Trends in fentanyl prescriptions and fentanyl-related mortality in Australia

Correlates of heroin use, pharmaceutical fentanyl misuse, and dual heroin-fentanyl use: evidence from the USA

Purpose

The emergence of fentanyl has deepened concerns about the opioid crisis. The shift has created new distinctions in patterns of opioid use, which may be important for prevention and intervention. This paper aims to examine sociodemographic correlates as well as health and substance use characteristics of different groups of opioid users.

Design/methodology/approach

This paper used the 2015–2019 National Survey on Drug Use and Health to examine distinctions between groups (n = 11,142) of individuals who misuse prescription opioids, use heroin but not fentanyl, misuse pharmaceutical fentanyl but not heroin and use both heroin and fentanyl. Multinomial and logistic regression models were used to identify these distinctions.

Findings

Few sociodemographic differences emerged between the prescription opioid group and pharmaceutical fentanyl misuse group. While those who misuse fentanyl have higher odds of using other drugs and experiencing certain mental health problems than those misusing prescription pills, both the heroin and fentanyl–heroin use groups reported considerably poorer health and substance use indicators relative to those who solely misuse fentanyl. It is also notable that both heroin use groups are more highly associated with cocaine and methamphetamine use than those misusing fentanyl alone.

Research limitations/implications

While this study identifies important distinctions between the opioid use groups studied, individuals using both heroin and pharmaceutical fentanyl report the poorest health and substance use characteristics. Important differences between the fentanyl-only group and the group who consume both drugs may have implications for prevention, intervention and clinical work amid shifting patterns of opioid use.

Practical implications

Important differences between the fentanyl-only group and the group who consume both drugs may have implications for prevention, intervention and clinical work amid shifting patterns of opioid use.

Originality/value

This study highlights distinctions between pharmaceutical fentanyl users, heroin users and users of both substances.

Twenty-year trends in pharmaceutical fentanyl and illicit fentanyl deaths, Australia 2001-2021

BACKGROUND

Increasing overdose deaths attributable to illicitly manufactured fentanyl and fentanyl analogues in North America has driven international concern about the expansion of these substances into drug markets elsewhere. This paper investigates 20-year trends in fentanyl deaths in Australia, distinguishing between deaths attributable to pharmaceutical, and to illicitly manufactured fentanyl and fentanyl analogues.

METHODS

Analysis of fentanyl overdose deaths (2001-2021), extracted from the National Coronial Information System (NCIS).

RESULTS

833 fentanyl-related deaths were identified, predominantly occurring among males (73%), and people with a history of injecting drug use (67%). Rates of fentanyl deaths significantly increased between 2001 and 2014 and declined between 2015 and 2021. Drug dependence remained the most significant factor in deaths among people with a history of injecting drug use (87% vs 23% without such a history), while having died by suicide was the most significant factor for those without a history of injecting drug use (20% vs 4% respectively). Three quarters (72%) of deaths were attributable to pharmaceutical fentanyl and 21% to probable pharmaceutical fentanyl, with 5% attributable to fentanyl analogues (3%) (predominantly furanylfentanyl and acetylfentanyl) and illicitly manufactured fentanyl (2%). Deaths attributable to illicitly manufactured fentanyl and fentanyl analogues occurred from 2013 onwards.

CONCLUSION

Pharmaceutical fentanyl deaths in Australia have declined since 2015, in parallel with overall declines in pharmaceutical opioids (including fentanyl) dispensed since 2014. Deaths continue to occur among people with a history of injecting drug use and drug dependence. Deaths attributable to illicit fentanyl have emerged since 2013 but remain low in comparison to pharmaceutical fentanyl deaths.

The overdose epidemic: a study protocol to determine whether people who use drugs can influence or shape public opinion via mass media

BACKGROUND

We are currently witnessing an ongoing drug overdose death epidemic in many nations linked to the distribution of illegally manufactured potent synthetic opioids. While many health policy makers and researchers have focused on the root causes and possible solutions to the current crisis, there has been little focus on the power of advocacy and community action by people who use drugs (PWUDs). Specifically, there has been no research on the role of PWUDs in engaging and influencing mass media opinion.

METHODS

By relying on one of the longest and largest peer-run drug user advocacy groups in the world, the Vancouver Area Network of Drug Users (VANDU), newspaper articles, television reports, and magazines that VANDU or its members have been directly involved in will be identified via two data bases (the Canadian Newsstream & Google News). The news articles and videos related to the health of PWUDs and issues affecting PWUDs from 1997 to the end of 2020 will be analyzed qualitatively using Nvivo software.

DISCUSSION

As our communities are entering another phase of the drug overdose epidemic, acknowledging and partnering with PWUDs could play an integral part in advancing the goals of harm reduction, treatment, and human rights.

Trends in transdermal fentanyl utilisation and fatal fentanyl overdose across Australia (2003-2015)

INTRODUCTION

Fentanyl-related overdose is an ongoing concern among countries with high prescription opioid utilisation. This study examines trends in transdermal fentanyl utilisation and fatal fentanyl overdose across Australia between 2003 and 2015, overall, and by age/sex.

METHODS

This was a retrospective nationwide study of prescription dispensings and coronial records. Transdermal fentanyl utilisation was examined using Pharmaceutical Benefits Scheme dispensing records. Details of fatal fentanyl overdoses were extracted from the National Coronial Information System.

RESULTS

Transdermal fentanyl utilisation increased 5.1-fold between 2003 and 2015, from 0.28 to 1.39 mg/1000 population/day and was consistently higher among females and adults aged ≥85 years. The utilisation of higher strength patches (75 and 100 mcg/h) was more common among males aged 25-44 years. A total of 291 fatal fentanyl overdoses were recorded, increasing from no recorded deaths in 2003 to 2.23 deaths/1 000 000 population in 2015. Rates were higher among males (increasing from 0 to 3.72 deaths/1 000 000 population) and for adults aged 25-44 years (increasing from 0 to 5.34 deaths/1 000 000 population). The number of deaths/kg fentanyl dispensed was highest among males aged <25 years (45.45, 95% confidence interval 21.80-83.59). Most deaths (70.1%) involved the intravenous administration of fentanyl from transdermal patches.

DISCUSSION AND CONCLUSIONS

Rates of transdermal fentanyl utilisation and fatal fentanyl overdose across Australia increased between 2003 and 2015. Although transdermal fentanyl utilisation was consistently greater among females and older adults, rates of fatal fentanyl overdose were highest among younger males. Interventions to reduce extramedical use among this high-risk population group are necessary to minimise fentanyl-related harms.

Illicit synthetic opioid consumption in Asia and the Pacific: Assessing the risks of a potential outbreak

BACKGROUND

Illegally manufactured potent synthetic opioids (IMPSO) like fentanyl have contributed to rises in overdose deaths in parts of North America and Europe. While many of these substances are produced in Asia, there is little evidence they have entered markets there. We consider the susceptibility to IMPSO's encroachment in markets in the Asia-Pacific region.

METHODS

Our analysis focuses on Australia, China, India, and Myanmar. Using a mixed-methods approach comprising interviews, literature review, and secondary data analyses, we examine factors facilitating or impeding incursion of IMPSO. Finally, we illustrate the potential for IMPSO fatalities in Australia.

RESULTS

Australia reports some signs of three facilitating factors to IMPSO's emergence: 1) existing illicit opioid markets, 2) disruption of opioid supply, and 3) user preferences. The other three countries report only existing illicit opioid markets. While diverted pharmaceutical opioids are a noted problem in Australia and India, heroin is the dominant opioid in all four countries. There are divergent trends in heroin use, with use declining in China, increasing in India, and stable in Australia and Myanmar. If IMPSO diffused in Australia as in North America from 2014 to 2018, and our assumptions generally hold, deaths from IMPSO could range from 1500-5700 over a five-year period.

CONCLUSIONS

This analysis and illustrative calculations serve as an early indication for policymakers. With the exception of Australia, many countries in the region fail to properly record overdose deaths or monitor changes in local drug markets. Early assessment and monitoring can give officials a better understanding of these changing threats.

Trends in opioid prescribing in Australia: a systematic review

Objective This review systematically identified studies that estimated the prevalence of prescription opioid use in Australia, assessed the prevalence estimates for bias and identified areas for future research. Methods Literature published after 2000 containing a potentially representative estimate of prescription opioid use in adults, in the community setting, in Australia was included in this review. Studies that solely assessed opioid replacement, illicit opioid usage or acute hospital in-patient use were excluded. Databases searched included PubMed, EMBASE, Web of Science and the grey literature. Results The search identified 2253 peer-reviewed publications, with 34 requiring full-text review. Of these, 20 were included in the final qualitative analysis, in addition to four publications from the grey literature. Most studies included analysed prescription claims data for medicines dispensed via Australia's national medicines subsidy scheme (the Pharmaceutical Benefits Scheme). Although data sources were good quality, all prevalence estimates were at least at moderate risk of bias, predominantly due to incompleteness of data or potential confounding. Included publications demonstrated a significant rise in opioid use up to 2017 (including a 15-fold increase in prescriptions dispensed over the 20 years to 2015), predominantly driven by a sharp rise in oxycodone use. Although opioid prescription numbers continue to escalate, usage, as measured by oral morphine equivalent per capita, may have plateaued since 2014. Codeine remains the most prevalently obtained opioid, followed by oxycodone and tramadol. There was a substantial delay (median 30 months; interquartile range 20-37 months) to publication of opioid usage data from time of availability. Conclusions Australia has experienced a marked increase in opioid prescribing since the 1990s. Current published literature is restricted to incomplete, delayed and historical data, limiting the ability of clinicians and policy makers to intervene appropriately. What is known about the topic? Opioid prescriptions in Australia have continued to increase since the 1990s and may be mirroring the epidemic being seen in the US. What does this paper add? This paper systematically identifies all publications that have examined the prevalence of prescription opioid use in Australia since 2000, and only identified prevalence estimates that were at moderate or high risk of bias, and found significant delays to publication of these estimates. What are the implications for practitioners? Because published literature on the prevalence of prescription opioid consumption is restricted to incomplete, delayed and historical data, the ability of clinicians and policy makers to appropriately intervene to curb prescription opioid use is limited. A national policy of real-time monitoring and reporting of opioid prescribing may support improvements in practice.

The fentanyls: a 'future threat' for Australia?

OBJECTIVE

The fentanyls have emerged as a significant public health threat in North America but much less so in Australia. We sought to identify reasons for this discrepancy and highlight harm reduction approaches that may mitigate a future Australian fentanyl epidemic.

CONCLUSIONS

Differences in drug use 'culture' and a supply of cheap high-quality methamphetamine in Australia may be reasons for the observed difference in fentanyl-related harm. More worryingly, it is possible that Australia is following North American trends and that the fentanyl epidemic is still to come.

Antidepressant Use Among People Prescribed Opioids for Chronic Noncancer Pain

OBJECTIVE

Although depression and chronic pain often coexist, few studies have examined antidepressant use among people with pain. This study examines the prevalence and characteristics associated with antidepressant use among people prescribed opioids for chronic noncancer pain (CNCP).

DESIGN

Baseline data from a prospective cohort study.

SETTING

Australian community.

SUBJECTS

A total of 1166 people prescribed opioids for CNCP.

METHODS

Baseline data collection consisted of a self-completed seven-day medication diary and telephone interview to collect information on sociodemographic characteristics and mental/physical health using validated questionnaires. Logistic regression was used to examine characteristics associated with antidepressant use, reporting adjusted odds ratios (AORs) and 95% confidence intervals (CIs).

RESULTS

Of the 1166 participants, 668 (57.3%) were female, and the median (interquartile range) age was 59 (49-68) years. About half the cohort (N = 637, 54.6%) used antidepressants. Of these, 329 (51.7%) reported moderate to severe depression. Amitriptyline was the most commonly used antidepressant (17.3%). Factors independently associated with antidepressant use were being female (AOR = 1.47, 95% CI = 1.13-1.92), more years lived in pain (AOR = 1.01, 95% CI = 1.00-1.02), and use of nonopioid analgesics (AOR = 1.34, 95% CI = 1.01-1.78), benzodiazepines and related drugs (AOR = 1.84, 95% CI = 1.36-2.49), antiepileptics (AOR = 1.86, 95% CI = 1.38-2.51), and antipsychotics (AOR = 2.15, 95% CI = 1.22-3.77).

CONCLUSIONS

Antidepressant use is common among people with CNCP prescribed opioids. Those using antidepressants were more likely to use other psychotropic medicines concurrently, highlighting that they are a high-risk population requiring comprehensive assessment to optimize outcomes and reduce potential harms from polypharmacy.

Overdose Risk and Acquiring Opioids for Nonmedical Use Exclusively from Physicians in Vancouver, Canada

BACKGROUND

A primary response to the alarming rise in overdose and mortality due to nonmedical prescription opioid (PO) use has been to restrict opioid prescribing; however, little is known about the relationship between obtaining opioids from a physician and overdose risk among people who use POs nonmedically and illicit street drugs. Objectives: Investigate the relationship between non-fatal overdose and acquiring POs exclusively from physicians for the purposes of engaging in nonmedical PO use. Methods: Data were collected between 2013 and 2016 among participants in two harmonized prospective cohort studies of people who use drugs in Vancouver: the At-Risk Youth Study (ARYS) and the Vancouver Injection Drug Users Study (VIDUS). Analyses were restricted to participants who engaged in nonmedical PO use and used generalized estimating equations. Results: Among 599 participants who used POs nonmedically, 82 (14%) individuals reported acquiring POs exclusively from a physician and 197 (33%) experienced a non-fatal overdose at some point over the study period. Acquiring POs exclusively from physicians was significantly and negatively associated with non-fatal overdose in the bivariate analysis (Odds Ratio = 0.60, 95% Confidence Interval (CI): 0.39-0.94) but not the final multivariate analysis (Adjusted Odds Ratio =0.87, 95% CI: 0.53-1.44). Conclusions: Compared to individuals who acquired POs from friends or the streets, participants who acquired POs exclusively from a physician were not at an increased risk of non-fatal overdose. Although responsible opioid prescribing is an important priority, additional strategies to address nonmedical PO use are urgently needed to reduce overdose and related morbidity and mortality.

Duration of opioid use and association with socioeconomic status, daily dose and formulation: a two-decade population study in Queensland, Australia

Background There is an association between the duration of prescription opioids use and an increased risk of serious harm, often unintentional. Objective (1) Describe the trends in duration of prescription opioids dispensing and, (2) determine the risk of long-term use (≥4 months) based on patients' socioeconomic status, daily dose in oral daily morphine milligram equivalent, and opioid formulation. Setting Residents of Queensland (2,827,727), Australia from the age 18 years and who were dispensed pharmaceutical opioids from 1 January 1997 to 31 December 2018. Method Retrospective, longitudinal population-based analysis using data obtained from the Monitoring of Drugs of Dependence system of the Monitored Medicines Unit of Queensland Health. Main outcome measure Contribution of socioeconomic status, and daily dose and opioid formulation (modified-release or immediate-release) to the risk of long-term opioid use. Results There was little difference between the number of patients dispensed opioids for ≥4 months and ≤3 months between 1997 and 2011. Thereafter, the number for those using opioids long-term increased. The highest risk of having opioids dispensed for ≥4 months were for patients in the lowest level of socioeconomic status (adjusted odds ratio 1.36; 95% CI, 1.34, 1.38), compared to people in the highest socioeconomic status areas, followed by the low-socioeconomic status areas, mid-socioeconomic status areas, and high-socioeconomic status areas respectively. The risk of being dispensed prescription opioids for ≥4 months significantly increased as the dose increased: adjusted odds ratio 1.73; 95% CI, 1.71, 1.75, adjusted odds ratio 1.89; 95% CI, 1.87, 1.92, and adjusted odds ratio 3.63; 95% CI, 3.58, 3.69 for the ≥20 to <50 oral daily morphine milligram equivalent, ≥50 to <100 oral daily morphine milligram equivalent and ≥100 oral daily morphine milligram equivalent dose categories, respectively. Conclusion Higher doses and living in a low socioeconomic status areas were associated with increased risk of long-term dispensing of opioid prescriptions.

Genetic and environmental risk factors in the non-medical use of over-the-counter or prescribed analgesics, and their relationship to major classes of licit and illicit substance use and misuse in a population-based sample of young adult twins

BACKGROUND AND AIMS

The non-medical use of over-the-counter or prescribed analgesics (NMUA) is a significant public health problem. Little is known about the genetic and environmental etiology of NMUA and how these risks relate to other classes of substance use and misuse. Our aims were to estimate the heritability NMUA and sources of genetic and environmental covariance with cannabis and nicotine use, cannabis and alcohol use disorders and nicotine dependence in Australian twins.

DESIGN

Biometrical genetic analyses or twin methods using structural equation univariate and multivariate modeling.

SETTING

Australia.

PARTICIPANTS

A total of 2007 young adult twins [66% female; μage  = 25.9, standard deviation (SD) = 3.6, range = 18-38] from the Brisbane Longitudinal Twin Study retrospectively assessed between 2009 and 2016.

MEASUREMENTS

Self-reported NMUA (non-opioid or opioid-based), life-time nicotine, cannabis and opioid use, DSM-V cannabis and alcohol use disorders and the Fagerström Test for Nicotine Dependence.

FINDINGS

Life-time NMUA was reported by 19.4% of the sample. Univariate heritability explained 46% [95% confidence interval (CI) = 0.29-0.57] of the risks in NMUA. Multivariate analyses revealed that NMUA is moderately associated genetically with cannabis (rg  = 0.41) and nicotine (rg  = 0.45) use and nicotine dependence (rg  = 0.34). In contrast, the genetic correlations with cannabis (rg  = 0.15) and alcohol (rg  = 0.07) use disorders are weak.

CONCLUSIONS

In young male and female adults in Australia, the non-medical use of over-the-counter or prescribed analgesics appears to have moderate heritability. NMUA is moderately associated with cannabis and nicotine use and nicotine dependence. Its genetic etiology is largely distinct from that of cannabis and alcohol use disorders.

Preference for drugs containing fentanyl from a cross-sectional survey of people who use illicit opioids in three United States cities

BACKGROUND

Death from fentanyl-related overdose is now a leading cause of mortality among US adults. We sought to characterize fentanyl preference among street-based people who use drugs (PWUD).

METHODS

Cross-sectional surveys were administered to PWUD (N = 308) who illicitly used heroin or prescription opioids in the prior six months. Recruitment occurred in 2017 in three US east coast cities with high overdose mortality: Baltimore, Boston, and Providence. Our main outcome was preference for fentanyl (yes/no); exposures included sociodemographics, drug use, and overdose history. Pearson's χ2, Shapiro-Wilk-Mann rank-sum tests, and tiered log-binomial regression determined sociodemographic and exposure-related factors associated with fentanyl preference.

RESULTS

Preference for nonmedical use of fentanyl was reported by 27% (n = 83) of the sample. Fentanyl preference was associated with non-Hispanic white race (adjusted risk ratio (ARR) = 1.68, 95% confidence interval (CI):1.18-2.40), daily illicit drug use (aRR = 2.2, CI:1.71-2.87), and overdose ≥1 year ago (aRR = 1.33, CI:1.18-1.50). Age (in decades; aRR = 0.77, CI:0.61-0.98) and overdose <1 year ago (aRR = 0.92, CI:0.87-0.97) were associated with a decreased likelihood of preference. In our model excluding sociodemographics, initiating opioid use with non-prescribed opioids was associated with fentanyl preference (aRR = 1.48, CI:1.26-1.73).

CONCLUSION

In three cities with high levels of opioid use and overdose, a quarter of street based PWUD reported preferring fentanyl. An opioid use age cohort effect and disproportionate access to prescription opioids by race could be contributing to preference. Frequency of opioid use, not route of administration, was associated with preference. Our data demonstrate the need to consider preferences for fentanyl when targeting services and interventions for PWUD.

The relative lethal toxicity of pharmaceutical and illicit substances: A 16-year study of the Greater Newcastle Hunter Area, Australia

AIMS

We aim to calculate 2 metrics of relative lethal toxicity; the fatal toxicity index (FTI; number of deaths per year of a daily dose) and the case fatality (CF; number of deaths per overdose) with a focus on opioids, antidepressants, antipsychotics, benzodiazepines and illicit drugs.

METHODS

This descriptive cohort study used the Australian National Coronial Information System (NCIS) to identify a population of individuals with drug-associated deaths in the Greater Newcastle Hunter Area between January 2002 and December 2016. This was combined with Australian medicine dispensing data and corresponding data from the Hunter Area Toxicology Service to calculate FTI and CF.

RESULTS

There were 444 drug-related deaths and 21,296 overdoses during the study period. FTI and CF were well correlated (Spearman's rho 0.64, P < .001). Of the classes of interest, opioids had the highest FTI (40.3 95% confidence interval [CI] 35.2-45.4 deaths per 100 years of use at the defined daily dose or deaths/DDD/100 years) and CF (12.4% 95%CI 11.0-13.9). Fentanyl, methadone and morphine had the highest relative fatal toxicity within this class. Tricyclic antidepressants had the highest relative fatal toxicity of all antidepressants (FTI 14.5 95%CI 9.7-19.3 deaths/DDD/100 years and CF 7.1% [95%CI 4.8-9.3]) and benzodiazepines appeared to be more associated with multiple agent deaths than single. Of the illicit drugs, heroin had the highest CF (26.4%, 95%CI 19.1-33.7).

CONCLUSION

Knowledge of relative lethal toxicity is useful to prescribers and medicines and public health policy makers in restricting access to more toxic drugs and may also assist coroners in determining cause of death.

U.S. prescribing trends of fentanyl, opioids, and other pain medications in outpatient and emergency department visits from 2006 to 2015

The United States is currently facing an epidemic of opioid-related deaths, increasingly associated with fentanyl use. Our objective was to characterize rates of fentanyl, general opioid and non-opioid pain medication prescription at a national level in both outpatient and emergency department settings. We used a retrospective cross-sectional research design using data from the 2006-2015 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. Between 2006-2015, 66,987 (17.4%) of 390,538 office-based outpatient visits (nationally-representative of 961 million visits) and 134,953 (45.0%) of 305,570 ED visits (nationally-representative of 130 million visits) listed a pain medication prescription. The proportion of all outpatient visits in which any pain medication was prescribed increased from 15.0% in 2006-2007 to 20.5% in 2014-2015 (p < 0.001). The proportion of all outpatient visits in which any fentanyl product was prescribed remained stable at 0.3% and 0.4% (p = 0.32), but increased among ED visits from 0.5% to 1.1% (p = 0.006). In contrast, the proportion of all outpatient visits in which any opioid product was prescribed increased from 6.6% to 9.7% (p < 0.001), but remained relatively stable among ED visits from 26.2% to 24.4% (p = 0.07). Non-opioid pain medication prescription increased in both settings, from 9.7% to 13.7% (p < 0.001) in the outpatient setting and from 25.6% to 27.6% (p = 0.02) in the ED setting between 2006-2007 and 2014-2015, respectively. To address current opioid crisis, both clinical and public health interventions are needed, such as targeted education outreach on evidence-based opioid prescribing and non-opioid alternatives.

Illicit fentanyls in the opioid street market: desired or imposed?

BACKGROUND

Illicitly manufactured fentanyl and its analogues are appearing in countries throughout the world, often disguised as heroin or counterfeit prescription pills, with resulting high overdose mortality. Possible explanations for this phenomenon include reduced costs and risks to heroin suppliers, heroin shortages, user preferences for a strong, fast-acting opioid and the emergence of Dark Web cryptomarkets. This paper addresses these potential causes and asks three questions: (1) can users identify fentanyl; (2) do users desire fentanyl; and (3) if users want fentanyl, can they express this demand in a way that influences the supply?

ARGUMENT/ANALYSIS

Existing evidence, while limited, suggests that some users can identify fentanyl, although not reliably, and some desire it, but because fentanyl is frequently marketed deceptively as other drugs, users lack information and choice to express demand effectively. Even when aware of fentanyl's presence, drug users may lack fentanyl-free alternatives. Cryptomarkets, while difficult to quantify, appear to offer buyers greater information and competition than offline markets. However, access barriers and patterns of fentanyl-related health consequences make cryptomarkets unlikely sources of user influence on the fentanyl supply. Market condition data indicate heroin supply shocks and shortages prior to the introduction of fentanyl in the United States and parts of Europe, but the much lower production cost of fentanyl compared with heroin may be a more significant factor CONCLUSION: Current evidence points to a supply-led addition of fentanyl to the drug market in response to heroin supply shocks and shortages, changing prescription opioid availability and/or reduced costs and risks to suppliers. Current drug users in affected regions of the United States, Canada and Europe appear largely to lack both concrete knowledge of fentanyl's presence in the drugs they buy and access to fentanyl-free alternatives.

Acceptability of implementing community-based drug checking services for people who use drugs in three United States cities: Baltimore, Boston and Providence

BACKGROUND

North America is experiencing a rising trend of opioid overdose exacerbated primarily in recent years through adulteration of the heroin supply with fentanyl and its analogues. The east coast of the United States has been particularly hard hit by the epidemic. In three east coast states of Maryland, Massachusetts and Rhode Island, fentanyl has been detected in over half of all overdoses with available toxicology screens. To determine the acceptability of drug checking involving fentanyl test strips (FTS) or other technologies among those at high risk for overdose, we assessed correlates of intention to utilize such services and logistical preferences among people who use drugs (PWUD).

METHODS

Through FORECAST (the Fentanyl Overdose REduction Checking Analysis STudy), street-based PWUD (N = 334) were recruited in Baltimore, Maryland, Boston, Massachusetts, and Providence, Rhode Island. Questionnaires 7were administered from June to October 2017 and ascertained drug use, overdose history, fentanyl knowledge, and drug checking intent and logistical preferences. Pearson's χ² and logistic regression determined factors associated with drug checking intent.

RESULTS

Overall, 84% were concerned about fentanyl, 63% had ever overdosed, and 42% had ever witnessed a fatal overdose. Ninety percent felt drug checking would help them prevent an overdose, the majority of those interested would utilize drug checking at least daily (54%). Factors independently associated with intent to use drug checking included: older age (aOR: 1.5, 95% CI: 1.3-1.8); homelessness (aOR: 0.6, 95% CI: 0.5-0.7); being non-white (aOR: 2.0, 95% CI: 1.0-4.0); witnessing ≥1 fatal overdose (aOR: 1.6, 95% CI:1.1-2.3); and suspected recent fentanyl exposure (aOR: 1.8, 95% CI: 1.1-3.1).

CONCLUSIONS

The majority of PWUD endorsed drug checking for overdose prevention, with intent amplified by having witnessed a fatal overdose and recent fentanyl exposure. Drug checking should be part of a comprehensive approach to address the risks associated with the proliferation of fentanyl.

An analysis of issues in the classification and reporting of heroin-related deaths

AIMS

To investigate the extent of variability in the reporting of heroin-related deaths in Victoria, Australia. Additionally, to identify opportunities to improve the accuracy and consistency of heroin-related death reporting by examining variability in the attribution, death certification, classification and coding of heroin-related death cases.

METHODS

Heroin-related deaths in Victoria, Australia during a 2-year period (2012-13) were identified using the National Coronial Information System (NCIS) and used as the 'gold standard' measure in this study. Heroin-related death data from the Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS) were then compared. Differences in the number of deaths reported as well as the classification and coding assigned to the identified heroin-related death cases were investigated by cross-referencing these data sets and examining the assigned ICD-10 codes.

RESULTS

A total of 243 heroin-related deaths were identified through the NCIS compared with 165 heroin-related deaths reported by the AIHW and assigned the heroin-specific ICD-10 code of T40.1. Forty per cent of all the missed heroin-related death cases resulted from either the attribution of the death to morphine toxicity or with non-specific drug toxicity certification; 30% occurred where the cases had been attributed to heroin but there were irregularities in death certification. Additional missed heroin-related death cases occurred as a result of late initial registration of these deaths to the Registry of Births, Deaths and Marriages, and where these cases were then not assessed by the ABS for classification and coding purposes.

CONCLUSIONS

In Victoria, Australia, in 2012 and 2013, the overall number of heroin-related deaths was under-reported by 32% compared with the number of deaths currently identified by the Australian Bureau of Statistics and reported by the Australian Institute of Health and Welfare.

Combating escalating harms associated with pharmaceutical opioid use in Australia: the POPPY II study protocol

INTRODUCTION

Opioid prescribing has increased 15-fold in Australia in the past two decades, alongside increases in a range of opioid-related harms such as opioid dependence and overdose. However, despite concerns about increasing opioid use, extramedical use and harms, there is a lack of population-level evidence about the drivers of long-term prescribed opioid use, dependence, overdose and other harms.

METHODS AND ANALYSIS

We will form a cohort of all adult residents in New South Wales (NSW), Australia, who initiated prescribed opioids from 2002 using Pharmaceutical Benefits Scheme dispensing records. This cohort will be linked to a wide range of other datasets containing information on sociodemographic and clinical characteristics, health service use and adverse outcomes (eg, opioid dependence and non-fatal and fatal overdose). Analyses will initially examine patterns and predictors of prescribed opioid use and then apply regression and survival analysis to quantify the risks and risk factors of adverse outcomes associated with prescribed opioid use.

ETHICS AND DISSEMINATION

This study has received full ethical approval from the Australian Institute of Health and Welfare Ethics Committee, the NSW Population and Health Services Research Committee and the ACT Health Human Research Ethics Committee. This will be the largest postmarketing surveillance study of prescribed opioids undertaken in Australia, linking exposure and outcomes and examining risk factors for adverse outcomes of prescribed opioids. As such, this work has important translational promise, with direct relevance to regulatory authorities and agencies worldwide. Project findings will be disseminated at scientific conferences and in peer-reviewed journals. We will also conduct targeted dissemination with policy makers, professional bodies and peak bodies in the pain, medicine and addiction fields through stakeholder workshops and advisory groups. Results will be reported in accordance with the REporting of studies Conducted using Observational Routinely collected Data (RECORD) Statement.

Use of rapid fentanyl test strips among young adults who use drugs

BACKGROUND

The overdose epidemic has been exacerbated by a dramatic increase in deaths involving illicitly manufactured fentanyl (IMF). Drug checking is a novel strategy to identify IMF in illicit drugs. We examined the uptake and acceptability of rapid fentanyl test strips among young adults.

METHODS

From May to September 2017, we recruited 93 young adults in Rhode Island who reported injecting drugs or using heroin, cocaine, or illicitly obtained prescription pills in the past 30 days. Participants were asked to test either their urine after drug use (post-consumption) or a drug sample prior to use (pre-consumption) using rapid fentanyl test strips. After a questionnaire and a brief training, participants received ten strips for their personal use and were asked to return for a one-month follow-up visit, which assessed the uptake and acceptability of the rapid strips tests and the behavioral outcomes associated with receipt of a positive test.

RESULTS

Of the 81 (87%) participants who returned for follow-up and who had complete data, the mean age was 27, 45 (56%) were male, and 37 (46%) were non-white. A total of 62 participants (77%) reported using at least one test strip. Of these, 31 (50%) received at least one positive result. A positive result was associated with older age, homelessness, heroin use, injection drug use, ever witnessing an overdose, and concern about overdose or drugs being laced with fentanyl (all p < 0.05). Receiving a positive result was significantly associated with reporting a positive change in overdose risk behavior between baseline and follow-up (p ≤  0.01). Among all participants, 79 (98%) reported confidence in their ability to use the test strips and 77 (95%) wanted to use them in the future.

CONCLUSIONS

Young adults reported high uptake and acceptability of fentanyl test strips to detect IMF in illicit drugs.

New synthetic opioids: Part of a new addiction landscape

Synthetic opioids (SO) are a major risk for public health across the world. These drugs can be divided into 2 categories, pharmaceutical and non-pharmaceutical fentanyls. A new generation of SO has emerged on the drug market since 2010. North America is currently facing an opioid epidemic of morbi-mortality, caused by over-prescription of opioids, illegally diverted prescribed medicines, the increasing use of heroin and the emergence of SO. Furthermore, this opioid crisis is also seen in Europe. SO are new psychoactive substances characterized by different feature such as easy availability on the Internet, low price, purity, legality, and lack of detection in laboratory tests. They have not been approved or are not recommended for human use. Opioid misuse is associated with somatic and psychiatric complications. For many substances, limited pharmacological information is available, increasing the risk of harmful adverse events. Health actors and the general population need to be clearly informed of the potential risks and consequences of the diffusion and use of SO.

Predictors of persistent prescription opioid analgesic use among people without cancer in Australia

AIMS

To identify patterns of opioid analgesic use and determine predictors of persistent opioid use among people without cancer.

METHODS

A population-based cohort study of Australians initiating prescription opioids from July 2013 to December 2015 was conducted using data from a random 10% sample of people who accessed medicines through Australia's Pharmaceutical Benefits Scheme. A 12-month retrospective period was used to define opioid initiation, exclude people with cancer and determine comorbidities. Persistent use over 12 months since initiation was identified through group-based trajectory modelling. Odds ratios (OR) and 95% confidence intervals (CIs) for predictors of opioid persistence were estimated using logistic regression.

RESULTS

The cohort consisted of 431 963 people without cancer who initiated opioids. A total of 11 323 (2.6%) persistent opioid users were identified. Predictors of persistence included initiation with transdermal formulations (OR 4.2, 95% CI 3.9-4.5), or initiation with total oral morphine equivalents (OME) ≥ 750 mg (3.7, 3.3-4.1), having depression (1.6, 1.5-1.7) or psychotic illness (2.0, 1.9-2.2). Previous dispensing of paracetamol (2.0, 1.9-2.1), pregabalin (2.0, 1.8-2.1) and benzodiazepines (1.53, 1.4-1.6) predicted persistence. Compared to people aged 18-44 years, those ≥75 years were 2.5 (2.3-2.6) times more likely to be persistent users.

CONCLUSIONS

Patient-specific characteristics (older age, prior history of mental health comorbidities and use of non-opioid analgesics) and prescriber choice of initial opioid (transdermal formulation and higher total OMEs) were found to strongly predict persistent use. This information may help prescribers target monitoring and early intervention efforts in order to prevent harms associated with the long-term use of opioids.

Intravenous fentanyl use among people who inject drugs in Australia

INTRODUCTION AND AIMS

There is a current epidemic of pharmaceutical opioid (PO) misuse, particularly fentanyl and fentanyl analogues, globally. Fentanyl is a highly potent synthetic opioid with rapid onset and significantly higher risk of overdose compared with other opioids. Contexts and correlates of fentanyl use among people who inject drugs (PWID) in Australia are under-researched.

DESIGN AND METHODS

The Australian Needle Syringe Program Survey is conducted annually. Consenting PWID complete a self-administered questionnaire and provide a capillary dried blood spot for human immunodeficiency virus and hepatitis C virus antibody testing. Bivariate and multivariate logistic regressions determined correlates of recent (last 6 months) fentanyl injection in 2014.

RESULTS

Recent fentanyl injection was reported by 8% (n = 193) of the total sample. Among the 848 PWID who recently injected POs, 23% injected fentanyl. Compared with PO injectors who had not injected fentanyl, those who had injected fentanyl were significantly more likely to identify as Indigenous Australian [adjusted odds ratio (AOR) 1.61; 95% confidence interval (CI) 1.04, 2.51; P = 0.034], inject daily or more frequently (AOR 1.92; 95% CI 1.30, 2.83; P = 0.005), inject in public (AOR 1.43; 95% CI 1.01, 2.02; P = 0.042) and to have overdosed in the past year (AOR 2.16; 95% CI 1.48, 3.13; P < 0.001), but were significantly less likely to receptively share syringes (AOR 0.56; 95% CI 0.36, 0.87; P = 0.010).

DISCUSSION AND CONCLUSIONS

Fentanyl injectors in Australia are significantly more likely to identify as Indigenous, report frequent injection, inject in public and experience overdose. Increased access to harm reduction interventions, including naloxone distribution, wheel filters and supervised injection facilities, are likely to benefit this population.

Twenty-five years of prescription opioid use in Australia: a whole-of-population analysis using pharmaceutical claims

AIM

The aim of this paper is to investigate 25-year trends in community use of prescribed opioid analgesics in Australia, and to map these trends against major changes to opioid registration and subsidy.

METHODS

We obtained dispensing data from 1990 to 2014 from two sources: dispensing claims processed under Australia's national drug subsidy programme, the Pharmaceutical Benefits Scheme, including under co-payment records from 2012; and estimates of non-subsidized medicine use from a survey of Australian pharmacies (until 2011). Utilization was expressed in defined daily doses (DDD)/1000 population/day.

RESULTS

Opioid dispensing increased almost four-fold between 1990 and 2014, from 4.6 to 17.4 DDD/1000 pop/day. In 1990, weak, short-acting or orally administered opioids accounted for over 90% of utilization. Use of long-acting opioids increased over 17-fold between 1990 and 2000, due primarily to the subsidy of long-acting morphine and increased use of methadone for pain management. Between 2000 and 2011, oxycodone, fentanyl, buprenorphine, tramadol and hydromorphone use increased markedly. Use of strong opioids, long-acting and transdermal preparations also increased, largely following the subsidy of various opioids for noncancer pain. In 2011, the most dispensed opioids were codeine (41.1% of total opioid use), oxycodone (19.7%) and tramadol (16.1%); long-acting formulations comprised approximately half, and strong opioids 40%, of opioid dispensing.

CONCLUSIONS

Opioid utilization in Australia is increasing, although these figures remain below levels reported in the US and Canada. The increased use of opioids was largely driven by the subsidy of long-acting formulations and opioids for the treatment of noncancer pain.

The extent and correlates of community-based pharmaceutical opioid utilisation in Australia

PURPOSE

There has been concern regarding the increasing use of opioids and related harm. We present data on opioid utilisation across Australia and consider sociodemographic factors that may affect utilisation rates.

METHODS

IMS Health national sales data for over-the-counter (codeine) and prescription opioids (buprenorphine, codeine, dextropropoxyphene, fentanyl, hydromorphone, methadone, morphine, oxycodone, tapentadol and tramadol) were used to estimate total utilisation rates in the community during 2013, mapped to Statistical Local Areas (SLAs) and Remoteness Areas. All opioid amounts were measured in pack sales and milligrammes then converted to oral morphine equivalent milligrammes (OME mg) for comparison across opioids. Data on the demographic characteristics of SLAs were obtained from the ABS (sex and age distribution, income and levels of physical labour) and other sources (number of pharmacies in SLAs) and were included in linear regression analyses.

RESULTS

In 2013, an estimated 10 747 kg (OME) of opioids were sold across Australia, equating to 481 OME mg per person. There was considerable geographic variation in opioid utilisation, with higher rates of use in rural and regional areas. Geographic areas that were less populated, had more men and older people, proportionally more low-income earning households and greater proportions in jobs requiring physical labour had higher utilisation rates.

CONCLUSIONS

Substantial geographic variation in opioid utilisation was identified, with areas outside of major cities having higher rates of utilisation of all types of opioids. Prescription monitoring and best practice interventions aimed at improving opioid use need to have a particular focus on areas outside of major cities. Copyright © 2016 John Wiley & Sons, Ltd.

Sensitivity and specificity of administrative mortality data for identifying prescription opioid-related deaths

BACKGROUND

Comprehensive systems for surveilling prescription opioid-related harms provide clear evidence that deaths from prescription opioids have increased dramatically in the United States. However, these harms are not systematically monitored in Canada. In light of a growing public health crisis, accessible, nationwide data sources to examine prescription opioid-related harms in Canada are needed. We sought to examine the performance of 5 algorithms to identify prescription opioid-related deaths from vital statistics data against data abstracted from the Office of the Chief Coroner of Ontario as a gold standard.

METHODS

We identified all prescription opioid-related deaths from Ontario coroners' data that occurred between Jan. 31, 2003, and Dec. 31, 2010. We then used 5 different algorithms to identify prescription opioid-related deaths from vital statistics death data in 2010. We selected the algorithm with the highest sensitivity and a positive predictive value of more than 80% as the optimal algorithm for identifying prescription opioid-related deaths.

RESULTS

Four of the 5 algorithms had positive predictive values of more than 80%. The algorithm with the highest sensitivity (75%) in 2010 improved slightly in its predictive performance from 2003 to 2010.

INTERPRETATION

In the absence of specific systems for monitoring prescription opioid-related deaths in Canada, readily available national vital statistics data can be used to study prescription opioid-related mortality with considerable accuracy. Despite some limitations, these data may facilitate the implementation of national surveillance and monitoring strategies.

An overview of the patterns of prescription opioid use, costs and related harms in Australia

AIMS

To report Australian population trends in subsidized prescribed opioid use, total costs to the Australian government to subsidize these medicines and opioid-related harms based on hospitalizations and accidental poisoning deaths.

METHODS

We utilized three national aggregated data sources including dispensing claims from the Pharmaceutical Benefits Scheme, opioid-related hospitalizations from the National Hospital Morbidity Database and accidental poisoning deaths from the Australian Bureau of Statistics.

RESULTS

Between 1992 and 2012, opioid dispensing episodes increased 15-fold (500 000 to 7.5 million) and the corresponding cost to the Australian government increased 32-fold ($8.5 million to $271 million). Opioid-related harms also increased. Opioid-related hospitalizations increased from 605 to 1464 cases (1998-2009), outnumbering hospitalizations due to heroin poisonings since 2001. Deaths due to accidental poisoning (pharmaceutical opioids and illicit substances combined) increased from 151 to 266 (2002-2011), resulting in a rise in the death rate of 0.78 to 1.19 deaths/100 000 population over 10 years. Death rates increased 1.8 fold in males and 1.4 fold in females.

CONCLUSIONS

The striking increase in opioid use and related harms in Australia is consistent with trends observed in other jurisdictions. Further, there is no evidence to suggest these increases are plateauing. There is currently limited evidence in Australia about individual patterns of opioid use and the associated risk of adverse events. Further research should focus on these important issues so as to provide important evidence supporting effective change in policy and practice.

The health consequences of injecting tablet preparations: foreign body pulmonary embolization and pulmonary hypertension among deceased injecting drug users

AIMS

To determine: (1) the characteristics of cases presenting to the Department of Forensic Medicine Sydney (1997-2013) with foreign body pulmonary embolization; (2) the extent and locations of embolization; and (3) the relationship between extent, and use of other injection sites, with pathology.

DESIGN

Analysis of consecutive case presentations with foreign body pulmonary embolization.

SETTING/PARTICIPANTS

Sydney, Australia, with a total of 373 cases (271 males, 102 females).

MEASUREMENTS

Full autopsy reports, microscopy of tissue samples, and full toxicology. The extent and locations of embolization, inflammatory responses, clinical signs of pulmonary hypertension and signs of right-sided heart failure were examined.

FINDINGS

Cases increased from three (1997) to 58 (2013). In 43.4%, foreign particles were moderate-abundant in extent. Cases with moderate-abundant emboli were more likely to have injection sites other than the cubital fossa [odds ratio (OR) = 2.4]. In 6.9% of cases emboli were also found in other organs. A foreign body inflammatory response was present in 45.3%, vascular scarring in 8.0%, signs of pulmonary hypertension in 10.2% and signs of right-sided heart pathology in 5.4%. Cases with moderate-abundant deposition were more likely to have emboli in other organs (OR = 7.9), a foreign body inflammatory response (OR = 5.3), vascular scarring (OR = 3.4), signs of pulmonary hypertension (OR = 5.4) and right-sided heart pathology (OR = 5.3).

CONCLUSIONS

Cases of foreign body pulmonary embolization (resulting from injecting crushed tablets meant for oral use, such as benzodiazepines and pharmaceutical opioids) in Sydney, Australia increased markedly from 1997 to 2013. In a large proportion there were clinical consequences. More extensive embolization was associated with higher levels of pulmonary hypertension and right-sided heart pathology.

Fentanyls: Are we missing the signs? Highly potent and on the rise in Europe

Fentanyl is a synthetic opioid analgesic historically used as a pain reliever and an anaesthetic. Recent concerns have arisen around the illicit use of fentanyl and its analogues in a number of European countries, linked to their high potency and associated risk of fatal overdose. Evidence has been emerging from Estonia for over a decade of entrenched patterns of fentanyl use, including injection of the drug and hundreds of overdose deaths. More recently, reports indicate that both fentanyl and 3-methylfentanyl (TMF) have been marketed as a replacement for heroin in European countries (e.g. Bulgaria, Slovakia) affected by heroin shortages. In addition, Germany, Finland and the United Kingdom, reported new outbreaks of fentanyl-related deaths. This combination of increasing mortality data alongside law enforcement intelligence suggesting both diversion and illicit production of fentanyls, prompted wider investigation using a targeted multi-source data collection exercise and analysis. This identified that in the European context, fentanyls are 'low use but high risk/harm' substances. Evidence shows that Estonia stands out as having an endemic problem, while the use of fentanyls in other European countries appears to be geographically localised. Developments in illicit supply of fentanyls reflect the complexity of Europe's contemporary drug market: manifesting illicit production and use, the diversion and misuse of medicines, and the online sale of non-controlled new psychoactive substances. Likewise effective and integrated responses will need to address fentanyl production, diversion as well as ensuring the availability of harm reduction measures to users.

Changes in non-opioid substitution treatment episodes for pharmaceutical opioids and heroin from 2002 to 2011

BACKGROUND

There has been a well-documented increase in the non-medical use of pharmaceutical opioids (PO) worldwide. However, there has been little detailed examination of treatment demand, or the characteristics of those presenting for treatment, particularly for treatments other than opioid substitution.

METHODS

Data from closed drug and alcohol treatment episodes from the Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS-NMDS, representing non-opioid substitution treatment) in Australia for 2002-2003 to 2010-2011 were examined. In the four jurisdictions where detailed data were available, episodes where heroin was the principal drug of concern were compared to episodes for the four most frequently reported pharmaceutical opioids (morphine, codeine, fentanyl and oxycodone).

RESULTS

In 2002-2003, most (93%) opioid treatment was related to heroin with seven percent of all opioid treatment episodes reporting a PO as the principal drug of concern. In 2010-2011, 20% of all opioid treatment episodes were attributed to POs. Distinct changes over time were observed for different opioids. There was an increase in the average age at the start of treatment for heroin and oxycodone episodes, and a reduction in the proportion of females for codeine episodes, with 67% in 2002-2003 compared with 44% in 2010-2011. Codeine and oxycodone episodes had the lowest current or past injection rates.

CONCLUSIONS

Clear differences were observed over time and between different opioids. Monitoring these emerging patterns will be important to inform treatment needs, particularly in light of different patterns of poly drug use, different routes of administration and changing demographic characteristics.

The POPPY Research Programme protocol: investigating opioid utilisation, costs and patterns of extramedical use in Australia

INTRODUCTION

Opioid prescribing is increasing in many countries. In Australia, there is limited research on patterns of prescribing and access, or the outcomes associated with this use. The aim of this research programme is to use national dispensing data to estimate opioid use and costs, including problematic or extramedical use in the Australian population.

METHODS AND ANALYSIS

In a cohort of persons dispensed at least one opioid in 2013, we will estimate monthly utilisation and costs of prescribed opioids, overall and according to individual opioid formulations and strengths. In a cohort of new opioid users, commencing therapy between 1 July 2009 and 31 December 2013, we will examine patterns of opioid use including initiation of therapy, duration of treatment and concomitant use of opioids and other prescribed medicines. We will also examine patterns of extramedical opioid use based on indicators including excess dosing, use of more than one opioid concomitantly, doctor/pharmacy shopping and accelerated time to prescription refill.

ETHICS AND DISSEMINATION

This protocol was approved by the NSW Population and Health Services Ethics Committee (March 2014) and data access approved by the Department of Human Services External Review Evaluation Committee (June 2014). This will be one of the first comprehensive Australian studies with the capability to investigate individual patterns of use and track extramedical use. In the first instance our analysis will be based on 5 years of dispensing data but will be expanded with ongoing annual data updates. This research has the capability to contribute significantly to pharmaceutical policy within Australia and globally. In particular, the trajectory of extramedical prescription-opioid use has been the subject of limited research to date. The results of this research will be published widely in general medical, pharmacoepidemiology, addiction and psychiatry journals.

Patterns of, and Factors Associated With, Illicit Pharmaceutical Opioid Analgesic Use in a Prospective Cohort of People Who Inject Drugs in Melbourne, Australia

BACKGROUND

People who inject drugs (PWID) are a key population engaging in pharmaceutical opioid analgesic (PO) use, yet little is known about patterns of illicit PO use among this group.

OBJECTIVES

The aims of this research were to measure the prevalence and frequency of lifetime and past-month illicit PO use and injection in a sample of regular PWID, to examine patterns of past-month illicit PO use within individuals over time, and to identify factors independently associated with past-month illicit PO use.

METHODS

Data were drawn from a prospective cohort study of regular PWID (N = 666) in Melbourne, Australia. Data from five waves of annual data collection (including baseline) were analyzed descriptively and using generalized estimating equations (GEE).

RESULTS

At baseline, 59% of participants reported lifetime illicit PO use and 20% reported past-month use, predominantly through injecting. Most illicit PO users at baseline transitioned to nonuse of illicit POs across the study period. In multivariable GEE analysis, factors associated with past-month illicit PO use included past-year arrest [adjusted odds ratio (AOR): 1.39], opioids other than heroin as drug of choice (AOR: 5.14), experiencing poorer physical health (AOR: 0.98) and a range of other drug use variables.

CONCLUSIONS

We found little evidence of ongoing illicit PO use among those followed up, with illicit PO use linked to polydrug use more broadly. Nonetheless, trends in illicit PO use among PWID should continue to be monitored and harm reduction interventions implemented to reduce the associated public health risks.

Prescription opioid abuse based on representative postmortem toxicology

Opioids are important medications for pain and opioid maintenance treatment. Increasing use and abuse of prescription opioids has, however, caused worldwide concern. Our aim was to estimate the ratio between prescription opioid abuse and total use, based on representative postmortem toxicology. Our material included all the medico-legally examined deaths in Finland during 2010-2011 involving positive findings involving buprenorphine, codeine, fentanyl, methadone, oxycodone, or tramadol. We studied drug abuse by age group, with "abuse" meaning licit opioids used illicitly as narcotics. Drug-abuse history, drug injecting, or laboratory findings of illicit drugs defined an abuser case. We then compared abuser cases and other opioid-related cases between the opioids with the number of fatal poisonings, accidents, suicides, alcohol findings, concomitant opioid use, and median postmortem blood opioid concentrations. Opioid findings numbered 2499 in 2088 cases. Drug abuse involved 545 opioid-positive cases, which in Finland represented 0.5% of those deceased. The proportion of abuser cases among all opioid-related cases for buprenorphine was 85.5%, for methadone 82.4%, for tramadol 29.4%, for codeine 16.3%, for fentanyl 14.5%, and for oxycodone 6.9%. Abuse in age-groups >60 was rare. Concomitant other opioid findings were more frequent in abuser- than in other cases for codeine, oxycodone, and tramadol, whereas alcohol findings were more frequent in buprenorphine, codeine, and fentanyl abuse. Buprenorphine and methadone were most often related to drug abuse. Every other opioid studied involved some abuse, and especially tramadol. Abuse and fatal poisonings were concentrated in men aged 20-49.

Diversion of prescribed opioids by people living with chronic pain: results from an Australian community sample

INTRODUCTION AND AIMS

There has been an increase in prescription of opioids for chronic non-cancer pain, and concern exists over possible diversion of prescription opioids to the illicit marketplace. Recent media coverage suggests that elderly patients sell their prescribed opioids for additional income. This study investigated the extent to which an Australian community sample of chronic pain patients prescribed opioids reported supplying their prescribed opioids to others.

DESIGN AND METHODS

Participants living with chronic non-cancer pain and prescribed opioids for their pain (n=952) were recruited across Australia via advertisements at pharmacies. A telephone interview included questions about their pain condition and opioid medication.

RESULTS

Participants had been living with pain for a mean of 14.2 years; most common conditions included chronic back/neck problems and arthritis/rheumatism. Around half (43%) were currently prescribed one opioid, and 55% had been prescribed 2-5 opioids; the most common was oxycodone. Forty-two participants (4%) reported ever supplying prescribed opioids to another person; one participant reported receiving payment. Participants who supplied opioids to others were younger (odds ratio 0.97, 95% confidence interval 0.95-0.99) and engaged in a greater number of aberrant behaviours relating to their opioid medication (odds ratio 1.77, 95% confidence interval 1.45-2.17), including tampering with doses, taking opioids by alternative routes, seeing doctors to obtain extra opioids and refilling prescriptions early.

DISCUSSION AND CONCLUSION

Few people with chronic non-cancer pain divert their opioids to others. Media reports of elderly patients selling their opioids to supplement their income may be reflective of exceptional cases. Future studies may investigate the extent to which other patient groups divert prescription opioids to the illicit marketplace.