Denial of prescription analgesia among people who inject drugs in a Canadian setting

Characterizing the Use of Healthcare Access Supports Among People Who Use Drugs in Vancouver, Canada, 2017 to 2020: A Cohort Study

BACKGROUND

For structurally marginalized populations, including people who use drugs (PWUD), equitable access to healthcare can be achieved through healthcare access supports. However, few studies characterized utilization of formal (eg, outreach workers, healthcare professionals) and informal (eg, friends/family) supports. Therefore, we sought to estimate the prevalence of and factors associated with receiving each type of support among PWUD.

METHODS

We used data from 2 prospective cohort studies of PWUD in Vancouver, Canada, in 2017 to 2020. We constructed separate multivariable generalized linear mixed-effects models to identify factors associated with receiving each of the 3 types of supports (ie, healthcare professionals, outreach workers/peer navigators, and informal supports) compared to no supports.

RESULTS

Of 996 participants, 350 (35.1%) reported receiving supports in the past 6 months at baseline, through informal supports (6.2%), outreach workers (14.1%), and healthcare professionals (20.9%). In multivariable analyses, HIV positivity, chronic pain, and avoiding healthcare due to the past mistreatment were positively associated with receiving supports from each of healthcare professionals and outreach workers. Men were less likely to receive any types of the supports (all P < .05).

CONCLUSIONS

Utilization of healthcare access supports was relatively low in this sample. However, formal supports appeared to have reached PWUD exhibiting more comorbidities and experiencing discrimination in healthcare. Further efforts to make formal supports more available would benefit PWUD with unmet healthcare needs, particularly men.

Denial of prescription pain medication among people who use drugs in Vancouver, Canada

BACKGROUND

People who use drugs experience pain at two to three times the rate of the general population and yet continue to face substantial barriers to accessing appropriate and adequate treatment for pain. In light of the overdose crisis and revised opioid prescribing guidelines, we sought to identify factors associated with being denied pain medication and longitudinally investigate denial rates among people who use drugs.

METHODS

We used multivariable generalized estimating equations analyses to investigate factors associated with being denied pain medication among people who use drugs reporting pain in three prospective cohort studies in Vancouver, Canada. Analyses were restricted to study periods in which participants requested a prescription for pain from a healthcare provider. Descriptive statistics detail denial rates and actions taken by participants after being denied.

RESULTS

Among 1168 participants who requested a prescription for pain between December 2012 and March 2020, the median age was 47 years and 63.0% were male. Among 4,179 six-month observation periods, 907 (21.7%) included a report of being denied requested pain medication. In multivariable analyses, age was negatively associated with prescription denial (adjusted odds ratio [AOR] = 0.98, 95% confidence interval [CI]:0.97-0.99), while self-managing pain (AOR = 2.48, 95%CI:2.04-3.00), experiencing a non-fatal overdose (AOR = 1.51, 95%CI:1.22-1.88), engagement in opioid agonist therapy (AOR = 1.32, 95%CI:1.09-1.61), and daily use of heroin or other unregulated opioids (AOR = 1.32, 95%CI:1.05-1.66) were positively associated with being denied. Common actions taken (n = 895) after denial were accessing the unregulated drug supply (53.5%), doing nothing (30.6%), and going to a different doctor/emergency room (6.1%). The period following the introduction of new prescribing guidelines was not associated with a change in denial rates.

CONCLUSIONS

A substantial proportion of people who use drugs continue to be denied prescriptions for pain, with such denial associated with important substance use-related harms, including non-fatal overdose. Guidelines specific to the pharmaceutical management of pain among people who use drugs are needed.

Cannabis use to manage opioid cravings among people who use unregulated opioids during a drug toxicity crisis

BACKGROUND

Accumulating evidence has indicated that cannabis substitution is often used as a harm reduction strategy among people who use unregulated opioids (PWUO) and people living with chronic pain. We sought to investigate the association between cannabis use to manage opioid cravings and self-reported changes in opioid use among structurally marginalized PWUO.

METHODS

The data were collected from a cross-sectional questionnaire administered to PWUO in Vancouver, Canada. Binary logistic regression was used to analyze the association between cannabis use to manage opioid cravings and self-reported changes in unregulated opioid use.

RESULTS

A total of 205 people who use cannabis and opioids were enrolled in the present study from December 2019 to November 2021. Cannabis use to manage opioid cravings was reported by 118 (57.6%) participants. In the multivariable analysis, cannabis use to manage opioid cravings (adjusted Odds Ratio [aOR] = 2.13, 95% confidence interval [CI]: 1.07, 4.27) was significantly associated with self-reported reductions in opioid use. In the sub-analyses of pain, cannabis use to manage opioid cravings was only associated with self-assessed reductions in opioid use among people living with moderate to severe pain (aOR = 4.44, 95% CI: 1.52, 12.97). In the sub-analyses of males and females, cannabis use to manage opioid cravings was only associated with self-assessed reductions in opioid use among females (aOR = 8.19, 95% CI: 1.20, 55.81).

CONCLUSIONS

These findings indicate that cannabis use to manage opioid cravings is a prevalent motivation for cannabis use among PWUO and is associated with self-assessed reductions in opioid use during periods of cannabis use. Increasing the accessibility of cannabis products for therapeutic use may be a useful supplementary strategy to mitigate exposure to unregulated opioids and associated harm during the ongoing drug toxicity crisis.

Estimating the prevalence and correlates of pain among people living with HIV who use unregulated drugs in a Canadian setting

Although prevalent among people living with human immunodeficiency virus (HIV) (PLWH) and people who use unregulated drugs (PWUD), pain and its possible links to substance use patterns and engagement in HIV treatment remains poorly characterized. We sought to evaluate the prevalence and correlates of pain among a cohort of PLWH who use un-regulated drugs. Between December 2011 and November 2018, 709 participants were recruited, and data were analyzed using generalized linear mixed-effects (GLMM). At baseline, 374 (53 percent) individuals reported moderate-to-extreme pain in the previous 6 months. In a multivariable model, pain was significantly associated with nonmedical prescrip-tion-opioid use (adjusted odds ratio (AOR) = 1.63, 95 percent confidence interval (CI): 1.30-2.05), nonfatal overdose (AOR = 1.46, 95 percent CI: 1.11-1.93), self-managing pain (AOR = 2.25, 95 percent CI: 1.94-2.61), requesting pain medication in the previous 6 months (AOR = 2.01, 95 percent CI: 1.69-2.38), and ever being diagnosed with a mental illness (AOR = 1.47, 95 percent CI: 1.11-1.94). Establishing accessible pain management interventions that address the complex intersection of pain, drug use, and HIV-infection has potential to improve quality of life outcomes among this population.

"They Just Assume That We're All Going to Do the Wrong Thing With It. It's Just Not True": Stakeholder Perspectives About Peripherally Inserted Central Catheters in People Who Inject Drugs

Background

In the absence of adequate harm reduction opportunities, people who inject drugs (PWID) are at increased risk for serious infections. Infectious diseases guidelines recommend extended periods of intravenous antibiotic treatment through peripherally inserted central catheters (PICCs), but PWID are often deemed unsuitable for this treatment. We conducted semi-structured interviews and focus groups to understand the perspectives and opinions of patients and clinicians on the use of PICCs for PWID.

Methods

We approached patients and clinicians (doctors, nurses, PICC nurses, social workers, and case workers) involved in patient care at Tufts Medical Center (Boston, Massachusetts) between August 2019 and April 2020 for semi-structured interviews and focus groups.

Results

Eleven of 14 (79%) patients agreed to participate in an in-depth interview, and 5 role-specific clinician focus groups (1 group consisting of infectious diseases, internal medicine, and addiction psychiatry doctors, 2 separate groups of floor nurses, 1 group of PICC nurses, and 1 group of social workers) were completed. Emergent themes included the overall agreement that PICCs improve healthcare, patients' feelings that their stage of recovery from addiction was not taken into consideration, and clinicians' anecdotal negative experiences driving decisions on PICCs.

Conclusions

When analyzed together, the experiences of PWID and clinicians shed light on ways the healthcare system can improve the quality of care for PWID hospitalized for infections. Further research is needed to develop a system of person-centered care for PWID that meets the specific needs of patients and improves the relationship between them and the healthcare system.

Suboptimal nonmedical qualities of primary care linked with care avoidance among people who use drugs in a Canadian setting amid an integrated health care reform

BACKGROUND

People who use unregulated drugs (PWUD) often face significant barriers to-and thereby avoid seeking-health care. In Vancouver, Canada, a neighborhood-wide health care system reform began in 2016 to improve health care delivery and quality. In the wake of this reform, we sought to determine the prevalence of health care avoidance and its association with emergency department use among PWUD in this setting and examine patient-reported nonmedical qualities of health care ("responsiveness").

METHODS

The study derived data from two prospective cohort studies of community-recruited PWUD in Vancouver in 2017-18. Responsiveness was ascertained by the World Health Organizations' standardized measurements and we evaluated seven domains of responsiveness (dignity, autonomy, communication, confidentiality, prompt attention, choice of provider, and quality of basic amenities). The study used Pearson chi-squared test to examine differences in responsiveness between those who did and did not avoid care. The study team used multivariable logistic regression to determine the relationship between care avoidance due to past mistreatment and emergency department use, adjusting for potential confounders.

RESULTS

Among 889 participants, 520 (58.5%) were male, 204 (22.9%) reported avoiding health care, most commonly for chronic pain (47.4%). Overall, 6.6% to 36.2% reported suboptimal levels (i.e., not always meeting the expected quality) across all seven measured domain of responsiveness. Proportions reporting suboptimal qualities were significantly higher among those who avoided care than those who did not across all domains, including care as soon as wanted (51.0% vs. 31.8%), listened to carefully (44.1% vs. 20.4%), and involved in health care decision-making (27.9% vs. 12.7%) (all p < 0.05). In multivariable analyses, avoidance of health care was independently associated with self-reported emergency department use (adjusted odds ratio = 1.49; 95% confidence interval:1.01-2.19).

CONCLUSION

We found that almost a quarter of our sample of PWUD avoided seeking health care due to past mistreatment, and all seven measured domains of responsiveness were suboptimal and linked with avoidance. Individuals who reported avoidance of health care were significantly more likely to report emergency department use. Multi-level interventions are needed to remedy the suboptimal qualities of health care and thereby reduce care avoidance.

Review of management priorities for invasive infections in people who inject drugs: highlighting the need for patient-centred multidisciplinary care

There has been a global increase in the burden of invasive infections in people who inject drugs (PWID). It is essential that patient-centred multidisciplinary care is provided in the management of these infections to engage PWID in care and deliver evidence-based management and preventive strategies. The multidisciplinary team should include infectious diseases, addictions medicine (inclusive of alcohol and other drug services), surgery, psychiatry, pain specialists, pharmacy, nursing staff, social work and peer support workers (where available) to help address the comorbid conditions that may have contributed to the patient's presentation. PWID have a range of antimicrobial delivery options that can be tailored in a patient-centred manner and thus are not limited to prolonged hospital admissions to receive intravenous antimicrobials for invasive infections. These options include discharge with outpatient parenteral antimicrobial therapy, long-acting lipoglycopeptides (dalbavancin and oritavancin) and early oral antimicrobials. Open and respectful discussion with PWID including around harm reduction strategies may decrease the risk of repeat presentations with injecting-related harms.

Frequency and characteristics of patient exclusion criteria in Canadian multidisciplinary pain treatment facilities: a cross-sectional study

PURPOSE

A multidisciplinary approach is recommended for patients with complex chronic pain (CP). Many multidisciplinary pain treatment facilities (MTPFs) use patient exclusion criteria but little is known about their characteristics. The objective of this study was to describe the frequency and characteristics of exclusion criteria in public Canadian MTPFs.

METHODS

We conducted a cross-sectional study in which we defined an MPTF as a clinic staffed with professionals from three disciplines or more (including at least one medical specialty) and whose services were integrated within the facility. We disseminated a web-based questionnaire in 2017-2018 to the administrative leads of MPTFs across the country. They were invited to complete the questionnaire about the characteristics of their facilities. Data were analyzed using descriptive statistics and correlation measures.

RESULTS

A total of 87 MTPFs were included in the analyses. Half of them (52%) reported using three exclusion criteria or more. There was no significant association between the number of exclusion criteria and wait time for a first appointment or number of new consultations in the past year. Fibromyalgia and migraine were the most frequently excluded pain syndromes (10% and 7% of MPTFs, respectively). More than one MPTF out of four excluded patients with mental health disorders (30%) and/or substance use disorders (29%), including MPTFs with specialists in their staff.

CONCLUSIONS

Multidisciplinary pain treatment facility exclusion criteria are most likely to affect CP patients living with complex pain issues and psychosocial vulnerabilities. Policy efforts are needed to support Canadian MPTFs in contributing to equitable access to pain management.

Experiences Using a Multidisciplinary Model for Treating Injection Drug Use Associated Infections: A Qualitative Study

Background

Over the past two decades, the United States has experienced a dramatic increase in the rate of injection drug use, injection associated infections, and overdose mortality. A hospital-based program for treating opioid use disorder in people who inject drugs presenting with invasive infections was initiated at an academic tertiary care center in 2020. The goal of this program was to improve care outcomes, enhance patient experiences, and facilitate transition from the hospital to longer term addiction care. The purpose of this study was to interview two cohorts of patients, those admitted before vs. after initiation of this program, to understand the program's impact on care from the patient's perspective and explore ways in which the program could be improved.

Methods

Thirty patients admitted to the hospital with infectious complications of injection drug use were interviewed using a semi-structured format. Interviews were transcribed and coded. Emergent themes were reported. Limited descriptive statistics were reported based on chart review.

Results

Thirty interviews were completed; 16 participants were part of the program (admitted after program implementation) while 14 were not participants (admitted prior to implementation). Common themes associated with hospitalization included inadequate pain control, access to medications for opioid use disorder (MOUD), loss of freedom, stigma from healthcare personnel, and benefits of having an interprofessional team. Participants in the program were more likely to report adequate pain control and access to MOUD and many cited benefits from receiving care from an interprofessional team.

Conclusions

Patients with opioid use disorder admitted with injection related infections reported improved experiences when receiving care from an interprofessional team focused on their addiction. However, perceived stigma from healthcare personnel and loss of freedom related to hospitalization were continued barriers to care before and after implementation of this program.

Chronic Pain and Prescription Opioid Use Among Socially Marginalized Nigerian Women: Exploring Supply Channels and Pathways to Misuse

This study explores pathways to prescription opioid misuse and supply channels based on in-depth interviews with 16 socially marginalized Nigerian women suffering chronic pain. The pathways identified were medical pain treatment, prior substance use and opioid use for recreation and coping with psychological distress. Facing barriers to prescription opioids due to prescribing restrictions and provider stigma, many resorted to unlicensed chemist stores and street drug dealers for opioid analgesics, including fake and potentially harmful products. Patterns of prescription opioid misuse were woven into multiple and overlapping dynamics of marginalization shaping the lives of these women, including homelessness, sex work, substance use and intimate partner violence. Findings show a need to improve access to prescription opioids and other evidence-based approaches, framed within a trauma-informed approach to pain management. Further, integrating substance abuse treatment and pain management could make services responsive to the inter-related problems of chronic pain and prescription opioid misuse.

Chronic Pain among Individuals Experiencing Homelessness and Its Interdependence with Opioid and Other Substance Use and Mental Illness

Chronic pain and substance use disorders are serious conditions that are prevalent among homeless populations. The aim of this study was to examine the association between chronic pain and substance use among individuals experiencing homelessness and mental illness. We analyzed cross-sectional data from two sites of the At Home/Chez Soi study (Vancouver and Toronto) using bivariate statistics and multivariate logistic regression. Substance use and chronic pain parameters were assessed with the Maudsley Addiction Profile and purpose-designed short instruments. The sample comprised 828 participants. Mean age was 42.4 years and 54% reported chronic pain. In bivariate analysis, chronic pain was significantly associated with use of opioids and stimulants, daily substance use, polysubstance use and injecting as route of administration. In multivariate analysis, only daily substance use (OR: 1.46, 95% CI: 1.02-2.09) and injecting (OR: 1.81, 95% CI: 1.08-3.05) remained as significant associated factors, whereas neither use of opioids nor use of stimulants specifically were significantly associated with chronic pain. Among participants with chronic pain, daily substance users (50% vs. 22%, p < 0.001) and injectors (66% vs. 24%, p < 0.001) were more likely to use non-prescribed medication for pain. Participants with daily substance use were less likely to receive professional treatment (52% vs. 64%, p = 0.017) and prescribed pain medication (42% vs. 54%, p = 0.023). Our findings suggest an association of chronic pain with patterns related to severity of substance use rather than to specific substance use in homeless persons with mental illness. Interventions aiming at prevention and treatment of chronic pain in this population should consider severity of substance use and associated risk behavior over use of specific substances.

Prescription opioid treatment for non-cancer pain and initiation of injection drug use: large retrospective cohort study

OBJECTIVE

To assess the association between long term prescription opioid treatment medically dispensed for non-cancer pain and the initiation of injection drug use (IDU) among individuals without a history of substance use.

DESIGN

Retrospective cohort study.

SETTING

Large administrative data source (containing information for about 1.7 million individuals tested for hepatitis C virus or HIV in British Columbia, Canada) with linkage to administrative health databases, including dispensations from community pharmacies.

PARTICIPANTS

Individuals age 11-65 years and without a history of substance use (except alcohol) at baseline.

MAIN OUTCOME MEASURES

Episodes of prescription opioid use for non-cancer pain were identified based on drugs dispensed between 2000 and 2015. Episodes were classified by the increasing length and intensity of opioid use (acute (lasting <90 episode days), episodic (lasting ≥90 episode days; with <90 days' drug supply and/or <50% episode intensity), and chronic (lasting ≥90 episode days; with ≥90 days' drug supply and ≥50% episode intensity)). People with a chronic episode were matched 1:1:1:1 on socioeconomic variables to those with episodic or acute episodes and to those who were opioid naive. IDU initiation was identified by a validated administrative algorithm with high specificity. Cox models weighted by inverse probability of treatment weights assessed the association between opioid use category (chronic, episodic, acute, opioid naive) and IDU initiation.

RESULTS

59 804 participants (14 951 people from each opioid use category) were included in the matched cohort, and followed for a median of 5.8 years. 1149 participants initiated IDU. Cumulative probability of IDU initiation at five years was highest for participants with chronic opioid use (4.0%), followed by those with episodic use (1.3%) and acute use (0.7%), and those who were opioid naive (0.4%). In the inverse probability of treatment weighted Cox model, risk of IDU initiation was 8.4 times higher for those with chronic opioid use versus those who were opioid naive (95% confidence interval 6.4 to 10.9). In a sensitivity analysis limited to individuals with a history of chronic pain, cumulative risk for those with chronic use (3.4% within five years) was lower than the primary results, but the relative risk was not (hazard ratio 9.7 (95% confidence interval 6.5 to 14.5)). IDU initiation was more frequent at higher opioid doses and younger ages.

CONCLUSIONS

The rate of IDU initiation among individuals who received chronic prescription opioid treatment for non-cancer pain was infrequent overall (3-4% within five years) but about eight times higher than among opioid naive individuals. These findings could have implications for strategies to prevent IDU initiation, but should not be used as a reason to support involuntary tapering or discontinuation of long term prescription opioid treatment.

Opioid prescribing practice standard in British Columbia, Canada: Rationale, controversies, and directions

British Columbia (BC) has been the hardest hit province in Canada's ongoing overdose epidemic. As part of the province-level response, the College of Physicians and Surgeons of British Columbia (CPSBC) implemented the "Safe Prescribing of Drugs with Potential for Misuse/Diversion" practice standard in June 2016. The practice standard established specific dose and quantity thresholds for opioid prescribing as professional and ethical conduct expectations for physicians in BC. This supply side intervention was based on expert interpretation of available evidence of non-superiority of opioid treatments to non-opioid treatments. However, the potential for misinterpretation of dosage ceiling thresholds and the negative repercussions to patients that could follow raised concerns among both physicians and patients. We provide a comprehensive overview of the rationale, early impact, controversies, and potential shortcomings of the CPSBC's practice standard.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Soft Tissue, Bone, and Joint Infections in People Who Inject Drugs

Infections are a common complication among people who inject drugs (PWID). Skin and soft tissue infections (SSTI) as well as bone and joint infections comprise a significant source of morbidity and mortality among this population. The appropriate recognition and management of these infections are critical for providers, as is familiarity with harm-reduction strategies. This review provides an overview of the presentation and management of SSTI and bone and joint infections among PWID, as well as key prevention measures that providers can take.

"People need them or else they're going to take fentanyl and die": A qualitative study examining the 'problem' of prescription opioid diversion during an overdose epidemic

The practice of prescription opioid (PO) diversion remains highly controversial and has been characterized as a source of significant drug-related harm by physicians and public health officials. We critically analyze the "problem" of diversion through an examination of the perspectives of people who divert POs during an overdose epidemic to better understand the practice, including benefits and challenges, as well as how diversion is shaped by structural contexts. Qualitative semi-structured interviews were conducted with 21 participants recruited from ongoing cohort studies involving people who use drugs in Vancouver, Canada. Prohibitive prescribing policies made accessing POs difficult, leading some to smuggle drugs out of clinics. Others would buy POs in bulk or do trades to acquire them. Participants risked having their prescriptions terminated, but rationalized this risk as a protective measure that allows them to provide safer drugs to others (e.g., to prevent overdose or treat withdrawal). Poverty also framed diversion, with some participants diverting their POs to generate income to pay for expenses including food and sometimes illicit fentanyl (perceived as a stronger alternative). However, diversion was shaped by other constraints, including criminalization, negative health impacts from not consistently consuming POs, and supplies running out, which led some participants to rely on other illegal means to generate income. This study highlights the intricate means by which POs are acquired and diverted and how environmental contexts frame how participants negotiated risk and rationalized diversion. Our study provides an alternative perspective on the "problem" of diversion and demonstrate a positive effect in providing a safer drug supply to others during an overdose crisis. Given that drug policy, criminalization, and poverty created challenges, our findings demonstrate the need for strategies that engender greater safety, reduce harm, and alleviate the effects of these constraints, including through policies promoting safer drug supplies, decriminalization, and employment.

Cohort profile: development and characteristics of a retrospective cohort of individuals dispensed prescription opioids for non-cancer pain in British Columbia, Canada

PURPOSE

Prescription opioids (POs) are widely prescribed for chronic non-cancer pain but are associated with several risks and limited long-term benefit. Large, linked data sources are needed to monitor their harmful effects. We developed and characterised a retrospective cohort of people dispensed POs.

PARTICIPANTS

We used a large linked administrative database to create the Opioid Prescribing Evaluation and Research Activities cohort of individuals dispensed POs for non-cancer pain in British Columbia (BC), Canada (1996-2015). We created definitions to categorise episodes of PO use based on a review of the literature (acute, episodic, chronic), developed an algorithm for inferring clinical indication and assessed patterns of PO use across a range of characteristics.

FINDINGS TO DATE

The current cohort includes 1.1 million individuals and 3.4 million PO episodes (estimated to capture 40%-50% of PO use in BC). The majority of episodes were acute (81%), with most prescribed for dental or surgical pain. Chronic use made up 3% of episodes but 88% of morphine equivalents (MEQ). Across the acute to episodic to chronic episode gradient, there was an increasing prevalence of higher potency POs (hydromorphone, oxycodone, fentanyl, morphine), long-acting formulations and chronic pain related indications (eg, back, neck, joint pain). Average daily dose (MEQ) was similar for acute/episodic but higher for chronic episodes. Approximately 7% of the cohort had a chronic episode and chronic pain was the characteristic most strongly associated with chronic PO use. Individuals initiating a chronic episode were also more likely to have higher social/material deprivation and previous experience with a mental health condition or a problem related to alcohol or opioid use. Overall, these findings suggest our episode definitions have face validity and also provide insight into characteristics of people initiating chronic PO therapy.

FUTURE PLANS

The cohort will be refreshed every 2 years. Future analyses will explore the association between POs and adverse outcomes.

Factors associated with health-related cannabis use intentions among a community sample of people who inject drugs in Los Angeles and San Francisco, CA 2016 to 2018

OBJECTIVE

Cannabis motivations have been studied extensively among patients of medicinal cannabis dispensaries, but less is known about motivations in community samples of opioid-using people who inject drugs. Our objective is to describe cannabis use motivations associated with self-treatment of physical pain, emotional issues, and as an opioid substitute.

METHODS

Data come from 6-month follow-up interviews with people who inject drugs who participated in a study on the efficacy of an injection initiation prevention intervention in Los Angeles and San Francisco, California from 2016-18. The analytic sample consists of 387 people who inject drugs who reported past-month cannabis use. We developed multivariable logistic regression models by reported cannabis use motivations: physical pain relief, emotional problems, and opioid substitute.

RESULTS

The most common cannabis use motivations reported by people who inject drugs was to "get high," relieve physical pain and emotional problems, and reduce opioid use. In separate multivariate models, using cannabis for physical pain relief was associated with higher odds of using cannabis as a substitute for opioids; cannabis for emotional problems was associated with being diagnosed with depression; and cannabis as a substitute for opioids was associated with non-prescribed, non-injection methadone use.

CONCLUSION

People who inject drugs reported using cannabis for health-related motivations. This motivation aligns with health needs and suggests the acceptability of cannabis use for health reasons in this population. Studies to determine the medical effectiveness of cannabis products for these common health and mental health needs among people who inject drugs are needed.

Pain and Barriers to Accessing Health Services Among People Who Use Drugs

BACKGROUND

The opioid overdose crisis underscores the need for health services among people who use drugs (PWUD) with concurrent pain.

AIMS

Investigating the effect of pain on barriers to accessing health services among PWUD.

DESIGN

Prospective cohort study.

SETTINGS

A setting of universal access to no-cost medical care in Vancouver, Canada from June 2014 to May 2016.

PARTICIPANTS/SUBJECTS

PWUD who completed at least one study interview.

METHODS

Data derived from interviewer-administered questionnaires were used for multivariable generalized linear mixed-effects multiple regression (GLMM) analyses.

RESULTS

Among 1,348 PWUD, 469 (34.8%) reported barriers to accessing health services at least once during the study period. The median average pain severity was 3 (IQR: 0-6) out of 10. A dose-response relationship was observed between greater pain and increased odds of reporting barriers to accessing health services (adjusted odds ratio [AOR]: 1.59, 95% confidence interval [CI]: 1.15-2.21, p = .005 for mild versus no pain; AOR: 1.76, 95% CI: 1.30-2.37, p < .001 for moderate versus no pain; AOR: 2.55, 95% CI: 1.92-3.37, p < .001 for severe versus no pain). Common barriers included poor treatment by health professionals, socio-structural barriers such as transportation or mobility, and long wait lists or wait times.

CONCLUSIONS

Pain may be a significant risk factor associated with increased barriers to accessing health services among PWUD. Attention to pain management may improve access to health services, and reducing barriers to health services may conversely improve pain management and its related risks and harms.

High prevalence of unmet healthcare need among people who use illicit drugs in a Canadian setting with publicly-funded interdisciplinary primary care clinics

BACKGROUND

People who use illicit drugs (PWUD) experience significant barriers to healthcare. However, little is known about levels of attachment to primary care (defined as having a regular family doctor or clinic they feel comfortable with) and its association with unmet healthcare needs in this population. In a Canadian setting that features novel publicly-funded interdisciplinary primary care clinics, we sought to examine the prevalence and correlates (including attachment to primary care) of unmet healthcare needs among PWUD. Methods: Data were derived from two prospective cohort studies of PWUD in Vancouver, Canada between December 2017 and November 2018. Multivariable logistic regression was used to identify factors associated with self-reported unmet healthcare needs among participants reporting any health issues. Results: In total, 743 (83.6%) of 889 eligible participants reported attachment to primary care and 220 (24.7%) reported an unmet healthcare need. In multivariable analyses, attachment to primary care at an integrated care clinic (adjusted odds ratio [AOR] = 0.14; 95% Confidence Interval [CI]: 0.06-0.34) was negatively associated with an unmet healthcare need, while being treated poorly at a healthcare facility (AOR = 5.50; 95% CI: 3.59-8.60) and self-reported chronic pain (AOR = 2.00, 95% CI: 1.30-3.01) were positively associated with an unmet healthcare need. Conclusion: Despite the high level of attachment to primary care, a quarter of our sample reported an unmet healthcare need. Our findings suggest that multi-level interventions are required to address the unmet need, including pain management and integrated care, to support PWUD with complex health needs.

Evaluating the intended and unintended consequences of opioid-prescribing interventions on primary care in British Columbia, Canada: protocol for a retrospective population-based cohort study

INTRODUCTION

Between 2015 and 2018, there were over 40 000 opioid-related overdose events and 4551 deaths among residents in British Columbia (BC). During this time the province mobilised a variety of policy levers to encourage physicians to expand access to opioid agonist treatment and the College of Physicians and Surgeons of British Columbia (CPSBC) released a practice standard establishing legally enforceable minimum thresholds of professional behaviour in the hopes of curtailing overdose events. Our goal is to conduct a comprehensive investigation of the intended and unintended consequences of these policy changes. Specifically, we aim to understand the effects of these measures on physician prescribing behaviours, identify physician characteristics associated with uptake of the new measures, and measure the effects of the policy changes on patients' access to quality primary care.

METHODS AND ANALYSIS

This is a population-level, retrospective cohort study of all BC primary care physicians who prescribed any opioid medication for opioid-use disorder or chronic non-cancer pain during the study period, and their patients. The study period is 1 January 2013-31 December 2018, with a 1-year wash-in period (1 January 2012-31 December 2012) to exclude patients who initiated long-term opioid treatment prior to our study period or whose pain type (ie, 'chronic non-cancer', 'acute', 'cancer or palliative', or 'other') cannot be confirmed. The project combines five administrative health datasets under the authority of the BC Ministry of Health, with the CPSBC's Physician Registry, BC Cancer Agency's Cancer Registry and Vital Statistics' Mortality data. We will create measures of prescribing concordance, access, continuity, and comprehensiveness to assess primary care delivery and quality at both the physician and patient level. We will use generalised estimating equations, interrupted time series, mixed effects models, and funnel plots to identify factors related to changes in prescribing and evaluate the impact of the changes to prescribing policies. Results will be reported using appropriate Enhancing the QUAlity and Transparency Of health Research guidelines (eg, STrengthening the Reporting of OBservational studies in Epidemiology).

ETHICS AND DISSEMINATION

This study has been approved by McGill University's Institutional Review Board (#A11-M55-19A), and the University of British Columbia's Research Ethics Board (#H19-03537). We will disseminate results via a combination of open access peer-reviewed journal publications, conferences, lay summaries and OpEds.

Prevalence, Characteristics, and Management of Chronic Noncancer Pain Among People Who Use Drugs: A Cross-Sectional Study

INTRODUCTION

Most studies on chronic noncancer pain (CNCP) in people who use drugs (PWUD) are restricted to people attending substance use disorder treatment programs. This study assessed the prevalence of CNCP in a community-based sample of PWUD, identified factors associated with pain, and documented strategies used for pain relief.

METHODS

This was a cross-sectional study nested in an ongoing cohort of PWUD in Montreal, Canada. Questionnaires were administered to PWUD seen between February 2017 and January 2018. CNCP was defined as pain lasting three or more months and not associated with cancer.

RESULTS

A total of 417 PWUD were included (mean age = 44.6 ± 10.6 years, 84% men). The prevalence of CNCP was 44.8%, and the median pain duration (interquartile range) was 12 (5-18) years. The presence of CNCP was associated with older age (>45 years old; odds ratio [OR] = 1.8, 95% CI = 1.2-2.7), male sex (OR = 2.3, 95% CI = 1.2-4.2), poor health condition (OR = 1.9, 95% CI = 1.3-3.0), moderate to severe psychological distress (OR = 2.9, 95% CI = 1.8-4.7), and less frequent cocaine use (OR = 0.5, 95% CI = 0.3-0.9). Among CNCP participants, 20.3% used pain medication from other people, whereas 22.5% used alcohol, cannabis, or illicit drugs to relieve pain. Among those who asked for pain medication (N = 24), 29.2% faced a refusal from the doctor.

CONCLUSIONS

CNCP was common among PWUD, and a good proportion of them used substances other than prescribed pain medication to relieve pain. Close collaboration of pain and addiction specialists as well as better pain assessment and access to nonpharmacological treatments could improve pain management in PWUD.

Frequent Cannabis Use Is Negatively Associated with Frequency of Injection Drug Use Among People Who Inject Drugs in a Canadian Setting

Objectives: High levels of morbidity and mortality associated with injection drug use continue to represent a significant public health challenge in many settings worldwide. Previous studies have shown an association between cannabis use and decreased risk of some drug-related harms. We sought to evaluate the association between high-intensity cannabis use and the frequency of injection drug use among people who inject drugs (PWID). Methods: The data for this analysis were collected from three prospective cohorts of PWID in Vancouver, Canada, between September 2005 and May 2018. Generalized linear mixed-effects models were used to analyze the association between daily cannabis use and the frequency of injecting illegal drugs (i.e., self-reported average number of injections per month). Results: Among the 2,619 active PWID, the frequency of injection drug use was significantly lower among people who use cannabis daily compared with people who use it less than daily (adjusted odds ratio [AOR]=0.84, 95% confidence interval [CI]: 0.73-0.95). Sub-analyses indicated that this effect was restricted to the frequency of illegal opioid injection (AOR=0.78, 95% CI: 0.68-0.90); the association between daily cannabis use and the frequency of illegal stimulant injection was not significant (AOR=1.08, 95% CI 0.93-1.25). Discussion: The findings from these prospective cohorts suggest that people who use cannabis daily were less likely to report daily injection of illegal drugs compared with people who use it less than daily. These results suggest the potential value of conducting experimental research to test whether controlled administration of cannabinoids impacts the frequency of illegal opioid injection among PWID.

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.

Characterizing motivations for cannabis use in a cohort of people who use illicit drugs: A latent class analysis

Background

Cannabis use is common among marginalized people who use illicit drugs (PWUD) but reasons for use remain poorly investigated. We sought to explore how different intentions for cannabis use relate to social, structural, and behavioural factors among PWUD in Vancouver, Canada.

Methods

We used data from cannabis-using participants in two community-recruited prospective cohort studies of PWUD. Using latent class analysis, we identified discrete cannabis-using groups based on self-reported intentions for use. Generalized estimating equations were used to examine correlates of class membership.

Results

Between June 2016 and December 2018, 2,686 observations from 897 participants cannabis-using PWUD were analyzed. Four latent classes of cannabis use emerged: Class 1 (31.6%), characterized by non-medical purposes; Class 2 (37.5%), characterized by non-pain therapeutic use (e.g., stress, nausea/loss of appetite, and insomnia); characterized by Class 3 (21.9%) predominantly pain relief; and Class 4 (9.0%), characterized by a wide range of therapeutic uses in addition to pain management, including insomnia, stress, nausea/loss of appetite, and harm reduction. Class-specific structural, substance-, and health-related differences were observed, including indicators of better physical and mental health among the “recreational” class, despite evidence of more structural vulnerabilities (e.g., homelessness, incarceration).

Conclusions

Our findings demonstrate a wide spectrum of motivations for cannabis use among PWUD. We observed important health-related differences between latent classes, demonstrating possible unmet healthcare needs among PWUD reporting therapeutic cannabis use. These findings inform ongoing policy surrounding access to cannabis for harm reduction purposes and applications of medical cannabis for PWUD.

Factors associated with chronic pain and non-medical opioid use among people who inject drugs

INTRODUCTION

Despite rising morbidity and mortality from the opioid epidemic and other addictions, people who inject drugs (PWID) remain understudied regarding pain outcomes. Data among PWID regarding chronic pain and drug use, including non-medical use of opioids, is largely unknown. We examined the prevalence of chronic pain and drug use for pain in this population.

METHODS

Standardized surveys captured self-report of demographics, chronic pain, and non-prescription drug use in 203 PWID in an urban syringe services program between April and November 2016. Chronic pain was defined as self-report of chronic pain diagnosis or persistent pains over the past 6 months.

RESULTS

Overall, 47% (95% CI, 40%-54%) of PWID reported chronic pain, while 35% (95% CI, 29%-42%) reported non-prescription drug use of any type for pain. Among those with chronic pain, drug use to treat pain was commonly reported (76%; 95% CI, 66%-83%). Non-medical opioid use did not differ among PWID with or without chronic pain or drug use for pain. A multivariable logistic regression model showed chronic pain was more likely among non-Hispanic whites and those with arthritis, older age, and homelessness.

CONCLUSIONS

Chronic pain serves as an important factor in the persistence of drug use in more than one-third of PWID in this sample. The high prevalence of chronic pain with drug use for pain suggests that proper pain management is likely to be an essential component of preventing or regressing injection drug use in PWID, with data needed on effective interventions for this population.

Frequency of cannabis and illicit opioid use among people who use drugs and report chronic pain: A longitudinal analysis

BACKGROUND

Ecological research suggests that increased access to cannabis may facilitate reductions in opioid use and harms, and medical cannabis patients describe the substitution of opioids with cannabis for pain management. However, there is a lack of research using individual-level data to explore this question. We aimed to investigate the longitudinal association between frequency of cannabis use and illicit opioid use among people who use drugs (PWUD) experiencing chronic pain.

METHODS AND FINDINGS

This study included data from people in 2 prospective cohorts of PWUD in Vancouver, Canada, who reported major or persistent pain from June 1, 2014, to December 1, 2017 (n = 1,152). We used descriptive statistics to examine reasons for cannabis use and a multivariable generalized linear mixed-effects model to estimate the relationship between daily (once or more per day) cannabis use and daily illicit opioid use. There were 424 (36.8%) women in the study, and the median age at baseline was 49.3 years (IQR 42.3-54.9). In total, 455 (40%) reported daily illicit opioid use, and 410 (36%) reported daily cannabis use during at least one 6-month follow-up period. The most commonly reported therapeutic reasons for cannabis use were pain (36%), sleep (35%), stress (31%), and nausea (30%). After adjusting for demographic characteristics, substance use, and health-related factors, daily cannabis use was associated with significantly lower odds of daily illicit opioid use (adjusted odds ratio 0.50, 95% CI 0.34-0.74, p < 0.001). Limitations of the study included self-reported measures of substance use and chronic pain, and a lack of data for cannabis preparations, dosages, and modes of administration.

CONCLUSIONS

We observed an independent negative association between frequent cannabis use and frequent illicit opioid use among PWUD with chronic pain. These findings provide longitudinal observational evidence that cannabis may serve as an adjunct to or substitute for illicit opioid use among PWUD with chronic pain.

Postoperative opioid misuse in patients with opioid use disorders maintained on opioid agonist treatment

BACKGROUND

Patients recovering from opioid use disorders (OUD) may be prone to relapse and opioid misuse in the postoperative period due to re-exposure to prescription opioids for pain control. This retrospective study analyzed the incidence of confirmed opioid misuse in the postoperative period in patients with OUDs enrolled in an opioid agonist treatment (OAT) program.

METHODS

The study population was US veterans with a diagnosis of OUD who enrolled in the OAT program at VA Maryland Health Care System (Baltimore, Maryland, USA) between 1/1/2000 and 12/31/2016. The patients were excluded if they were enrolled in OAT for less than a year, or if they had surgery within the first 180 days after OAT admission. The surgical group consisted of veterans who had surgery or an invasive procedure during their enrollment in the OAT program. The control (reference) group consisted of enrolled veterans who did not have any invasive procedure. The primary outcome was the first opioid misuse within 365 days after surgery date in the surgical group or a randomly assigned sham surgery date in controls. Opioid misuse was defined as either inappropriate use of opioids detected via urinalysis or admission with a diagnosis of an opioid overdose.

RESULTS

From a total of 1352 patients enrolled in the OAT program, 413 were excluded because they were enrolled for less than a year, and 26 were excluded because they had surgery within the first 180 days after admission to the OAT program. Of the 923 eligible patients, 87 had surgery while enrolled and 836 did not. Using propensity scores, all 87 of the surgical cases were matched to 249 of the control cases. In the matched groups, surgery was positively associated with postoperative opioid misuse (odds ratio (OR) of 1.91, 95% CI 1.05-3.48, p = 0.034) in logistic regression.

CONCLUSION

Among patients with a history of opioid use disorders, the postoperative period was associated with an increased risk of opioid misuse. Moreover, opioid misuse among patients in an opioid agonist treatment program may well be considered a surgical hazard.

Chronic pain management among people who use drugs: A health policy challenge in the context of the opioid crisis

BACKGROUND

In Canada, the rise in prescription opioid (PO) overdoses and addiction is a major public health concern. Various health authorities have recently recommended that physicians use caution when prescribing opioids, especially to people with histories of substance use. As a result, fewer therapeutic options are available for people who use drugs (PWUD) and suffer from chronic non-cancer pain (CNCP). This paper examines how PWUD describe their experiences with CNCP management in the context of the opioid crisis.

METHODS

This qualitative study is based on in-depth interviews with Montreal (Canada) PWUD experiencing CNCP for 3 months or more.

RESULTS

Most of the 25 participants (27-61 years; 10 women, 15 men) were polysubstance users (cocaine, opioids, amphetamine, etc.) suffering from CNCP for several years, with multiple additional health and social problems. The majority were unsatisfied with their CNCP management. They felt labelled as "addicts" and stigmatized within the healthcare system. Many participants had been denied PO, even those with severe CNCP and those who were not opioid-dependent. Participants expressed a desire to access non-pharmacological CNCP therapies, but these were often too expensive. Some PWUD were offered methadone to relieve CNCP and found this inappropriate. As a last resort several participants reported self-medicating CNCP with street drugs, increasingly known to be laced with fentanyl.

CONCLUSION

PWUD with CNCP are affected by two opioid crises: the PO crisis and the street-opioid crisis. The lack of a coherent policy that addresses their pain management produces reoccurring problems when seeking CNCP relief. Restrictive prescription measures implemented in response to the PO crisis may have consequences similar to prohibitionist policies: they heighten overdose risks for PWUD by increasing exposure to street drugs laced with fentanyl. Improving access to diverse CNCP management options for PWUD can help reduce harms related to street-opioid use.

Correlates of opioid and benzodiazepine co-prescription among people living with HIV in British Columbia, Canada: A population-level cohort study

BACKGROUND

Co-prescribing benzodiazepines and opioids is relatively contraindicated due to the possible overdose risk. However, people living with HIV (PLWH) may have concurrent psychiatric and/or chronic pain diagnoses that may lead to the use of opioids and/or benzodiazepines for symptomatic treatment. Consequently, some PLWH may be at-risk for the health harms associated with the co-prescribing of these medications. Given this, the objectives of this study were to first examine the prevalence of opioids and benzodiazepines co-prescribing, and second, to characterize patient factors associated with the co-prescribing of opioids and benzodiazepines among PLWH in British Columbia (BC), Canada.

METHODS

Using data derived from a longitudinal BC cohort, we used bivariable and multivariable generalized estimating equation models to establish the prevalence of a benzodiazepine and opioid co-prescription and determine factors associated with this practice.

RESULTS

Between 1996 and 2015, 14 484 PLWH were included in the study and were followed for the entire study period. At baseline, 548 people (4%) were co-prescribed opioids and benzodiazepines, 6593 (46%) were prescribed opioids only, 2887 (20%) were prescribed benzodiazepines only, and 4456 (31%) were prescribed neither medication. A total of 3835 (27%) participants were prescribed both medications at least once during the study period. Factors positively associated with concurrent opioid and benzodiazepine prescribing included: depression/mood disorder [adjusted odds ratio (AOR) = 1.32; 95% confidence interval (CI) = 1.22-1.43] and anxiety disorder (AOR = 1.45; 95% CI = 1.27-1.66), whereas female sex (AOR = 0.76; 95% CI = 0.64-0.91) and substance use disorder (SUD) (AOR = 0.82; 95% CI = 0.74-0.90) were negatively associated with the outcome.

CONCLUSION

Our findings indicate that co-prescription of opioids and benzodiazepines was seen at some point during study follow-up in over a quarter of PLWH. Given the known risks associated with this prescribing practice, future research can focus on the outcomes of co-prescribing among this patient population and the development of strategies to reduce the co-prescribing of opioids and benzodiazepines.

An age-based analysis of nonmedical prescription opioid use among people who use illegal drugs in Vancouver, Canada

BACKGROUND

Nonmedical prescription opioid use (NMPOU) is a serious public health problem in North America. At a population-level, previous research has identified differences in the prevalence and correlates of NMPOU among younger versus older age groups; however, less is known about age-related differences in NMPOU among people who use illegal drugs.

METHODS

Data were collected between 2013 and 2015 from two linked prospective cohort studies in Vancouver, Canada: the At-Risk Youth Study (ARYS) and the Vancouver Injection Drug Users Study (VIDUS). Factors independently associated with NMPOU among younger (ARYS) and older (VIDUS) participants were examined separately using bivariate and multivariate generalized estimating equations.

RESULTS

A total of 1162 participants were included. Among 405 eligible younger participants (Median age = 25; Inter-Quartile Range [IQR]: 22-28), 40% (n = 160) reported engaging in NMPOU at baseline; among 757 older participants (Median age = 48, IQR: 40-55), 35% (n = 262) reported engaging in NMPOU at baseline. In separate multivariate analyses of younger and older participants, NMPOU was positively and independently associated with heroin use (younger: Adjusted Odds Ratio [AOR] = 3.12, 95% Confidence Interval [CI]: 2.08-4.68; older: AOR = 2.79, 95% CI: 2.08-3.74), drug dealing (younger: AOR = 2.22, 95% CI: 1.58-3.13; older: AOR = 1.87, 95% CI: 1.40-2.49), and difficulty accessing services (younger: AOR = 1.47, 95% CI: 1.04-2.09; older: AOR = 1.74, 95% CI: 1.32-2.29). Among the youth cohort only, NMPOU was associated with younger age (AOR = 1.12, 95% CI: 1.05-1.19), crack use (AOR = 1.56, 95% CI: 1.06-2.30), and binge drug use (AOR = 1.41, 95% CI: 1.00-1.97); older participants who engaged in NMPOU were more likely to report crystal methamphetamine use (AOR = 1.97, 95% CI: 1.46-2.66), non-fatal overdose (AOR = 1.76, 95% CI: 1.20-2.60) and sex work (AOR = 1.49, 95% CI: 1.00-2.22).

DISCUSSION

The prevalence of NMPOU is similar among younger and older people who use drugs, and independently associated with markers of vulnerability among both age groups. Adults who engage in NMPOU are at risk for non-fatal overdose, which highlights the need for youth and adult-specific strategies to address NMPOU that include better access to health and social services, as well as a range of addiction treatment options for opioid use. Findings also underscore the importance of improving pain treatment strategies tailored for PWUD.

Pain as a risk factor for substance use: a qualitative study of people who use drugs in British Columbia, Canada

Background

People who use drugs have a significantly higher prevalence of chronic non-cancer pain compared to the general population, yet little is known about how various policy, economic, physical, and social environments may serve as risk or protective factors in the context of concurrent pain and substance use. Therefore, this study sought to explore perspectives, risks, and harms associated with pain among people who use drugs.

Methods

Thirteen focus group interviews were held across British Columbia, Canada, from July to September 2015. In total, 83 people who had lived experience with substance use participated in the study. Using an interpretive description approach, themes were conceptualized according to the Rhodes’ Risk Environment and patient-centered care frameworks.

Results

Participants described how their experiences with inadequately managed pain in various policy, economic, physical, and social environments reinforced marginalization, such as restrictive policies, economic vulnerability, lack of access to socio-physical support systems, stigma from health professionals, and denial of pain medication leading to risky self-medication. Principles of patient-centered care were often not upheld, from a lack of recognition of patients as experts in understanding their unique pain needs and experiences, to an absence of shared power and decision-making, which often resulted in distrust of the patient-provider relationship.

Conclusions

Various risk environments and non-patient-centered interactions may contribute to an array of health and social harms in the context of inadequately managed pain among people who use drugs.

Willingness to use an in-hospital supervised inhalation room among people who smoke crack cocaine in Vancouver, Canada

INTRODUCTION AND AIMS

People who use illicit drugs (PWUD) often engage in drug use during hospitalisation. Adverse outcomes may arise from efforts to conceal inpatient drug use, especially in hospital settings that rely on abstinence-based policies. Harm reduction interventions, including supervised drug consumption services, have not been well studied in hospital settings. This study examines factors associated with willingness to use an in-hospital supervised inhalation room (SIR) among people who smoke crack cocaine in Vancouver, Canada.

DESIGN AND METHODS

Cross-sectional data from two open prospective cohorts of PWUD involving people who smoke crack cocaine were collected between June 2013 and May 2014. Multivariable logistic regression analyses were used to identify factors associated with willingness to use an in-hospital SIR.

RESULTS

Among 539 participants, 320 (59.4%) reported willingness to use an in-hospital SIR. Independent factors positively associated with willingness included: ever used drugs in hospital [adjusted odds ratio (AOR) = 1.89], and daily non-injection crack use (AOR = 1.63). Difficulty accessing new crack pipes (AOR = 0.51) was negatively associated with willingness (all P < 0.05). The most commonly reported reasons for willingness were to: remain in hospital (50.6%), reduce drug-related risks (25.6%) and reduce the stress of hospital discharge for using drugs (24.7%).

DISCUSSION AND CONCLUSIONS

A high proportion of people who smoke crack cocaine reported willingness to use an in-hospital SIR, and those willing were more likely to report heavy drug use and previous in-hospital use. These findings highlight the potential utility of SIRs to complement existing in-hospital services for PWUD.

Dose-response relationship between functional pain interference and nonmedical analgesic use: Findings from a nationally representative Canadian survey

Background

Despite the epidemic of nonmedical analgesic use (NMAU) in North America, there is a scarcity of research quantifying the effect of pain on NMAU.

Aims

This study sought to investigate the relationship between NMAU and functional pain interference, defined as the perceived level of interference in performing activities of daily living due to pain, in a population-based sample of the general Canadian population.

Methods

Data from the 2012 Canadian Community Health Survey (CCHS)–Mental Health, a nationally representative cross-sectional survey, were used to conduct bivariable and multivariable logistic regression analyses.

Results

The weighted prevalences of pain and NMAU were 20.6% and 6.6%, respectively. After adjusting for age, sex, education, culture/race, and chronic mental health diagnosis, a dose–response relationship was observed between higher functional pain interference and increased odds of NMAU, ranging from 1.61 (95% confidence interval [CI], 1.22–2.12) to 2.98 (95% CI, 2.21–4.01) from the lowest to the highest levels of functional pain interference. Elevated odds of NMAU were also observed among younger respondents aged 20–29 years and 15–19 years, respondents with a chronic mental illness diagnosis, and males. Secondary analyses revealed that the dose–response relationship between greater function pain interference and increased odds of NMAU persisted within subgroups with and without mental illness, as well as within subgroups aged 40 to 69.

Conclusions

These findings highlight the potential role of pain on increasing NMAU and the need for targeted strategies to reduce harms of NMAU among high-risk subgroups such as young adults.

Pain-related anxiety and opioid misuse in a racially/ethnically diverse young adult sample with moderate/severe pain

Pain problems are of significant public health concern, and with opioid-related problems and death due to overdose at an all-time high, there is significant public health importance to identify risk factors that link instances of pain to opioid misuse among persons with pain whether or not they have been prescribed opioids for pain management. Severe pain and pain-related problems have been associated with increased risk for opioid misuse, and recent research indicates that pain-related anxiety (worry about the negative consequences of pain) may contribute to a more debilitating pain experience. Additionally, pain-related anxiety has previously been linked to substance use motives and dependence for cannabis and tobacco. However, little research has examined pain-related anxiety as a transdiagnostic risk factor for opioid misuse. The current study examined the relationship between pain-related anxiety and self-reported opioid misuse (addiction, prescription denial, family concerns, detox) in a racially/ethnically diverse sample of young adults (N = 256, M _age = 22.84) reporting moderate to severe bodily pain over the previous four weeks. Results indicated that pain-related anxiety was significantly related to several indicators of opioid misuse as well as an increased number of opioid-related problems. Findings from the current study suggest that targeting pain-related anxiety may be one therapeutic strategy to reduce opioid misuse.

Increasing availability of illicit and prescription opioids among people who inject drugs in a Canadian setting, 2010-2014

BACKGROUND

Nonmedical use of prescription opioid and illicit opioid has been increasing at an alarming rate in North America over the past decade.

OBJECTIVE

We sought to examine the temporal trends and correlates of the availability of illicit and prescription opioids among people who inject drugs (PWID) in Vancouver, Canada.

METHODS

Data were derived from three prospective cohort studies of PWID in Vancouver between 2010 and 2014. In semiannual interviews, participants reported the availability of five sets of illicit and prescription opioids: (1) heroin; (2) Percocet (oxycodone/acetaminophen), Vicodin (hydrocodone/acetaminophen), or Demerol (meperidine); (3) Dilaudid (hydromorphone); (4) Morphine; (5) oxycontin/OxyNEO (controlled-release oxycodone). We defined perceived availability as immediate (e.g., available within 10 minutes) versus no availability/available after 10 minutes. The trend and correlation of immediate availability were identified by multivariable generalized estimating equations logistic regression.

RESULTS

Among 1584 participants, of which 564 (35.6%) were female, the immediate availability of all illicit and prescribed opioids (except for oxycontin/OxyNEO) increased over time, independent of potential confounders. The Adjusted Odds Ratios of immediate availability associated with every calendar year increase were between 1.09 (95% confidence interval 1.05-1.12) (morphine and Dilaudid) and 1.13 (95% confidence interval 1.09-1.17) (Percocet/Vicodin/Demerol) (all p-values <0.05).

CONCLUSION

The availability of most prescription opioids had continued to increase in recent years among our sample of PWID in Vancouver. Concurrent increases in the availability of heroin were also observed, raising concerns regarding combination of both illicit and prescription opioid use among PWID that could potentially increase the risk of overdose.

Associations Between Physical Pain, Pain Management, and Frequency of Nonmedical Prescription Opioid Use Among Young Adults: A Sex-specific Analysis

OBJECTIVES

We sought to determine sex-specific associations between experiences of physical pain, pain management, and frequency of nonmedical prescription opioid (NMPO) use among young adults.

METHODS

Among participants enrolled in the Rhode Island Young Adult Prescription Drug Study, we identified associations between physical pain in the past 6 months, pain history, pain management, polysubstance use, and weekly NMPO use. In sex-specific models, independent correlates of weekly NMPO use were identified via modified stepwise Poisson regression.

RESULTS

Of 199 participants, the mean age was 24.6, and 65.3% were male. The racial composition was 16.6% black, 60.8% white, and 22.1% mixed or other race. A total of 119 (59.8%) participants reported weekly or greater NMPO use. The majority of male (86.2%) and female (84.1%) participants reported ever experiencing severe pain. A majority of males (72.3%) and females (81.2%) reported that they engaged in NMPO use to treat their physical pain, and one-quarter (26.9%) of males and one-third (36.2%) of females had been denied a prescription from a doctor to treat severe pain. Among males, frequent NMPO use was independently associated with white race (P < 0.001) and reporting greater physical pain (P = 0.002). Among females, older age (P = 0.002) and monthly or greater nonmedical benzodiazepine use (P = 0.001) were independently associated with weekly NMPO use.

CONCLUSIONS

Among young men in Rhode Island, physical pain may be related to frequent NMPO use. More research is needed to identify sex-specific, pain-related factors that are linked with NMPO use to improve harm reduction and pain management interventions.

Physical pain is common and associated with nonmedical prescription opioid use among people who inject drugs

Background

People who inject drugs (PWID) often have poor health and lack access to health care. The aim of this study was to examine whether PWID engage in self-treatment through nonmedical prescription opioid use (NMPOU). We describe the prevalence and features of self-reported physical pain and its association with NMPOU.

Methods

PWID (N = 702) in San Francisco, California (age 18+) were recruited to complete interviewer administered surveys between 2011 and 2013. Multivariate logistic regression analysis was conducted to examine the associations among self-reported pain dimensions (past 24-h average pain, pain interference with functional domains) and NMPOU, controlling for age, sex, psychiatric illness, opioid substitution treatment, homelessness, street heroin use and unmet healthcare needs.

Results

Almost half of the sample reported pain, based on self-reported measures in the 24 h before their interview. The most common pain locations were to their back and lower extremities. Past 24-h NMPOU was common (14.7%) and associated with past 24 h average pain intensity on a 10 point self-rating scale (adjusted odds ratio [AOR] = 2.15, 95% confidence interval [CI] 1.21–3.80), and past 24 h pain interference with general activity (AOR 1.82 [95% CI 1.04–3.21]), walking ability (AOR 2.52 [95% CI 1.37–4.63]), physical ability (AOR 2.01 [95% CI 1.16–3.45]), sleep (AOR 1.98 [95% CI 1.13–3.48]) and enjoyment of life (AOR 1.79 [95% CI 1.02–3.15]).

Conclusion

Both pain and NMPOU are common among PWID, and highly correlated in this study. These findings suggest that greater efforts are needed to direct preventive health and services toward this population.

Pain in methadone patients: Time to address undertreatment and suicide risk (ANRS-Methaville trial)

Background

Pain in opioid-dependent patients is common but data measuring the course of pain (and its correlates) using validated scales in patients initiating methadone treatment are sparse. We aimed to assess pain and its interference in daily life, associated correlates, and undertreatment before and during methadone treatment.

Methods

This is a secondary analysis using longitudinal data of a randomized trial comparing two methadone initiation models. We assessed the effect of methadone initiation and other correlates on pain intensity and interference (using the Brief Pain Inventory) at months 0, 6 and 12 using a mixed multinomial logistic regression model.

Results

The study group comprised 168 patients who had data for either pain intensity or interference for at least one visit. Moderate to severe pain was reported in 12.9% of patients at M0, 5.4% at M6 and 7.3% at M12. Substantial interference with daily functioning was reported in 36.0% at M0, 14.5% at M6 and 17.1% at M12. Of the 98 visits where patients reported moderate to severe pain or substantial interference, 55.1% reported no treatment for pain relief, non-opioid analgesics were reported by 34.7%, opioid analgesics by 3.1% and both opioid and non-opioid analgesics by 7.1%. Methadone was associated with decreased pain intensity at 6 months (OR = 0.29, p = 0.04) and 12 months (OR = 0.30, p = 0.05) of follow-up and tended to be associated with substantial pain interference. Suicide risk was associated with both pain intensity and pain interference.

Conclusions

Methadone in opioid-dependent patients can reduce pain. However, undertreatment of pain in methadone patients remains a major clinical concern. Patients with pain are at higher risk of suicide. Adequate screening and management of pain in this population is a priority and needs to be integrated into routine comprehensive care.

Initiation into prescription opioid injection and associated trends in heroin use among people who use illicit drugs

OBJECTIVES

Prescription opioid (PO) injection among people who use illicit drugs (PWUD) is an ongoing concern, yet little is known about drug use trajectories associated with initiating PO injection, including potential associations with heroin use. This study aimed to identify predictors of PO injection initiation among PWUD, and examine trends in heroin use before and after initiating PO injection.

METHODS

Data were merged from three cohorts of PWUD recruited between September 2005 and November 2015. Predictors of PO injection initiation were identified using extended Cox regression models. Trends in heroin use pre- and post-initiation were examined with McNemar's test and compared to matched controls with linear growth curve models.

RESULTS

Among 1580 participants, 247 initiated PO injection yielding an incidence density of 3.9 (95% Confidence Interval [CI]: 3.4-4.4) per 100 person-years. In a multivariable analysis, independent predictors of PO injection initiation included heroin injection (Adjusted Hazard Ratio [AHR]=4.39, 95% CI: 3.24-5.95) and non-injection PO use (AHR=1.99, 95% CI: 1.25-3.17). In a sub-analysis, compared to matched controls, PO injection corresponded with elevated heroin use post-initiation (p≤0.05).

DISCUSSION

In this study, heroin use and non-injection PO use strongly predicted PO injection initiation. Those who initiated PO injecting had elevated heroin use patterns post-initiation compared to controls. These findings suggest that transitioning to PO injection does not appear to be a substitute for heroin use among PWUD. These findings highlight the importance of addressing PO injection in harm reduction and treatment settings.

Non-medical use of prescription opioids is associated with heroin initiation among US veterans: a prospective cohort study

AIMS

To estimate the influence of non-medical use of prescription opioids (NMUPO) on heroin initiation among US veterans receiving medical care.

DESIGN

Using a multivariable Cox regression model, we analyzed data from a prospective, multi-site, observational study of HIV-infected and an age/race/site-matched control group of HIV-uninfected veterans in care in the United States. Approximately annual behavioral assessments were conducted and contained self-reported measures of NMUPO and heroin use.

SETTING

Veterans Health Administration (VHA) infectious disease and primary care clinics in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh and Washington, DC.

PARTICIPANTS

A total of 3396 HIV-infected and uninfected patients enrolled into the Veterans Aging Cohort Study who reported no life-time NMUPO or heroin use, had no opioid use disorder diagnoses at baseline and who were followed between 2002 and 2012.

MEASUREMENTS

The primary outcome measure was self-reported incident heroin use and the primary exposure of interest was new-onset NMUPO. Our final model was adjusted for socio-demographics, pain interference, prior diagnoses of post-traumatic stress disorder and/or depression and self-reported other substance use.

FINDINGS

Using a multivariable Cox regression model, we found that non-medical use of prescription opioids NMUPO was associated positively and independently with heroin initiation [adjusted hazard ratio (AHR) = 5.43, 95% confidence interval (CI) = 4.01, 7.35].

CONCLUSIONS

New-onset non-medical use of prescription opioids (NMUPO) is a strong risk factor for heroin initiation among HIV-infected and uninfected veterans in the United States who reported no previous history of NMUPO or illicit opioid use.

Seeking prescription opioids from physicians for nonmedical use among people who inject drugs in a Canadian setting

BACKGROUND AND OBJECTIVES

Despite the high prevalence of prescription opioid (PO) misuse, little is known about the phenomenon of seeking POs for nonmedical use among high-risk populations, such as people who inject drugs (PWID). We therefore sought to examine the prevalence and correlates of seeking POs from a physician for nonmedical use among PWID in Vancouver, Canada.

METHODS

Cross-sectional data from two open prospective cohort studies of PWID in Vancouver were collected between June 2013 and May 2014 (n = 1252). Multivariable logistic regression was used to identify factors associated with seeking POs from physicians for nonmedical use.

RESULTS

Of 1252 participants, 458 individuals (36.6%) reported ever trying to get a PO prescription from a physician for nonmedical use and, of these, 343 (74.9%, comprising 27.4% of the total sample) reported ever being successful. Variables independently and positively associated with PO-seeking behavior included older age (adjusted odds ratio [AOR] = 1.02), Caucasian ethnicity (AOR = 1.38), having ever overdosed (AOR = 1.32), having ever participated in methadone maintenance therapy (AOR = 1.90), having ever dealt drugs (AOR = 1.65), and having ever been refused a prescription for pain medication (AOR = 2.02) (all p < .05).

DISCUSSION AND CONCLUSIONS

We observed that PO-seeking behavior was common among this sample of PWID and associated with several markers of higher intensity drug use.

SCIENTIFIC SIGNIFICANCE

Our findings highlight the need to identify evidence-based public health and clinical strategies to mitigate PO misuse among PWID without compromising care for PWID with legitimate medical concerns. (Am J Addict 2016;25:275-282).

Pain Symptoms Associated with Opioid Use among Vulnerable Persons with HIV: An exploratory study with implications for palliative care and opioid abuse prevention

Current or former injection drug users with human immunodeficiency virus (HIV) are at high risk for pain, which adversely affects their quality of life and may increase their risk for illicit drug use or relapse. We explored associations between pain symptoms and substance use among injection-drug-using study participants with HIV who had histories of heroin use. Using generalized estimating equations and controlling for prior substance use, we found that pain in each six-month period was associated with the use of heroin and prescription opioids, but not the use of nonopioid drugs or alcohol. Routine clinical assessment and improved management of pain symptoms may be needed for persons with HIV and a history of injection drug use, particularly those with chronic pain, for whom there is increased risk for heroin use.