult-to-crush opioids in the community. Lancet Psychiatry 2018; 5:98-100. [PMID: 29336949 DOI: 10.1016/s2215-0366(18)30004-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Nabarun Dasgupta
- Injury Prevention Research Center and Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, 27599, USA.
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Kovaliov M, Li S, Korkmaz E, Cohen-Karni D, Tomycz N, Ozdoganlar OB, Averick S. Extended-release of opioids using fentanyl-based polymeric nanoparticles for enhanced pain management. RSC Adv 2017. [DOI: 10.1039/c7ra08450a] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Fentanyl-terminated polyesters provide linear release of therapeutics with an effective antinociceptive effect in vivo.
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Affiliation(s)
- Marina Kovaliov
- Neuroscience Disruptive Research Lab
- Allegheny Health Network Research Institute
- Allegheny General Hospital
- Pittsburgh
- USA
| | - Shaohua Li
- Neuroscience Disruptive Research Lab
- Allegheny Health Network Research Institute
- Allegheny General Hospital
- Pittsburgh
- USA
| | - Emrullah Korkmaz
- Department of Mechanical Engineering
- Carnegie Mellon University
- Pittsburgh
- USA
| | - Devora Cohen-Karni
- Neuroscience Disruptive Research Lab
- Allegheny Health Network Research Institute
- Allegheny General Hospital
- Pittsburgh
- USA
| | - Nestor Tomycz
- Neuroscience Institute
- Allegheny Health Network
- Allegheny General Hospital
- Pittsburgh
- USA
| | - O. Burak Ozdoganlar
- Department of Mechanical Engineering
- Carnegie Mellon University
- Pittsburgh
- USA
- Department of Biomedical Engineering
| | - Saadyah Averick
- Neuroscience Disruptive Research Lab
- Allegheny Health Network Research Institute
- Allegheny General Hospital
- Pittsburgh
- USA
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8
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Peacock A, Bruno R, Larance B, Lintzeris N, Nielsen S, Ali R, Dobbins T, Degenhardt L. Same-day use of opioids and other central nervous system depressants amongst people who tamper with pharmaceutical opioids: A retrospective 7-day diary study. Drug Alcohol Depend 2016; 166:125-33. [PMID: 27430400 DOI: 10.1016/j.drugalcdep.2016.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 06/27/2016] [Accepted: 07/03/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aims were to determine: (i) quantity and frequency of same-day use of opioids with benzodiazepines and/or alcohol amongst people who regularly tamper with pharmaceutical opioids; and (ii) socio-demographic, mental health, harms and treatment profile associated with same-day use of high doses. METHOD The cohort (n=437) completed a retrospective 7-day diary detailing opioid, benzodiazepine, and alcohol intake. Oral morphine equivalent (OME) units and diazepam equivalent units (DEU) were calculated, with >200mg OME, >40mg DEU and >4 standard alcoholic drinks (each 10g alcohol) considered a "high dose". RESULTS One-half (47%) exclusively consumed opioids without benzodiazepines/alcohol; 26% had days of opioid use with and without benzodiazepines/alcohol; and 26% always used opioids and benzodiazepines/alcohol. Same-day use of opioids with benzodiazepines/alcohol typically occurred on 1-3days in the past week. Six in ten (61%) participants reported high dose opioid use on at least one day; one in five (20%) reported high dose opioid and high dose benzodiazepine/alcohol use on at least one day. The latter group were more likely to use prescribed opioid substitution therapy, often alongside diverted pharmaceutical opioids. Socio-demographic and clinical profiles did not vary according to high dose opioid, alcohol and benzodiazepine use, and there was no association with harms. CONCLUSIONS Same-day use of opioids with benzodiazepines/alcohol, and high dose combinations, are common amongst people who tamper with pharmaceutical opioids. Assessment of concomitant benzodiazepine/alcohol use during opioid therapy, implementation of real-time prescription monitoring systems, and research to clarify upper safe limits for polydrug depressant use, are potential implications.
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Affiliation(s)
- Amy Peacock
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia; School of Medicine, University of Tasmania, Tasmania, Australia.
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia; School of Medicine, University of Tasmania, Tasmania, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Nick Lintzeris
- Sydney Medical School, Sydney University, New South Wales, Australia; Drug and Alcohol Services, South East Sydney Local Health District, New South Wales, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia; Drug and Alcohol Services, South East Sydney Local Health District, New South Wales, Australia
| | - Robert Ali
- University of Adelaide, South Australia, Australia
| | - Timothy Dobbins
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
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Chilcoat HD, Coplan PM, Harikrishnan V, Alexander L. Decreased diversion by doctor-shopping for a reformulated extended release oxycodone product (OxyContin). Drug Alcohol Depend 2016; 165:221-8. [PMID: 27372220 DOI: 10.1016/j.drugalcdep.2016.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 06/09/2016] [Accepted: 06/11/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Doctor-shopping (obtaining prescriptions from multiple prescribers/pharmacies) for opioid analgesics produces a supply for diversion and abuse, and represents a major public health issue. METHODS An open cohort study assessed changes in doctor-shopping in the U.S. for a brand extended release (ER) oxycodone product (OxyContin) and comparator opioids before (July, 2009 to June, 2010) versus after (January, 2011 to June, 2013) introduction of reformulated brand ER oxycodone with abuse-deterrent properties, using IMS LRx longitudinal data covering >150 million patients and 65% of retail U.S. prescriptions. RESULTS After its reformulation, the rate of doctor-shopping decreased 50% (for 2+ prescribers/3+ pharmacies) for brand ER oxycodone, but not for comparators. The largest decreases in rates occurred among young adults (73%), those paying with cash (61%) and those receiving the highest available dose (62%), with a 90% decrease when stratifying by all three characteristics. The magnitude of doctor-shopping reductions increased with increasing number of prescribers/pharmacies (e.g., 75% reduction for ≥2 prescribers/≥4 pharmacies). CONCLUSIONS The rate of doctor-shopping for brand ER oxycodone decreased substantially after its reformulation, which did not occur for other prescription opioids. The largest reductions in doctor-shopping occurred with characteristics associated with higher abuse risk such as youth, cash payment and high dose, and with more specific thresholds of doctor-shopping. A higher prescriber and/or pharmacy threshold also increased the magnitude of the decrease, suggesting that it better captured the effect of the reformulation on actual doctor-shoppers.
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Affiliation(s)
- Howard D Chilcoat
- Risk Management and Epidemiology, Medical Affairs Strategic Research, Purdue Pharma L.P., Stamford, CT, United States; Adjunct, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Paul M Coplan
- Risk Management and Epidemiology, Medical Affairs Strategic Research, Purdue Pharma L.P., Stamford, CT, United States; Adjunct, Epidemiology Department, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - Venkatesh Harikrishnan
- Risk Management and Epidemiology, Medical Affairs Strategic Research, Purdue Pharma L.P., Stamford, CT, United States
| | - Louis Alexander
- Risk Management and Epidemiology, Medical Affairs Strategic Research, Purdue Pharma L.P., Stamford, CT, United States
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10
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Coplan PM, Chilcoat HD, Butler SF, Sellers EM, Kadakia A, Harikrishnan V, Haddox JD, Dart RC. The effect of an abuse-deterrent opioid formulation (OxyContin) on opioid abuse-related outcomes in the postmarketing setting. Clin Pharmacol Ther 2016; 100:275-86. [PMID: 27170195 PMCID: PMC5102571 DOI: 10.1002/cpt.390] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/01/2016] [Accepted: 05/04/2016] [Indexed: 01/14/2023]
Abstract
An extended‐release opioid analgesic (OxyContin, OC) was reformulated with abuse‐deterrent properties to deter abuse. This report examines changes in abuse through oral and nonoral routes, doctor‐shopping, and fatalities in 10 studies 3.5 years after reformulation. Changes in OC abuse from 1 year before to 3 years after OC reformulation were calculated, adjusted for prescription changes. Abuse of OC decreased 48% in national poison center surveillance systems, decreased 32% in a national drug treatment system, and decreased 27% among individuals prescribed OC in claims databases. Doctor‐shopping for OC decreased 50%. Overdose fatalities reported to the manufacturer decreased 65%. Abuse of other opioids without abuse‐deterrent properties decreased 2 years later than OC and with less magnitude, suggesting OC decreases were not due to broader opioid interventions. Consistent with the formulation, decreases were larger for nonoral than oral abuse. Abuse‐deterrent opioids may mitigate abuse and overdose risks among chronic pain patients.
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Affiliation(s)
- P M Coplan
- Department of Risk Management and Epidemiology, Purdue Pharma L.P., Stamford, Connecticut, USA.,Adjunct, Epidemiology Department, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - H D Chilcoat
- Department of Risk Management and Epidemiology, Purdue Pharma L.P., Stamford, Connecticut, USA.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - S F Butler
- Inflexxion Inc., Newton, Massachusetts, USA
| | - E M Sellers
- DL Global Partners Inc, Toronto, Canada.,Pharmacology and Toxicology, Medicine and Psychiatry, University of Toronto, Toronto, Canada
| | - A Kadakia
- Department of Risk Management and Epidemiology, Purdue Pharma L.P., Stamford, Connecticut, USA
| | - V Harikrishnan
- Department of Risk Management and Epidemiology, Purdue Pharma L.P., Stamford, Connecticut, USA
| | - J D Haddox
- Department of Health Policy, Purdue Pharma L.P., Stamford, Connecticut, USA.,Department of Public Health & Community Medicine, School of Medicine, Tufts University, Boston, Massachusetts, USA
| | - R C Dart
- Rocky Mountain Poison & Drug Center, Denver, Colorado, USA.,Surgery and Medicine, University of Colorado Health Sciences Center, Denver, Colorado, USA
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Csete J, Kamarulzaman A, Kazatchkine M, Altice F, Balicki M, Buxton J, Cepeda J, Comfort M, Goosby E, Goulão J, Hart C, Kerr T, Lajous AM, Lewis S, Martin N, Mejía D, Camacho A, Mathieson D, Obot I, Ogunrombi A, Sherman S, Stone J, Vallath N, Vickerman P, Zábranský T, Beyrer C. Public health and international drug policy. Lancet 2016; 387:1427-1480. [PMID: 27021149 PMCID: PMC5042332 DOI: 10.1016/s0140-6736(16)00619-x] [Citation(s) in RCA: 297] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In September 2015, the member states of the United Nations endorsed sustainable development goals (SDG) for 2030 that aspire to human rights-centered approaches to ensuring the health and well-being of all people. The SDGs embody both the UN Charter values of rights and justice for all and the responsibility of states to rely on the best scientific evidence as they seek to better humankind. In April 2016, these same states will consider control of illicit drugs, an area of social policy that has been fraught with controversy, seen as inconsistent with human rights norms, and for which scientific evidence and public health approaches have arguably played too limited a role. The previous UN General Assembly Special Session (UNGASS) on drugs in 1998 – convened under the theme “a drug-free world, we can do it!” – endorsed drug control policies based on the goal of prohibiting all use, possession, production, and trafficking of illicit drugs. This goal is enshrined in national law in many countries. In pronouncing drugs a “grave threat to the health and well-being of all mankind,” the 1998 UNGASS echoed the foundational 1961 convention of the international drug control regime, which justified eliminating the “evil” of drugs in the name of “the health and welfare of mankind.” But neither of these international agreements refers to the ways in which pursuing drug prohibition itself might affect public health. The “war on drugs” and “zero-tolerance” policies that grew out of the prohibitionist consensus are now being challenged on multiple fronts, including their health, human rights, and development impact. The Johns Hopkins – Lancet Commission on Drug Policy and Health has sought to examine the emerging scientific evidence on public health issues arising from drug control policy and to inform and encourage a central focus on public health evidence and outcomes in drug policy debates, such as the important deliberations of the 2016 UNGASS on drugs. The Johns Hopkins-Lancet Commission is concerned that drug policies are often colored by ideas about drug use and drug dependence that are not scientifically grounded. The 1998 UNGASS declaration, for example, like the UN drug conventions and many national drug laws, does not distinguish between drug use and drug abuse. A 2015 report by the UN High Commissioner for Human Rights, by contrast, found it important to emphasize that “[d]rug use is neither a medical condition nor does it necessarily lead to drug dependence.” The idea that all drug use is dangerous and evil has led to enforcement-heavy policies and has made it difficult to see potentially dangerous drugs in the same light as potentially dangerous foods, tobacco, alcohol for which the goal of social policy is to reduce potential harms.
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Affiliation(s)
| | | | - Michel Kazatchkine
- UN Special Envoy, HIV in Eastern Europe and Central Asia, Geneva, Switzerland
| | | | | | | | - Javier Cepeda
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Eric Goosby
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Carl Hart
- Columbia University, New York City, NY, USA
| | - Thomas Kerr
- University of British Columbia, Center of Excellence in HIV/AIDS, Vancouver, BC, Canada
| | | | | | | | | | | | | | | | | | - Susan Sherman
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Nandini Vallath
- Trivandrum Institute of Palliative Sciences, Trivandrum, India
| | | | | | - Chris Beyrer
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Larance B, Lintzeris N, Bruno R, Peacock A, Cama E, Ali R, Kihas I, Hordern A, White N, Degenhardt L. The characteristics of a cohort who tamper with prescribed and diverted opioid medications. J Subst Abuse Treat 2015; 58:51-61. [DOI: 10.1016/j.jsat.2015.06.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 05/29/2015] [Accepted: 06/01/2015] [Indexed: 11/28/2022]
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Peacock A, Degenhardt L, Larance B, Cama E, Lintzeris N, Ali R, Bruno R. A typology of people who tamper with pharmaceutical opioids: responses to introduction of a tamper-resistant formulation of controlled-release oxycodone. Pharmacoepidemiol Drug Saf 2015; 24:1321-33. [PMID: 26419615 DOI: 10.1002/pds.3883] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 08/10/2015] [Accepted: 09/06/2015] [Indexed: 11/07/2022]
Abstract
PURPOSE In April 2014, a tamper-resistant controlled-release oxycodone formulation was released in Australia. We aimed to determine whether there are latent classes of people who tamper with pharmaceutical opioids based on frequency of opioid and illicit drug use, the demographic and clinical profiles of these groups, and if there were changes in use and harms following the introduction. METHODS A prospective cohort of 606 people who regularly tamper with pharmaceutical opioids was interviewed January to March 2014 (Wave 1) and May to August 2014 (Wave 2). Latent class analysis identified groups based on non-prescribed opioid, illicit drug and prescribed opioid substitution therapy (OST) use at Wave 1. Regression models examined whether group membership predicted use and harms at Wave 2. RESULTS Four groups were identified: frequent OST group (39%), mixed OST/heroin group (7%), infrequent pharmaceutical opioid and heroin group (44%) and frequent oxycodone group (25%). Compared with the frequent OST group, the infrequent pharmaceutical opioid/heroin group was more likely to report non-everyday pain and risky alcohol use, and the frequent oxycodone group had higher odds of homelessness. At Wave 2, oxycodone use decreased across groups (odds ratios (OR) ≤ 0.18, p < 0.001, particularly for the frequent oxycodone group: OR ≤ 0.05, p < 0.001), with reductions in days of use (g ≥ 0.35, p < 0.050). Non-prescribed pharmaceutical opioid use, illicit drug use and harms remained stable or decreased. CONCLUSIONS Despite heterogeneity among people who tamper with pharmaceutical opioids, the tamper-resistant formulation was followed by reductions in oxycodone tampering among high-frequency and low-frequency users. There was no evidence of increased use of other opioids or illicit drugs.
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Affiliation(s)
- Amy Peacock
- School of Medicine (Psychology), University of Tasmania, Hobart, Tasmania, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Elena Cama
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Nicholas Lintzeris
- Discipline of Addiction Medicine, Faculty of Medicine, Sydney University, Sydney, New South Wales, Australia.,The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Sydney, New South Wales, Australia
| | - Robert Ali
- University of Adelaide, Adelaide, South Australia, Australia
| | - Raimondo Bruno
- School of Medicine (Psychology), University of Tasmania, Hobart, Tasmania, Australia
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Peacock A, Bruno R, Cama E, Kihas I, Larance B, Lintzeris N, Hordern A, White N, Ali R, Degenhardt L. Jurisdictional differences in opioid use, other licit and illicit drug use, and harms associated with substance use among people who tamper with pharmaceutical opioids. Drug Alcohol Rev 2015; 34:611-22. [DOI: 10.1111/dar.12279] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 03/26/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Amy Peacock
- School of Medicine; University of Tasmania; Hobart Australia
| | - Raimondo Bruno
- School of Medicine; University of Tasmania; Hobart Australia
| | - Elena Cama
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
| | - Ivana Kihas
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
| | - Nick Lintzeris
- Sydney Medical School; Sydney University; Sydney Australia
| | - Antonia Hordern
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
| | | | - Robert Ali
- University of Adelaide; Adelaide Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
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Peacock A, Degenhardt L, Hordern A, Larance B, Cama E, White N, Kihas I, Bruno R. Methods and predictors of tampering with a tamper-resistant controlled-release oxycodone formulation. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:1265-72. [PMID: 26123898 DOI: 10.1016/j.drugpo.2015.05.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 05/02/2015] [Accepted: 05/28/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND In April 2014, a tamper-resistant controlled-release oxycodone formulation was introduced into the Australian market. This study aimed to identify the level and methods of tampering with reformulated oxycodone, demographic and clinical characteristics of those who reported tampering with reformulated oxycodone, and perceived attractiveness of original and reformulated oxycodone for misuse (via tampering). METHODS A prospective cohort of 522 people who regularly tampered with pharmaceutical opioids and had tampered with the original oxycodone product in their lifetime completed two interviews before (January-March 2014: Wave 1) and after (May-August 2014: Wave 2) introduction of reformulated oxycodone. RESULTS Four-fifths (81%) had tampered with the original oxycodone formulation in the month prior to Wave 1; use and attempted tampering with reformulated oxycodone amongst the sample was comparatively low at Wave 2 (29% and 19%, respectively). Reformulated oxycodone was primarily swallowed (15%), with low levels of recent successful injection (6%), chewing (2%), drinking/dissolving (1%), and smoking (<1%). Participants who tampered with original and reformulated oxycodone were socio-demographically and clinically similar to those who had only tampered with the original formulation, except the former were more likely to report prescribed oxycodone use and stealing pharmaceutical opioid, and less likely to report moderate/severe anxiety. There was significant diversity in the methods for tampering, with attempts predominantly prompted by self-experimentation (rather than informed by word-of-mouth or the internet). Participants rated reformulated oxycodone as more difficult to prepare and inject and less pleasant to use compared to the original formulation. CONCLUSION Current findings suggest that the introduction of the tamper-resistant product has been successful at reducing, although not necessarily eliminating, tampering with the controlled-release oxycodone formulation, with lower attractiveness for misuse. Appropriate, effective treatment options must be available with increasing availability of abuse-deterrent products, given the reduction of oxycodone tampering and use amongst a group with high rates of pharmaceutical opioid dependence.
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Affiliation(s)
- Amy Peacock
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia.
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia
| | - Antonia Hordern
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia
| | - Elena Cama
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia
| | - Nancy White
- Sydney Medical School, Sydney University, NSW, Australia; University of Adelaide, South Australia, Australia
| | - Ivana Kihas
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia
| | - Raimondo Bruno
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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Degenhardt L, Bruno R, Ali R, Lintzeris N, Farrell M, Larance B. The introduction of a potentially abuse deterrent oxycodone formulation: Early findings from the Australian National Opioid Medications Abuse Deterrence (NOMAD) study. Drug Alcohol Depend 2015; 151:56-67. [PMID: 25910850 DOI: 10.1016/j.drugalcdep.2015.02.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 02/27/2015] [Accepted: 02/28/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is increasing concern about tampering of pharmaceutical opioids. We describe early findings from an Australian study examining the potential impact of the April 2014 introduction of an abuse-deterrent sustained-release oxycodone formulation (Reformulated OxyContin(®)). METHODS Data on pharmaceutical opioid sales; drug use by people who inject drugs regularly (PWID); client visits to the Sydney Medically Supervised Injecting Centre (MSIC); and last drug injected by clients of inner-Sydney needle-syringe programmes (NSPs) were obtained, 2009-2014. A cohort of n=606 people tampering with pharmaceutical opioids was formed pre-April 2014, and followed up May-August 2014. RESULTS There were declines in pharmacy sales of 80mg OxyContin(®) post-introduction of the reformulated product, the dose most commonly diverted and injected by PWID. Reformulated OxyContin(®) was among the least commonly used and injected drugs among PWID. This was supported by Sydney NSP data. There was a dramatic reduction in MSIC visits for injection of OxyContin(®) post-introduction of the new formulation (from 62% of monthly visits pre-introduction to 5% of visits, August 2014). The NOMAD cohort confirmed a reduction in OxyContin(®) use/injection post-introduction. Reformulated OxyContin(®) was cheaper and less attractive for tampering than Original OxyContin(®). CONCLUSIONS These data suggest that, in the short term, introduction of an abuse-deterrent formulation of OxyContin(®) in Australia was associated with a reduction in injection of OxyContin(®), with no clear switch to other drugs. Reformulated OxyContin(®), in this short follow-up, does not appear to be considered as attractive for tampering.
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Affiliation(s)
| | | | | | - Nicholas Lintzeris
- The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Australia
| | | | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW, Australia
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Dasgupta N, Raymond D. Commentary on Degenhardt et al (2015): a new formulation for research. Addiction 2015; 110:238-9. [PMID: 25602043 DOI: 10.1111/add.12812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 11/17/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Nabarun Dasgupta
- Epidemiology and Public Health, University of North Carolina School of Public Health, Chapel Hill, NC, USA.
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