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Le K, Le KDR, Nguyen J, Hua J, Munday S. The Role of Medicinal Cannabis as an Emerging Therapy for Opioid Use Disorder. Pain Ther 2024; 13:435-455. [PMID: 38676910 PMCID: PMC11111657 DOI: 10.1007/s40122-024-00599-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/28/2024] [Indexed: 04/29/2024] Open
Abstract
This narrative review explores current insights into the potential use of medicinal cannabis-related products as an emerging therapy for opioid use disorder in the landscape of increasing knowledge about medicinal cannabis-based products, commercialisation and global legalisation. Preclinical studies have provided preliminary insight into the putative neurobiological mechanisms that underpin the potential for medicinal cannabis to be considered a therapeutic in opioid use disorder and addiction. With the progressive legalisation of cannabis in many jurisdictions worldwide, contemporary research has highlighted further evidence that medicinal cannabis may have efficacy in reducing cravings and withdrawal effects, and therefore may be considered as an adjunct or standalone to current medications for opioid use disorder. Despite this potential, the landscape of research in this space draws from a large number of observational studies, with a paucity of rigorous randomised controlled trials to ascertain a true understanding of effect size and safety profile. With current challenges in implementation that arise from political and legal qualms about adopting medicinal cannabis on the background of associated social stigma, significant hurdles remain to be addressed by government, policy-makers, healthcare providers and researchers before medical cannabis can be introduced globally for the treatment of opioid use disorder.
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Affiliation(s)
- Kelvin Le
- Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia
| | - Khang Duy Ricky Le
- Department of General Surgical Specialties, The Royal Melbourne Hospital, 300 Grattan St., Parkville, Melbourne, VIC, 3050, Australia.
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Geelong Clinical School, Deakin University, Geelong, VIC, Australia.
- Department of Medical Education, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia.
| | - Johnny Nguyen
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Parkville, VIC, Australia
- Department of Pharmacy, Alfred Health, Melbourne, VIC, Australia
| | - Jean Hua
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Parkville, VIC, Australia
- Department of Pharmacy, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Sarah Munday
- The Royal Children's Hospital, Melbourne, VIC, Australia
- Monash Bioethics Centre, Faculty of Arts, Monash University, Clayton, VIC, Australia
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Oster C, Hunter S, Schultz T, Harvey G, Lawless M, Battersby M. Barriers and facilitators to the implementation of the Flinders Chronic Condition Management Program in outpatient drug and alcohol settings in Australia. Drug Alcohol Rev 2024; 43:705-717. [PMID: 38098184 DOI: 10.1111/dar.13799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/20/2023] [Accepted: 11/29/2023] [Indexed: 03/02/2024]
Abstract
INTRODUCTION There has been a growing call for drug and/or alcohol dependence to be managed as a chronic condition. The Flinders Chronic Condition Management Program (Flinders Program) was implemented in a drug and alcohol service in Australia in 2019-2022 to explore the feasibility of chronic condition management in outpatient clinics. Implementation involved: adaptation of the Flinders Program; adaptation of clinical procedures; training clinicians and managers; training Flinders Program Accredited Trainers; and system integration. This study aims to explore barriers and enablers to implementation. METHODS A qualitative formative evaluation was undertaken. Data included implementation documents (n = 7), responses to open-ended questions in post-training surveys (n = 27), and focus groups and interviews with implementation staff, clinicians, managers and a trainer (n = 16). Data were analysed using the Consolidated Framework for Implementation Research in a 'coding reliability' approach to thematic analysis. RESULTS Participants responded positively to the Flinders Program's philosophy, processes, tools and training. However, barriers were identified across three Consolidated Framework for Implementation Research domains: (i) outer setting (client suitability and incompatibility with external policies and incentives); (ii) characteristics of individuals (low self-efficacy); and (iii) inner setting (lack of system and workflow integration). DISCUSSION AND CONCLUSIONS Executive support and systems integration are important for the implementation of the Flinders Program in drug and alcohol services. This needs to be achieved within externally mandated key performance indicators for outpatient services. Further research is needed to fully evaluate the potential of a chronic condition management framework in Australian outpatient drug and alcohol services.
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Affiliation(s)
- Candice Oster
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Sarah Hunter
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Timothy Schultz
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Gillian Harvey
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Michael Lawless
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
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Lee IH, Kim SY, Park S, Ryu JG, Je NK. Impact of the Narcotics Information Management System on Opioid Use Among Outpatients With Musculoskeletal and Connective Tissue Disorders: Quasi-Experimental Study Using Interrupted Time Series. JMIR Public Health Surveill 2024; 10:e47130. [PMID: 38381481 PMCID: PMC10918548 DOI: 10.2196/47130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 09/09/2023] [Accepted: 01/07/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Opioids have traditionally been used to manage acute or terminal pain. However, their prolonged use has the potential for abuse, misuse, and addiction. South Korea introduced a new health care IT system named the Narcotics Information Management System (NIMS) with the objective of managing all aspects of opioid use, including manufacturing, distribution, sales, disposal, etc. OBJECTIVE This study aimed to assess the impact of NIMS on opioid use. METHODS We conducted an analysis using national claims data from 45,582 patients diagnosed with musculoskeletal and connective tissue disorders between 2016 and 2020. Our approach included using an interrupted time-series analysis and constructing segmented regression models. Within these models, we considered the primary intervention to be the implementation of NIMS, while we treated the COVID-19 outbreak as the secondary event. To comprehensively assess inappropriate opioid use, we examined 4 key indicators, as established in previous studies: (1) the proportion of patients on high-dose opioid treatment, (2) the proportion of patients receiving opioid prescriptions from multiple providers, (3) the overlap rate of opioid prescriptions per patient, and (4) the naloxone use rate among opioid users. RESULTS During the study period, there was a general trend of increasing opioid use. After the implementation of NIMS, significant increases were observed in the trend of the proportion of patients on high-dose opioid treatment (coefficient=0.0271; P=.01) and in the level of the proportion of patients receiving opioid prescriptions from multiple providers (coefficient=0.6252; P=.004). An abrupt decline was seen in the level of the naloxone use rate among opioid users (coefficient=-0.2968; P=.04). While these changes were statistically significant, their clinical significance appears to be minor. No significant changes were observed after both the implementation of NIMS and the COVID-19 outbreak. CONCLUSIONS This study suggests that, in its current form, the NIMS may not have brought significant improvements to the identified indicators of opioid overuse and misuse. Additionally, the COVID-19 outbreak exhibited no significant influence on opioid use patterns. The absence of real-time monitoring feature within the NIMS could be a key contributing factor. Further exploration and enhancements are needed to maximize the NIMS' impact on curbing inappropriate opioid use.
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Affiliation(s)
- Iyn-Hyang Lee
- College of Pharmacy, Yeungnam University, Gyeongsan, Republic of Korea
| | - So Young Kim
- Department of Pharmacy, Kosin University Gospel Hospital, Busan, Republic of Korea
| | - Susin Park
- College of Pharmacy, Woosuk University, Wanju, Republic of Korea
| | - Jae Gon Ryu
- Department of Pharmacy, Sungkyunkwan University Samsung Changwon Hospital, Changwon, Republic of Korea
| | - Nam Kyung Je
- College of Pharmacy, Pusan National University, Busan, Republic of Korea
- Research Institute for Drug Development, Pusan National University, Busan, Republic of Korea
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Osterhage KP, Hser YI, Mooney LJ, Sherman S, Saxon AJ, Ledgerwood M, Holtzer CC, Gehring MA, Clingan SE, Curtis ME, Baldwin LM. Identifying patients with opioid use disorder using International Classification of Diseases (ICD) codes: Challenges and opportunities. Addiction 2024; 119:160-168. [PMID: 37715369 PMCID: PMC10846664 DOI: 10.1111/add.16338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/27/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND AND AIMS International Classification of Diseases (ICD) diagnosis codes are often used in research to identify patients with opioid use disorder (OUD), but their accuracy for this purpose is not fully evaluated. This study describes application of ICD-10 diagnosis codes for opioid use, dependence and abuse from an electronic health record (EHR) data extraction using data from the clinics' OUD patient registries and clinician/staff EHR entries. DESIGN Cross-sectional observational study. SETTING Four rural primary care clinics in Washington and Idaho, USA. PARTICIPANTS 307 patients. MEASUREMENTS This study used three data sources from each clinic: (1) a limited dataset extracted from the EHR, (2) a clinic-based registry of patients with OUD and (3) the clinician/staff interface of the EHR (e.g. progress notes, problem list). Data source one included records with six commonly applied ICD-10 codes for opioid use, dependence and abuse: F11.10 (opioid abuse, uncomplicated), F11.20 (opioid dependence, uncomplicated), F11.21 (opioid dependence, in remission), F11.23 (opioid dependence with withdrawal), F11.90 (opioid use, unspecified, uncomplicated) and F11.99 (opioid use, unspecified with unspecified opioid-induced disorder). Care coordinators used data sources two and three to categorize each patient identified in data source one: (1) confirmed OUD diagnosis, (2) may have OUD but no confirmed OUD diagnosis, (3) chronic pain with no evidence of OUD and (4) no evidence for OUD or chronic pain. FINDINGS F11.10, F11.21 and F11.99 were applied most frequently to patients who had clinical diagnoses of OUD (64%, 89% and 79%, respectively). F11.20, F11.23 and F11.90 were applied to patients who had a diagnostic mix of OUD and chronic pain without OUD. The four clinics applied codes inconsistently. CONCLUSIONS Lack of uniform application of ICD diagnosis codes make it challenging to use diagnosis code data from EHR to identify a research population of persons with opioid use disorder.
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Affiliation(s)
- Katie P Osterhage
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Yih-Ing Hser
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, California, USA
| | - Larissa J Mooney
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, California, USA
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
- Center of Excellence in Substance Addiction Treatment and Education, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Maja Ledgerwood
- Rural Social Service Solutions, LLC, New Meadows, Idaho, USA
| | - Caleb C Holtzer
- Providence Northeast Washington Medical Group, Colville, Washington, USA
| | | | - Sarah E Clingan
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, California, USA
| | - Megan E Curtis
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, California, USA
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Laura-Mae Baldwin
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
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Schaffer AL, Gisev N, Blyth FM, Buckley NA, Currow D, Dobbins TA, Wilson A, Degenhardt L, Pearson S. Opioid prescribing patterns among medical practitioners in New South Wales, Australia. Drug Alcohol Rev 2023; 42:1472-1481. [PMID: 37159416 PMCID: PMC10946566 DOI: 10.1111/dar.13675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 03/16/2023] [Accepted: 04/11/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Prescriber behaviour is important for understanding opioid use patterns. We described variations in practitioner-level opioid prescribing in New South Wales, Australia (2013-2018). METHODS We quantified opioid prescribing patterns among medical practitioners using population-level dispensing claims data, and used partitioning around medoids to identify clusters of practitioners who prescribe opioids based on prescribing patterns and patient characteristics identified from linked dispensing claims, hospitalisations and mortality data. RESULTS The number of opioid prescribers ranged from 20,179 in 2013 to 23,408 in 2018. The top 1% of practitioners prescribed 15% of all oral morphine equivalent (OME) milligrams dispensed annually, with a median of 1382 OME grams (interquartile range [IQR], 1234-1654) per practitioner; the bottom 50% prescribed 1% of OMEs dispensed, with a median of 0.9 OME grams (IQR 0.2-2.6). Based on 63.6% of practitioners with ≥10 patients filling opioid prescriptions in 2018, we identified four distinct practitioner clusters. The largest cluster prescribed multiple analgesic medicines for older patients (23.7% of practitioners) accounted for 76.7% of all OMEs dispensed and comprised 93.0% of the top 1% of practitioners by opioid volume dispensed. The cluster prescribing analgesics for younger patients with high rates of surgery (18.7% of practitioners) prescribed only 1.6% of OMEs. The remaining two clusters comprised 21.2% of prescribers and 20.9% of OMEs dispensed. DISCUSSION AND CONCLUSION We observed substantial variation in opioid prescribing among practitioners, clustered around four general patterns. We did not assess appropriateness but some prescribing patterns are concerning. Our findings provide insights for targeted interventions to curb potentially harmful practices.
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Affiliation(s)
- Andrea L. Schaffer
- School of Population HealthFaculty of Medicine and Health, UNSW SydneySydneyAustralia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW SydneySydneyAustralia
| | - Fiona M. Blyth
- School of Public Health, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Nicholas A. Buckley
- Biomedical Informatics and Digital Health, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - David Currow
- Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
| | - Timothy A. Dobbins
- School of Population HealthFaculty of Medicine and Health, UNSW SydneySydneyAustralia
| | - Andrew Wilson
- Menzies Centre for Health Policy and Economics, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW SydneySydneyAustralia
| | - Sallie‐Anne Pearson
- School of Population HealthFaculty of Medicine and Health, UNSW SydneySydneyAustralia
- Menzies Centre for Health Policy and Economics, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
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Liu X, Wong CKH, Wu T, Tang EHM, Au ICH, Li L, Cheung CW, Lang BHH. Discharge of postoperative patients with an opioid prescription is associated with increased persistent opioid use, healthcare expenditures and mortality: a retrospective cohort study. Br J Anaesth 2023; 131:586-597. [PMID: 37474420 DOI: 10.1016/j.bja.2023.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/07/2023] [Accepted: 05/23/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND The risk factors for persistent opioid use after surgical discharge and the association between opioid prescription at discharge and postoperative emergency department visits, readmission, and mortality are unclear. METHODS This population-based retrospective cohort study involved opioid-naive patients who underwent surgical procedures from January 1, 2000 to November 30, 2020. The data source was Hong Kong Hospital Authority Clinical Management System electronic health record. The primary outcome was the incidence of new persistent opioid use. Other study outcomes included 30-day emergency department visits, 30-day readmission, and 30-day all-cause mortality. Multivariable logistic regression models were used to estimate the association between opioid prescription at discharge and persistent opioid use, emergency department visits, readmission, and all-cause mortality. RESULTS Over a median follow-up of 1 month with 36 104 person-years, 438 128 patients (opioid prescription: 32 932, no opioid prescription: 405 196) who underwent surgical procedures were analysed, of whom 15 112 (3.45%) had persistent opioid use after discharge. Prescribing opioids on discharge was associated with increased risks of developing persistent opioid use (odds ratio [OR]: 2.30, 95% confidence interval [CI]: 2.19-2.40, P<0.001), 30-day emergency department visits (OR: 1.28, 95% CI: 1.23-1.33, P<0.001), 30-day readmission (OR: 1.17, 95% CI: 1.13-1.20, P<0.001), and 30-day all-cause mortality (OR: 1.68, 95% CI: 1.53-1.86, P<0.001). CONCLUSIONS In this large cohort of patients undergoing surgery, an opioid prescription on discharge was associated with a higher chance of persistent opioid use and increased risks of postoperative emergency department visits, readmission, and mortality. Minimising opioid prescriptions on discharge could improve perioperative patient outcomes.
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Affiliation(s)
- Xiaodong Liu
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Carlos K H Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health Limited (D2(4)H), Hong Kong Special Administrative Region, China.
| | - Tingting Wu
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Eric H M Tang
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ivan C H Au
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Lanlan Li
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Chi W Cheung
- Department of Anaesthesiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Brian H-H Lang
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China.
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Robert M, Jouanjus E, Khouri C, Fouilhé Sam-Laï N, Revol B. The opioid epidemic: A worldwide exploratory study using the WHO pharmacovigilance database. Addiction 2023; 118:771-775. [PMID: 36331523 DOI: 10.1111/add.16081] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND AIMS The current opioid epidemic in the United States began 20 years ago and has become the leading cause of accidental deaths in the country. This crisis prompted us to explore trends in opioid abuse and dependence worldwide. We sought to identify other countries at high-risk of opioid use disorders, using the World Health Organization's (WHO) pharmacovigilance database. METHODS We performed a disproportionality analysis using VigiBase, the WHO Global Individual Case Safety Report (ICSR) database. Five opioids used worldwide were included: oxycodone, fentanyl, morphine, tramadol, and codeine. We extracted all ICSRs associated with the drugs of interest, considered as suspect medication and recorded up until 5 June 2021, using the narrow Standardised MedDRA Query (SMQ) for drug abuse and dependence. Countries with at least one ICSR for each of the five opioids were retained. The relationship between the use of a drug (i.e. an opioid) and the occurrence of an adverse drug reaction (i.e. drug abuse and dependence) for each country was assessed by calculating the information component (IC) and its 99.9% CI [IC0005 ; IC9995 ], using a quasi-Bayesian confidence propagation neural network (BCPNN). A hierarchical cluster analysis (Ward's method) of the IC0005 value for each of the five opioids was performed to identify subgroups of countries with similar reported risks of opioid abuse and dependence. RESULTS Among 21 countries, the optimal number of clusters was calculated to be four, each with a Jaccard index >0.5 (0.95, 0.78, 0.65 and 0.75, respectively). Six countries with the highest signals of drug abuse and dependence were identified in cluster 1, with significant CIs for the five opioids of interest (IC0005 > 0), ranging from 0.9 to 5.8 for the lower endpoint. CONCLUSIONS There appear to be four distinct clusters of countries with similar opioid abuse and dependence profiles. The group with the highest reported risk for the opioids oxycodone, fentanyl, morphine, tramadol and codeine includes Australia, Canada, France, Germans, the United Kingdom and the United States.
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Affiliation(s)
- Marion Robert
- Addictovigilance Department, Grenoble Alpes University Hospital, Grenoble, France.,Pharmacovigilance Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Emilie Jouanjus
- Addictovigilance Department, Toulouse University Hospital, Toulouse, France.,INSERM Unit 1027, Toulouse III University, Toulouse, France
| | - Charles Khouri
- Pharmacovigilance Department, Grenoble Alpes University Hospital, Grenoble, France.,INSERM Unit 1300, HP2 Laboratory, Grenoble Alpes University, Grenoble, France
| | - Nathalie Fouilhé Sam-Laï
- Addictovigilance Department, Grenoble Alpes University Hospital, Grenoble, France.,Pharmacovigilance Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Bruno Revol
- Addictovigilance Department, Grenoble Alpes University Hospital, Grenoble, France.,Pharmacovigilance Department, Grenoble Alpes University Hospital, Grenoble, France.,INSERM Unit 1300, HP2 Laboratory, Grenoble Alpes University, Grenoble, France
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Roxburgh A, Nielsen S. Twenty-year trends in pharmaceutical fentanyl and illicit fentanyl deaths, Australia 2001-2021. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 109:103854. [PMID: 36150355 DOI: 10.1016/j.drugpo.2022.103854] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/08/2022] [Accepted: 09/05/2022] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Amanda Roxburgh
- Health Risks Program, Burnet Institute, Melbourne, Australia; Monash Addiction Research Centre, Monash University, Melbourne, Australia.
| | - Suzanne Nielsen
- Health Risks Program, Burnet Institute, Melbourne, Australia; Monash Addiction Research Centre, Monash University, Melbourne, Australia
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Peri-OPerative Pain Management, Education & De-escalation (POPPMED), a novel anaesthesiologist-led program, significantly reduces acute and long-term postoperative opioid requirements: a retrospective cohort study. Pain Rep 2022; 7:e1028. [PMID: 36034601 PMCID: PMC9400930 DOI: 10.1097/pr9.0000000000001028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 05/30/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Perioperative pain management, education, and de-escalation, a single anaesthesiologist-led perioperative service, managed older, high-risk opioid-tolerant patients to achieve sustained oral morphine equivalent daily dosage reductions safely after major orthopaedic, abdominal, and neurosurgery. Introduction: The opioid tolerant patient requiring surgery is highly likely to be discharged on high Oral Morphine Equivalent Daily Dosages (OMEDDs), with concomitant risk of increased morbidity and mortality. Objectives: We proposed that a single anaesthesiologist-led POPPMED (Peri-Operative Pain Management, Education & De-escalation) service could reduce both short and long-term postoperative patient OMEDDs. Methods: From April 2017, our anaesthesiologist-led POPPMED service, engaged 102 perioperative patients treated with >50mg preoperative OMEDDs. We utilized behavioural interventions; acute opioid reduction and/ or rotation; and regional, multimodal and ketamine analgesia to achieve lowest possible hospital discharge and long term OMEDDs. Results: Patients' preoperative OMEDDs were [median (IQR): 115mg (114mg)], and were representative of an older [age 62 (15) years], high-risk [89% ASA status 3 or 4] patient population. 46% of patients received an acute opioid rotation; 70% received ketamine infusions; and 44% regional analgesia. OMEDDs on discharge [-25mg (82mg), p=0.003] and at 6-12 months [-55mg (105mg ), p<0.0001] were significantly reduced; 84% and 87% of patients achieved OMEDD reduction on discharge and at 6-12 months. Patients with >90mg preoperative OMEDDs achieved greater reductions [discharge: 71% of patients, -52 mg (118 mg) p<0.0001; 6-12 months: 90% of patients, -90mg (115mg), p<0.0001]. On comparison with a pre-POPPMED surgical cohort, Postoperative Day 1-3 11-point Numerical Rating Scale (NRS-11) area under the curve (AUC) measurements at rest and on movement were not significantly different (largest NRS-11:hours AUC difference [median(IQR)] 22 [13], p= 0.24). Hospital length of stay was variably increased. Conclusions: POPPMED achieved sustained OMEDD reductions safely in an older, high-risk opioid tolerant population, with analgesia comparable to a non-POPPMED cohort, and surgery specific effects on length of stay.
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Fiore JF, El-Kefraoui C, Chay MA, Nguyen-Powanda P, Do U, Olleik G, Rajabiyazdi F, Kouyoumdjian A, Derksen A, Landry T, Amar-Zifkin A, Bergeron A, Ramanakumar AV, Martel M, Lee L, Baldini G, Feldman LS. Opioid versus opioid-free analgesia after surgical discharge: a systematic review and meta-analysis of randomised trials. Lancet 2022; 399:2280-2293. [PMID: 35717988 DOI: 10.1016/s0140-6736(22)00582-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 03/12/2022] [Accepted: 03/18/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Excessive opioid prescribing after surgery has contributed to the current opioid crisis; however, the value of prescribing opioids at surgical discharge remains uncertain. We aimed to estimate the extent to which opioid prescribing after discharge affects self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen. METHODS In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, Scopus, AMED, Biosis, and CINAHL from Jan 1, 1990, until July 8, 2021. We included multidose randomised controlled trials comparing opioid versus opioid-free analgesia in patients aged 15 years or older, discharged after undergoing a surgical procedure according to the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity definition (minor, moderate, major, and major complex). We screened articles, extracted data, and assessed risk of bias (Cochrane's risk-of-bias tool for randomised trials) in duplicate. The primary outcomes of interest were self-reported pain intensity on day 1 after discharge (standardised to 0-10 cm visual analogue scale) and vomiting up to 30 days. Pain intensity at further timepoints, pain interference, other adverse events, risk of dissatisfaction, and health-care reutilisation were also assessed. We did random-effects meta-analyses and appraised evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluations scoring system. The review was registered with PROSPERO (ID CRD42020153050). FINDINGS 47 trials (n=6607 patients) were included. 30 (64%) trials involved elective minor procedures (63% dental procedures) and 17 (36%) trials involved procedures of moderate extent (47% orthopaedic and 29% general surgery procedures). Compared with opioid-free analgesia, opioid prescribing did not reduce pain on the first day after discharge (weighted mean difference 0·01cm, 95% CI -0·26 to 0·27; moderate certainty) or at other postoperative timepoints (moderate-to-very-low certainty). Opioid prescribing was associated with increased risk of vomiting (relative risk 4·50, 95% CI 1·93 to 10·51; high certainty) and other adverse events, including nausea, constipation, dizziness, and drowsiness (high-to-moderate certainty). Opioids did not affect other outcomes. INTERPRETATION Findings from this meta-analysis support that opioid prescribing at surgical discharge does not reduce pain intensity but does increase adverse events. Evidence relied on trials focused on elective surgeries of minor and moderate extent, suggesting that clinicians can consider prescribing opioid-free analgesia in these surgical settings. Data were largely derived from low-quality trials, and none involved patients having major or major-complex procedures. Given these limitations, there is a great need to advance the quality and scope of research in this field. FUNDING The Canadian Institutes of Health Research.
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Affiliation(s)
- Julio F Fiore
- Department of Surgery, McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
| | - Charbel El-Kefraoui
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | - Philip Nguyen-Powanda
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Uyen Do
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ghadeer Olleik
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Fateme Rajabiyazdi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Department of Systems and Computer Engineering, Carleton University, ON, Canada
| | - Araz Kouyoumdjian
- Department of Surgery, McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Alexa Derksen
- Patient Representative, Université de Montréal, Montreal, QC, Canada
| | - Tara Landry
- Medical Libraries, McGill University Health Centre, Montreal, QC, Canada; Bibliothèque de la Santé, Université de Montréal, Montreal, QC, Canada
| | | | - Amy Bergeron
- Medical Libraries, McGill University Health Centre, Montreal, QC, Canada
| | - Agnihotram V Ramanakumar
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Marc Martel
- Faculty of Dentistry, McGill University, Montreal, QC, Canada; Department of Anaesthesia, McGill University, Montreal, QC, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Gabriele Baldini
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Department of Anaesthesia, McGill University, Montreal, QC, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University, Montreal, QC, Canada; Division of Experimental Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
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11
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State-Level Prevalence and Associates of Opioid Dependence in the USA. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073825. [PMID: 35409508 PMCID: PMC8997413 DOI: 10.3390/ijerph19073825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 11/17/2022]
Abstract
Traditionally, opioid-related disease burden was primarily due to heroin use. However, increases in extra-medical (or non-medicinal use of prescription opioids; NMPOs) use has precipitated the current overdose epidemic in North America. We aim to examine the state-level prevalence of heroin and NMPO dependence and their associations with opioid-related mortality and state-level socio-demographic profiles. Data were pooled from the 2005-2014 National Survey on Drug Use and Health (NSDUH). We examine opioid-related mortality from CDC WONDER (Cause of Death database) by the past year prevalence of DSM-IV heroin and NMPO dependence, by age and sex, and their associations with state-level socio-demographic characteristics from census data. State-level rates of heroin dependence were associated with opioid-related death rates in young and mid-aged adults, while rates of NMPO dependence were associated with opioid-related death rates across all ages. The prevalence of heroin dependence was positively associated with state-level GDP/capita and urbanity. State-level NMPO dependence prevalence was associated with higher unemployment, lower GDP/capita, and a lower high-school completion rate. The prevalence of heroin and NMPO dependence are associated with a broad range of geographical and socio-demographic groups. Taking a wider view of populations affected by the opioid epidemic, inclusive interventions for all are needed to reduce opioid-related disease burden.
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12
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Black E, Monds LA, Chan B, Brett J, Hutton JE, Acheson L, Penm J, Harding S, Strumpman D, Demirkol A, Lintzeris N. Overdose and take-home naloxone in emergency settings: A pilot study examining feasibility of delivering brief interventions addressing overdose prevention with 'take-home naloxone' in emergency departments. Emerg Med Australas 2022; 34:509-518. [PMID: 35021268 DOI: 10.1111/1742-6723.13925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/16/2021] [Accepted: 12/02/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Although most unintentional opioid deaths in Australia are attributed to pharmaceutical opioids, take-home naloxone (THN) programmes have to date predominantly targeted people using illicit opioids in drug treatment and harm reduction settings. We sought to examine the feasibility of delivering THN brief interventions (THN-BIs) with intranasal naloxone in EDs. METHODS This pilot feasibility study was conducted across three major metropolitan EDs in Sydney and Melbourne. ED staff were surveyed about their perspectives regarding THN before completing a 30-min training programme in THN-BI delivery. Patients presenting with opioid overdose or considered high risk for future overdose were eligible to receive the THN-BI. Staff survey responses were compared between hospitals and provider types using one-way analysis of variances. Patient demographic and clinical characteristics were extracted from medical records and compared between hospitals and overdose type using Fisher's exact test and one-way analysis of variances. RESULTS One hundred and twenty-two ED staff completed the survey. One hundred and ten (90.2%) agreed that EDs should provide THN-BIs, whereas 23 (19.2%) identified time constraints and 17 (12.9%) felt uncomfortable discussing overdose with patients. Fifty-seven patients received the THN-BI, with the majority (n = 50, 87.7%) having presented following opioid overdose. The median age was 44 years and 40 (71.4%) were men. Two-thirds of the overdoses (n = 31, 66.0%) were attributed to heroin with one-third (n = 16, 34%) being attributed to pharmaceutical opioids. CONCLUSIONS ED-based delivery of THN-BIs can reach a wide range of individuals at-risk of overdose. The present study supports the feasibility of THN interventions in EDs and underscores the importance of addressing implementation barriers including staff training.
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Affiliation(s)
- Eleanor Black
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia.,School of Population Health, The University of New South Wales, Sydney, New South Wales, Australia.,New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia
| | - Lauren A Monds
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia.,New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia.,Faculty of Medicine and Health, Specialty of Addiction Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Betty Chan
- Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Jonathan Brett
- New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia.,Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - Jennie E Hutton
- Emergency Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Liam Acheson
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,National Drug and Alcohol Research Centre, The University of New South Wales, Sydney, New South Wales, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia.,Pharmacy Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Sally Harding
- Emergency Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Dana Strumpman
- Pharmacy Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Apo Demirkol
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia.,School of Population Health, The University of New South Wales, Sydney, New South Wales, Australia.,New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia
| | - Nicholas Lintzeris
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia.,New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia.,Faculty of Medicine and Health, Specialty of Addiction Medicine, The University of Sydney, Sydney, New South Wales, Australia
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13
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Busingye D, Daniels B, Brett J, Pollack A, Belcher J, Chidwick K, Blogg S. Patterns of real-world opioid prescribing in Australian general practice (2013-18). Aust J Prim Health 2021; 27:416-424. [PMID: 34521504 DOI: 10.1071/py20270] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 05/25/2021] [Indexed: 11/23/2022]
Abstract
Little is known about private-market opioid prescribing and how Australian opioid policies impact prescribing across public and private markets in Australia. We aimed to investigate publicly subsidised and private-market opioid prescribing from 2013 to 2018. We used prescribing records from MedicineInsight, an Australian primary care database, to examine trends in prescriptions for non-injectable opioid formulations from October 2013 to September 2018. We examined annual opioid prescribing trends overall, by opioid agent, and by market (public and private). We further examined patterns of fentanyl patch prescribing focusing on co-prescribed medicines and use in opioid-naïve patients. Opioids accounted for 8% of all prescriptions over the study period and 468 893 patients were prescribed at least one opioid of interest. Prescribing rates for oxycodone/naloxone and tapentadol increased, whereas those for fentanyl patches, morphine and single-agent oxycodone decreased over the study period. Private-market prescribing rates of codeine (schedule 4) increased notably following its up-scheduling to prescription-only status. Among patients prescribed fentanyl patches, 29% were potentially opioid-naïve and 49% were prescribed another opioid on the same day. The private-medicines market is a small but growing component of opioid use in Australia and one way in which prescribers and patients can avoid access restrictions in the public market for these medicines. Although fentanyl patch prescribing declined, there is room for improvement in prescribing fentanyl patches among opioid-naïve patients, and co-prescribing of fentanyl patches with other sedatives.
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Affiliation(s)
- Doreen Busingye
- NPS MedicineWise, Level 7/418A Elizabeth Street, Surry Hills, NSW 2010, Australia; and Corresponding author.
| | - Benjamin Daniels
- NPS MedicineWise, Level 7/418A Elizabeth Street, Surry Hills, NSW 2010, Australia; and Medicines Policy Research Unit, Centre for Big Data Research in Health, Level 2, AGSM Building (G27), UNSW, Sydney, NSW 2052, Australia
| | - Jonathan Brett
- Medicines Policy Research Unit, Centre for Big Data Research in Health, Level 2, AGSM Building (G27), UNSW, Sydney, NSW 2052, Australia
| | - Allan Pollack
- NPS MedicineWise, Level 7/418A Elizabeth Street, Surry Hills, NSW 2010, Australia
| | - Josephine Belcher
- NPS MedicineWise, Level 7/418A Elizabeth Street, Surry Hills, NSW 2010, Australia
| | - Kendal Chidwick
- NPS MedicineWise, Level 7/418A Elizabeth Street, Surry Hills, NSW 2010, Australia
| | - Suzanne Blogg
- NPS MedicineWise, Level 7/418A Elizabeth Street, Surry Hills, NSW 2010, Australia
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14
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Varney B, Zoega H, Gillies MB, Brett J, Pearson SA, Havard A. Prescription opioid use in Australian women of reproductive age: Implications for unplanned pregnancies. Br J Clin Pharmacol 2021; 88:1298-1320. [PMID: 34505707 DOI: 10.1111/bcp.15074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/20/2021] [Accepted: 08/29/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS To examine trends in the prevalence and incidence of prescription opioid analgesic use in Australian women of reproductive age and to estimate the number of calendar months each year that women were dispensed opioids. METHODS We conducted a retrospective cross-sectional study involving women aged 15-44 years using pharmaceutical dispensing claims for a 10% random sample of Australians. For the period 2013-2020, we calculated the annual prevalence and incidence of opioid analgesic dispensing per 100 (%) population by opioid type and age group. We also estimated the total number of calendar months that women were dispensed at least 1 opioid each year. RESULTS The prevalence of opioid use decreased from 12.8% in 2013 to 11.3% in 2020, representing a relative decrease of 11.6% (95% confidence interval 10.7, 12.6%). The incidence of opioid use decreased from 10.3% in 2014 to 8.3% in 2020, representing a relative decrease of 18.6% (95% confidence interval 17.6, 19.6%). Codeine in combination products, followed by oxycodone and tramadol, were the most prevalent opioids. Prevalence and incidence of opioid use were lowest in women aged 15-19 years and the highest in women 30 years and above. Among all women dispensed opioids, 72.7% were dispensed an opioid in only 1 month each year. CONCLUSION Prescription opioid use remains common, although decreasing, among women of reproductive age in Australia. However, it is reassuring that the majority of opioid use in this population is short term.
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Affiliation(s)
- Bianca Varney
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Helga Zoega
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Malcolm Bjørn Gillies
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Jonathan Brett
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Alys Havard
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Sydney, Australia.,National Drug and Alcohol Research Centre, Faculty of Medicine, University of New South Wales, Sydney, Australia
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15
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Marchetti Calônego MA, Sikandar S, Ferris FD, Moreira de Barros GA. Spread the Word: There Are Two Opioid Crises! Drugs 2021; 80:1147-1154. [PMID: 32533500 DOI: 10.1007/s40265-020-01342-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Pain is associated with emotional and physical suffering that severely impacts quality of life. Many guidelines for the treatment of moderate to severe cancer pain indicate the use of opioids. For a small proportion of the global population, opioids are readily accessible, but are consequently also subject to risk of overuse and misuse. On the other hand, many regions provide limited access to licensed opioid therapeutics and patients struggle for better pain management. The use of prescription opioids for treatment of severe cancer and acute pain is well established, but opioid use in chronic non-cancer pain is controversial and not supported by the literature. The opioid crisis and the increasing overdose fatalities in some countries have resulted in a resurgence of opiophobia in these countries, but even worse, amplified opiophobia in countries with lower opioid consumption. In this narrative review, we highlight how the opioid crisis of overuse in some countries can negatively impact appropriate access to opioids elsewhere. The availability of opioids for clinical and recreational use differs between countries worldwide-this is an important factor in determining the occurrence of a 'crisis of recreational use of opioids' or a 'crisis of under-prescription of opioids' for pain management.
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Affiliation(s)
| | - Shafaq Sikandar
- William Harvey Research Institute, Barts, The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Frank D Ferris
- Palliative Medicine, Research and Education, OhioHealth, Columbus, OH, USA
| | - Guilherme Antonio Moreira de Barros
- Anesthesiology Department, Medical School, Sao Paulo State University (UNESP), Av. Prof. Mario Rubens Guimaraes Montenegro, s/n, Botucatu, São Paulo, 18618687, Brazil.
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16
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Elison-Davies S, Märtens K, Yau C, Davies G, Ward J. Associations between baseline opioid use disorder severity, mental health and biopsychosocial functioning, with clinical responses to computer-assisted therapy treatment. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2021; 47:360-372. [PMID: 33428458 DOI: 10.1080/00952990.2020.1861618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Increasing rates of opioid-related overdose have been identified globally. Treatment for opioid use disorders (OUD) includes medications for opioid use disorder (MOUD) alongside behavioral support. Novel approaches to behavioral support should be explored, including computer-assisted therapy (CAT) programs.Objectives: Examine differences between baseline and post-treatment measures of opioid use and biopsychosocial functioning for individuals with OUD engaging with the CAT program 'Breaking Free Online,' and the extent to which participant characteristics may be associated with post-treatment measures.Methods: 1107 individuals engaged with CAT and provided baseline and post-treatment data - 724 (65.4%) were male, 383 (34.6%) were female.Results: Significant differences between baseline and post-treatment measures were identified (all p <.0001, effect sizes range:15 -.50). Participant characteristics were associated with post-treatment measures of opioid use, opioid dependence, mental health issues, quality of life, and biopsychosocial impairment (all p <.0001). An aggregated consensus measure of clinical impairment was found to be associated with changes in opioid use and post-treatment biopsychosocial functioning measures, with those participants with greater baseline clinical impairment demonstrating a greater magnitude of improvement from baseline to post-treatment than those with lower clinical impairment.Conclusion: CAT may reduce opioid use and improve biopsychosocial functioning in individuals with OUD. CAT could therefore provide a solution to the global opioid crisis if delivered as combination behavioral support alongside MOUD. Findings also indicate that it may be important for treatment systems to identify individuals with psychosocial complexity who might require behavioral support and MOUD.
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Affiliation(s)
| | - Kaspar Märtens
- Department of Statistics, University of Oxford, Oxford, UK
| | - Christopher Yau
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Glyn Davies
- Breaking Free Online, Manchester Science Park, Manchester, UK
| | - Jonathan Ward
- Breaking Free Online, Manchester Science Park, Manchester, UK
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17
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Li RJ, Caughey GE, Shakib S. Concomitant inpatient prescribing of strong opioids with sedatives: Associations with comorbid conditions. Pharmacol Res Perspect 2021; 9:e00717. [PMID: 33550717 PMCID: PMC7868063 DOI: 10.1002/prp2.717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/24/2020] [Indexed: 01/05/2023] Open
Abstract
Co-prescribing of opioids and sedatives is a known risk factor for opioid-induced ventilatory impairment (OIVI). Prevalence data for sedative and opioid co-prescription in inpatients in Australia are unknown. Our objective was to determine the prevalence of inpatient sedative and opioid co-prescribing and to identify factors associated with co-prescription. We conducted a retrospective cross-sectional study from July 2017 to October 2017 across four South Australian hospitals utilizing a centralized electronic health record. Multivariate analysis was used to identify characteristics predictive of co-prescribing of a strong opioid (fentanyl, hydromorphone, morphine, and oxycodone) and sedative medications (benzodiazepines, antiepileptics, antipsychotics, and tricyclic antidepressants). Of the 6170 inpatients, 2795 (45.3%) were prescribed a strong opioid and of those, 1889 (30.6% of all inpatients) were co-prescribed a sedative. Of those prescribed a strong opioid, five (0.18%) developed OIVI. Patients prescribed a strong opioid had a 27-77% increased likelihood of being prescribed a sedative. Factors predictive of sedative co-prescribing included the presence of disease of the central nervous system adjusted OR (aOR) 8.66 [95% CI 5.83-12.9] and respiratory disease aOR 1.42 [95% CI 1.17-1.72]. Nearly, one third of all hospital inpatients were co-prescribed a strong opioid and a sedative medication. Patients with comorbidities resulting in increased risk of respiratory depression/OIVI were more likely to have sedative co-prescription. Clinicians should be aware of the effects of high-risk medications and ensure that systems and monitoring are in place that help mitigate adverse outcomes.
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Affiliation(s)
- Ray J. Li
- Department of Clinical PharmacologyRoyal Adelaide HospitalAdelaideAustralia
- Discipline of PharmacologyAdelaide Medical SchoolThe University of AdelaideAdelaideAustralia
| | - Gillian E. Caughey
- Department of Clinical PharmacologyRoyal Adelaide HospitalAdelaideAustralia
- Discipline of PharmacologyAdelaide Medical SchoolThe University of AdelaideAdelaideAustralia
- Registry of Senior AustraliansSouth Australian Health and Medical Research InstituteAdelaideAustralia
- Division of Health SciencesUniversity of South AustraliaAdelaideAustralia
| | - Sepehr Shakib
- Department of Clinical PharmacologyRoyal Adelaide HospitalAdelaideAustralia
- Discipline of PharmacologyAdelaide Medical SchoolThe University of AdelaideAdelaideAustralia
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18
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Lin LA, Bohnert ASB, Blow FC, Gordon AJ, Ignacio RV, Kim HM, Ilgen MA. Polysubstance use and association with opioid use disorder treatment in the US Veterans Health Administration. Addiction 2021; 116:96-104. [PMID: 32428386 DOI: 10.1111/add.15116] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/14/2020] [Accepted: 05/12/2020] [Indexed: 11/28/2022]
Abstract
AIMS To understand the role of comorbid substance use disorders (SUDs), or polysubstance use, in the treatment of opioid use disorder (OUD), this study compared patients with OUD only to those with additional SUDs and examined association with OUD treatment receipt. DESIGN, SETTING AND PARTICIPANTS Retrospective national cohort study of Veterans diagnosed with OUD (n = 65 741) receiving care from the US Veterans Health Administration (VHA) in fiscal year (FY) 2017. MEASUREMENTS Patient characteristics were compared among those diagnosed with OUD only versus those with one other SUD (OUD + 1 SUD) and with multiple SUDs (OUD + ≥ 2 SUDs). The study examined the relationship between comorbid SUDs and receipt of buprenorphine, methadone and SUD outpatient treatment during 1-year follow-up, adjusting for patient demographic characteristics and clinical conditions. FINDINGS Among the 65 741 Veterans with OUD in FY 2017, 41.2% had OUD only, 22.9% had OUD + 1 SUD and 35.9% had OUD + ≥ 2 SUDs. Common comorbid SUDs included alcohol use disorder (41.3%), cocaine/stimulant use disorder (30.0%) and cannabis use disorder (22.4%). Adjusting for patient characteristics, patients with OUD + 1 SUD [adjusted odds ratio (aOR) = 0.87, 95% confidence interval (CI) = 0.82-0.93] and patients with OUD +≥ 2 SUDs (aOR = 0.65, 95% CI = 0.61-0.69) had lower odds of receiving buprenorphine compared with OUD only patients. There were also lower odds of receiving methadone for patients with OUD + 1 SUD (aOR = 0.91, 95% CI = 0.86-0.97)and for those with OUD + ≥2 SUDs (aOR = 0.79, 95% CI = 0.74-0.84). Patients with OUD + 1 SUD (aOR = 1.85, 95% CI = 1.77-1.93) and patients with OUD + ≥2 SUDs (aOR = 3.25, 95% CI = 3.103.41) were much more likely to have a SUD clinic visit. CONCLUSIONS The majority of Veterans in the US Veterans Health Administration diagnosed with opioid use disorder appeared to have at least one comorbid substance use disorder and many have multiple substance use disorders. Despite the higher likelihood of a substance use disorder clinic visit, having a non-opioid substance use disorder is associated with lower likelihood of buprenorphine treatment, suggesting the importance of addressing polysubstance use within efforts to expand treatment for opioid use disorder.
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Affiliation(s)
- Lewei A Lin
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Amy S B Bohnert
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Frederic C Blow
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Rosalinda V Ignacio
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - H Myra Kim
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Consulting for Statistics, Computing and Analytics Research (CSCAR), University of Michigan, Ann Arbor, MI, USA
| | - Mark A Ilgen
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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19
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Fischer B, Daldegan-Bueno D, Jones W. Comparison of Crude Population-Level Indicators of Opioid Use and Related Harm in New Zealand and Ontario (Canada). Pain Ther 2020; 10:15-23. [PMID: 33382438 PMCID: PMC8119530 DOI: 10.1007/s40122-020-00229-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022] Open
Abstract
North America and select other Commonwealth jurisdictions have been experiencing unprecedented opioid epidemics characterized by excessive and persistently high levels of opioid misuse, morbidity and mortality, and related disease burden. Recent discussions have considered whether New Zealand might undergo or needs to expect a similar ‘opioid crisis’. Towards further informing these considerations, we examine and compare essential, publicly available indicators of opioid utilization and harms (mortality) from New Zealand and the Canadian province of Ontario, due to the fact that both operate public health care systems in similar socio-cultural settings. We find that the two jurisdictions have featured vastly different population levels of opioid exposure, opioid consumption patterns (e.g., high-dose/long-term/high-risk prescribing) known as key predictors of adverse outcomes, and levels of opioid mortality as evidenced by concrete epidemiological indicators and data. Specifically for opioid-related death rates, these were already approximately threefold higher in Ontario compared to New Zealand based on most recent comparison data (e.g., 2012); these differentials have likely further grown more recently given major and distinct changes in population-level opioid exposure and risks, and subsequent opioid-related deaths since then in Ontario. Based on the present data and related evidence, New Zealand does not seem to need to anticipate an opioid mortality epidemic similar to that experienced in North America; however, it would be of interest to establish more comprehensive and timely surveillance of key system-level indicators of opioid use and harms as are standard in North America. As such, this inter-jurisdictional comparison makes for a case study in starkly contrasting scenarios of opioid use and harms, the drivers behind which deserve further systematic examination.
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Affiliation(s)
- Benedikt Fischer
- Faculty of Medical and Health Sciences, Schools of Population Health and Pharmacy, University of Auckland, Auckland, New Zealand. .,Faculty of Health Sciences, Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, Canada. .,Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.
| | - Dimitri Daldegan-Bueno
- Faculty of Medical and Health Sciences, Schools of Population Health and Pharmacy, University of Auckland, Auckland, New Zealand
| | - Wayne Jones
- Faculty of Health Sciences, Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, Canada
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20
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Community pharmacists' preparedness to intervene with concerns around prescription opioids: findings from a nationally representative survey. Int J Clin Pharm 2020; 43:411-419. [PMID: 32951182 DOI: 10.1007/s11096-020-01152-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/11/2020] [Indexed: 02/03/2023]
Abstract
Background Prescription opioid use and related harms have dramatically increased in many countries. Objective To investigate pharmacists' preparedness and confidence to intervene when concerned about supplying prescription opioids and strategies used when concerned about supplying these opioids. Setting Online survey among a representative sample of Australian community pharmacists. Method Pharmacists completed an online survey about their concerns, comfort and strategies used when supplying prescription opioids. Correlates of comfort to intervene and active intervention strategies were explored using multivariable ordered logistic regression and adjusted odd ratios (aOR) and 95% confidence intervals were reported. Main outcome measures Comfort to intervene when concerned about supplying prescription opioids and pharmacists' discussing these concerns with the patient, and the prescriber. Results Most pharmacists were concerned about supplying prescription opioids to patients in the past week. Being female [adjusted odds ratio (aOR) 0.63; 95% confidence interval (CI) 0.47-0.85] was associated with reduced comfort, while practicing within a large chain pharmacy (aOR 1.52, 95% CI 1.08-2.15) was associated with greater comfort to intervene when concerned about prescription opioid supply. Pharmacists practicing in rural areas were significantly less likely than those in capital cities to discuss concerns with patients (aOR 0.66, 95% CI 0.45-0.97). Post-graduate education about substance use disorders was associated with increased likelihood of discussing concerns with patients (aOR 1.54, 95% CI 1.12-2.13). Pharmacists that indicated greater comfort in intervening when concerned about prescription opioids were more likely to discuss concerns with both patients and prescribers. Females were significantly more likely to discuss concerns with prescribers (aOR 1.67, 95% CI 1.22-2.29), whereas years of practice reduced the odds of discussing concerns with prescribers (aOR 0.98, 95% CI 0.97-0.99). Conclusion Considering specific factors such as gender and years of practice to help target pharmacist training may lead to increased comfort in discussing concerns related to prescription opioids, which in turn may improve communication with prescribers and patients.
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21
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Edelman EJ, Li Y, Barry D, Braden JB, Crystal S, Kerns RD, Gaither JR, Gordon KS, Manhapra A, Merlin JS, Moore BA, Oldfield BJ, Park LS, Rentsch CT, Skanderson M, Williams EC, Justice AC, Tate JP, Becker WC, Marshall BD. Trajectories of Self-Reported Opioid Use Among Patients With HIV Engaged in Care: Results From a National Cohort Study. J Acquir Immune Defic Syndr 2020; 84:26-36. [PMID: 32267658 PMCID: PMC7147724 DOI: 10.1097/qai.0000000000002310] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND No prior studies have characterized long-term patterns of opioid use regardless of source or reason for use among patients with HIV (PWH). We sought to identify trajectories of self-reported opioid use and their correlates among a national sample of PWH engaged in care. SETTING Veterans Aging Cohort Study, a prospective cohort including PWH receiving care at 8 US Veterans Health Administration (VA) sites. METHODS Between 2002 and 2018, we assessed past year opioid use frequency based on self-reported "prescription painkillers" and/or heroin use at baseline and follow-up. We used group-based trajectory models to identify opioid use trajectories and multinomial logistic regression to determine baseline factors independently associated with escalating opioid use compared to stable, infrequent use. RESULTS Among 3702 PWH, we identified 4 opioid use trajectories: (1) no lifetime use (25%); (2) stable, infrequent use (58%); (3) escalating use (7%); and (4) de-escalating use (11%). In bivariate analysis, anxiety; pain interference; prescribed opioids, benzodiazepines and gabapentinoids; and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. In multivariable analysis, illness severity, pain interference, receipt of prescribed benzodiazepine medications, and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. CONCLUSION Among PWH engaged in VA care, 1 in 15 reported escalating opioid use. Future research is needed to understand the impact of psychoactive medications and marijuana use on opioid use and whether enhanced uptake of evidence-based treatment of pain and psychiatric symptoms can prevent escalating use among PWH.
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Affiliation(s)
- E. Jennifer Edelman
- Yale School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - Yu Li
- Brown University School of Public Health, Providence, RI
| | | | - Jennifer Brennan Braden
- University of Washington School of Medicine, Seattle, WA
- Valley Medical Center Psychiatry and Counseling, Behavioral Health Integration Program
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, Rutgers, NJ
| | - Robert D. Kerns
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Kirsha S. Gordon
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Ajay Manhapra
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Brent A. Moore
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | | | - Christopher T. Rentsch
- VA Connecticut Healthcare System, West Haven, CT
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Emily C. Williams
- VA Puget Sound Health Services Research and Development and Department of Health Services, University of Washington, Seattle, WA
| | - Amy C. Justice
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Janet P. Tate
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - William C. Becker
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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22
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Sullivan MD. Commentary on Higgins et al. (2020): How are chronic pain, psychological distress and opioid dependence related? Addiction 2020; 115:259-260. [PMID: 31884702 DOI: 10.1111/add.14850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 10/02/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Mark D Sullivan
- University of Washington, Psychiatry and Behavioral Sciences University of Washington System, Seattle,, WA, USA
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23
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Santo T, Larance B, Bruno R, Gisev N, Nielsen S, Degenhardt L, Campbell G. Correlates of indicators of potential extra-medical opioid use in people prescribed opioids for chronic non-cancer pain. Drug Alcohol Rev 2019; 39:128-134. [PMID: 31841260 DOI: 10.1111/dar.13021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/24/2019] [Accepted: 11/25/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION AND AIMS The opioid-related behaviours in treatment (ORBIT) scale are a measure of recent indicators of potential extra-medical opioid use. Indicators of potential extra-medical opioid use are divergent practices among people prescribed opioids that may place them at risk of harm. This study aimed to examine the correlates of indicators of potential extra-medical opioid use in people prescribed opioids for chronic non-cancer pain (CNCP). DESIGN AND METHODS The Pain and Opioids IN Treatment (POINT) study is a prospective cohort study of people prescribed opioids for CNCP in Australia. People prescribed opioids solely for opioid dependence were excluded. This cross-sectional study utilised logistic regression to determine the characteristics associated with reporting any indicators of potential extra-medical opioid use. RESULTS Of the 1505 participants, 38% reported at least one indicator of potential extra-medical opioid use, most commonly asking for an increase in prescribed opioid dose (21%) and early prescription renewal (12%). Indicators of potential extra-medical opioid use were associated with younger age (adjusted odds ratio [AOR] = 0.98; 95% confidence interval [CI] = 0.92, 0.99), male sex (AOR = 1.53; 95% CI = 1.15, 2.04), lifetime pharmaceutical opioid use disorder (AOR = 1.87; 95% CI = 1.31, 2.66) and lifetime illicit drug use disorder (AOR = 1.72; 95% CI = 1.18, 2.52). DISCUSSION AND CONCLUSIONS Over one-third of the POINT cohort reported one or more indicators of potential extra-medical opioid use. Lifetime substance use disorders were associated these divergent practices, highlighting the importance of clinical monitoring and patient education for this patient group. Longitudinal studies are needed to investigate whether indicators of potential extra-medical opioid use predict opioid use disorders in this population.
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Affiliation(s)
- Thomas Santo
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.,School of Psychology, University of Wollongong, Wollongong, Australia.,Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.,School of Medicine, University of Tasmania, Hobart, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.,Monash Addiction Research Centre, Monash University, Melbourne, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
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24
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Fiore JF, Olleik G, El-Kefraoui C, Verdolin B, Kouyoumdjian A, Alldrit A, Figueiredo AG, Valanci S, Marquez-GdeV JA, Schulz M, Moldoveanu D, Nguyen-Powanda P, Best G, Banks A, Landry T, Pecorelli N, Baldini G, Feldman LS. Preventing opioid prescription after major surgery: a scoping review of opioid-free analgesia. Br J Anaesth 2019; 123:627-636. [DOI: 10.1016/j.bja.2019.08.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/21/2019] [Accepted: 08/10/2019] [Indexed: 01/28/2023] Open
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25
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de Souza Boff B, Silveira Filho J, Nonemacher K, Driessen Schroeder S, Dutra Arbo M, Rezin KZ. New psychoactive substances (NPS) prevalence over LSD in blotter seized in State of Santa Catarina, Brazil: A six-year retrospective study. Forensic Sci Int 2019; 306:110002. [PMID: 31864775 DOI: 10.1016/j.forsciint.2019.110002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 08/26/2019] [Accepted: 10/21/2019] [Indexed: 11/29/2022]
Abstract
Designer drugs or new psychoactive substances (NPS) are a heterogeneous group of substances obtained through the modification of chemical structure of some natural products or drugs. NPS illegally commercialized in blotter papers mimicking the most common form of LSD consumption, with a great variability of colours and symbols, have largely increased worldwide, including in Brazil, becoming an important emerging public health issue. In this study, we have evaluated the presence and profile of NPS in blotters seized in the State of Santa Catarina, Brazil, over the period of 2011 to 2017. The state government criminal forensics staff has performed gas chromatography-mass spectrometer (GC-MS) analyses in order to determine the chemical composition of the blotters. During the evaluated period, there was a considerable increase in the seizing of blotters events, from 87 in 2011, to 301 in 2016 and reaching 277 in 2017. There was also an increase in the number of blotters seized per event. Interestingly, while in 2011, 100% of blotters contained LSD, this number decreased to 0,1% in 2014, and achieved 17,6% in 2017, when up to 25 different substances were detected in blotters seized. Drugs such as DOx, NBOMe, fentanyl, mescaline derivatives, triptamines, cathinones, and synthetic cannabinoids were detected and became the major substances found in blotters. In some cases, more than one substance was found in the same blotter, characterizing a new mixture scenario. The presence of several new psychoactive substances in blotters is a reality in forensic toxicology. In Brazil, it might be related to the fact that most of these substances were not considered illegal by Brazilian legislation by the time they emerged.
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Affiliation(s)
- Bruna de Souza Boff
- Instituto Geral de Perícias (IGP-SC), Rua Pastor Willian Richard Schisler Filho, 590 - Itacorubi - Florianópolis, Santa Catarina, Brazil.
| | - Jair Silveira Filho
- Instituto Geral de Perícias (IGP-SC), Rua Pastor Willian Richard Schisler Filho, 590 - Itacorubi - Florianópolis, Santa Catarina, Brazil
| | - Karina Nonemacher
- Instituto Geral de Perícias (IGP-SC), Rua Pastor Willian Richard Schisler Filho, 590 - Itacorubi - Florianópolis, Santa Catarina, Brazil
| | - Samilla Driessen Schroeder
- Instituto Geral de Perícias (IGP-SC), Rua Pastor Willian Richard Schisler Filho, 590 - Itacorubi - Florianópolis, Santa Catarina, Brazil
| | - Marcelo Dutra Arbo
- Laboratório de Toxicologia, (LATOX), Departamento de Análises, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul (UFRGS), Av. Ipiranga 2752/605B 90610-000 Porto Alegre, Rio Grande do Sul, Brazil
| | - Kéttulin Zomer Rezin
- Instituto Geral de Perícias (IGP-SC), Rua Pastor Willian Richard Schisler Filho, 590 - Itacorubi - Florianópolis, Santa Catarina, Brazil
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26
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Rege SV, Ngo DA, Ait-Daoud N, Holstege CP. Epidemiology of severe buprenorphine exposures reported to the U.S. Poison Centers. Drug Alcohol Depend 2019; 202:115-122. [PMID: 31344599 DOI: 10.1016/j.drugalcdep.2019.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/10/2019] [Accepted: 05/14/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study aims to evaluate the trends and risk factors of severe buprenorphine outcomes (SBO) reported to the U.S. Poison Centers (PCs). METHODS We queried the National Poison Data System for exposures to buprenorphine from 2011 to 2016. SBO cases were defined as exposures that resulted in either a death or major clinical outcomes. Trends were tested using Poisson regression. Characteristics of the exposures were descriptively assessed. Logistic regression was used to evaluate the risk factors of SBO. RESULTS SBO cases (967) reported to the PCs increased by 66.6% during this period (114-190, p < 0.001). While adults between 20 and 39 years were more frequent in the SBO group (50.4%) compared to the non-SBO group (38.7%), cases under 6 years (29.6% vs 13.8%) were more common among the non-SBO group. Intentional abuse (20.1% vs 24.9%) and suspected suicides (13.7% vs 37.5%) were significantly higher among the SBO group. Multisubstance exposures were more frequent among the SBO cases (36.4% vs 71.4%). SBO risk increased with age, with cases above 60 years (AOR: 1.66, 95% CI: 1.14-2.42) demonstrating significantly increased odds. Suspected suicide (AOR: 1.87, 95% CI: 1.53-2.28) and abuse (AOR: 1.40, 95% CI: 1.13-1.73) cases were more likely to result in a SBO. Multisubstance exposures significantly increased the risk of a SBO. CONCLUSIONS This study reflected an increase in the cases of SBO paralleling the rise in the buprenorphine prescriptions. Age, reasons for exposure and multi-substance exposures significantly increased the risk of SBO.
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Affiliation(s)
- Saumitra V Rege
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, 1222 Jefferson Park Avenue, Charlottesville, VA, 22903, USA.
| | - Duc Anh Ngo
- Department of Student Health, Division of Student Affairs, University of Virginia, 400 Brandon Ave, Charlottesville, VA 22903, USA
| | - Nassima Ait-Daoud
- Department of Student Health, Division of Student Affairs, University of Virginia, 400 Brandon Ave, Charlottesville, VA 22903, USA; Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, VA, 22903, USA
| | - Christopher P Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, 1222 Jefferson Park Avenue, Charlottesville, VA, 22903, USA; Department of Student Health, Division of Student Affairs, University of Virginia, 400 Brandon Ave, Charlottesville, VA 22903, USA
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27
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Harms associated with extramedical use of prescription opioid analgesics in Australia: A scoping review. Res Social Adm Pharm 2019; 15:925-935. [DOI: 10.1016/j.sapharm.2018.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/02/2018] [Indexed: 01/01/2023]
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28
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Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet 2019; 393:1547-1557. [PMID: 30983590 PMCID: PMC6556783 DOI: 10.1016/s0140-6736(19)30428-3] [Citation(s) in RCA: 268] [Impact Index Per Article: 53.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 02/07/2019] [Accepted: 02/15/2019] [Indexed: 12/11/2022]
Abstract
Worldwide, the use of prescription opioid analgesics more than doubled between 2001 and 2013, with several countries, including the USA, Canada, and Australia, experiencing epidemics of opioid misuse and abuse over this period. In this context, excessive prescribing of opioids for pain treatment after surgery has been recognised as an important concern for public health and a potential contributor to patterns of opioid misuse and related harm. In the second paper in this Series we review the evolution of prescription opioid use for pain treatment after surgery in the USA, Canada, and other countries. We summarise evidence on the extent of opioid overprescribing after surgery and its potential association with subsequent opioid misuse, diversion, and the development of opioid use disorder. We discuss evidence on patient, physician, and system-level predictors of excessive prescribing after surgery, and summarise recent work on clinical and policy efforts to reduce such prescribing while ensuring adequate pain control.
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Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian T Bateman
- Department of Anesthesia, Perioperative, and Pain Medicine, and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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29
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White R, Hayes C, Boyes AW, Chiu S, Paul CL. General practitioners and management of chronic noncancer pain: a cross-sectional survey of influences on opioid deprescribing. J Pain Res 2019; 12:467-475. [PMID: 30774416 PMCID: PMC6348964 DOI: 10.2147/jpr.s168785] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background General practitioners’ (GPs) views about deprescribing prescription opioid analgesics (POAs) may influence the care provided for patients experiencing chronic noncancer pain (CNCP). There are limited data addressing GPs’ beliefs about deprescribing, including their decisions to deprescribe different types of POAs. Aim To determine the proportion of GPs who hold attitudes congruent with local pain stewardship, describe their deprescribing decisions, and determine whether type of POA influences deprescribing. Design and setting In 2016, a cross-sectional survey of all GPs (n=1,570) in one mixed urban and regional primary health network (PHN) in Australia was undertaken. Methods A mailed self-report questionnaire assessed agreement with local guidelines for treating CNCP; influences on deprescribing POAs and likelihood of deprescribing in a hypothetical case involving either oral codeine or oxycodone. Results A response rate of 46% was achieved. Approximately half (54%) of GPs agreed POAs should be reserved for people with acute, cancer pain or palliative care and a third (32%) did not agree that a medication focus has limited benefits for peoples’ long-term quality of life and function. Most (77%) GPs were less likely to deprescribe when effective alternate treatments were lacking, while various patient factors (eg, fear of weaning) were reported to decrease the likelihood of deprescribing for 25% of GPs. A significantly higher proportion of GPs reported being very likely to deprescribe codeine compared to the equivalent opioid dose of oxycodone for a hypothetical patient. Conclusions Many GPs in the PHN hold attitudes at odds with local guidance that opioids are a nonsuperior treatment for CNCP. Attitudinal barriers to deprescribing include: a lack of consistent approach to deprescribing opioids as a class of drugs, perceived lack of effective treatment alternatives and patient fear of deprescribing. Therefore, the next step in this target population is to appropriately train and support GPs in how to apply the evidence in practice and how to support patients appropriately.
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Affiliation(s)
- Ruth White
- Hunter Integrated Pain Service, Hunter New England Health, Newcastle, NSW, Australia, .,School of Medicine and Public Health, University of Newcastle, NSW, Australia,
| | - Chris Hayes
- Hunter Integrated Pain Service, Hunter New England Health, Newcastle, NSW, Australia,
| | - Allison W Boyes
- School of Medicine and Public Health, University of Newcastle, NSW, Australia, .,Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Simon Chiu
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Christine L Paul
- School of Medicine and Public Health, University of Newcastle, NSW, Australia, .,Hunter Medical Research Institute, Newcastle, NSW, Australia
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30
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Lalic S, Ilomäki J, Bell JS, Korhonen MJ, Gisev N. Prevalence and incidence of prescription opioid analgesic use in Australia. Br J Clin Pharmacol 2019; 85:202-215. [PMID: 30338545 PMCID: PMC6303244 DOI: 10.1111/bcp.13792] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/03/2018] [Accepted: 10/05/2018] [Indexed: 12/30/2022] Open
Abstract
AIMS The aims of the current study were to determine the prevalence and incidence of prescription opioid analgesic use in Australia and compare the characteristics of people with and without cancer initiating prescription opioid analgesics. METHODS A retrospective population-based study was conducted using the random 10% sample of adults who were dispensed prescription opioid analgesics in Australia between July 2013 and June 2017 through the Pharmaceutical Benefits Scheme. Poisson regression was used to calculate rate ratios (RR) for opioid prevalence and incidence. The characteristics of people initiating opioids, including type of opioid initiated, total oral morphine equivalents dispensed, prescriber speciality, medical comorbidities, and past analgesic and benzodiazepine use, were compared for people with and without cancer. RESULTS Opioid prevalence increased {RR = 1.006 [95% confidence interval (CI) 1.004, 1.008]}, while incidence decreased [RR = 0.977 (95% CI 0.975,0.979)] from 2013/2014 to 2016/2017. There were between 287 677 and 307 772 prevalent users each year. In total, 769 334 adults initiated opioids between 2013/2014 and 2016/2017, and half of these initiations were by general practitioners. Initiation with a strong opioid occurred in 55.8% of those with cancer and 28.2% of those without cancer. CONCLUSION Rates of opioid use have remained high since 2013, with approximately 3 million adults using opioids and over 1.9 million adults initiating opioids each year. Between 2013 and 2017, opioid prevalence has slightly increased but incidence has decreased. People without cancer account for the majority of opioid use and are more likely to be initiated on short-acting and weak opioids. Initiation of strong opioids has increased over time, reinforcing concerns about increased use and the harms associated with strong opioids in the community.
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Affiliation(s)
- Samanta Lalic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, SciencesMonash UniversityMelbourneVICAustralia
- Pharmacy DepartmentAustin HealthMelbourneVICAustralia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, SciencesMonash UniversityMelbourneVICAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVICAustralia
| | - J. Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, SciencesMonash UniversityMelbourneVICAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVICAustralia
- School of Pharmacy and Medical SciencesUniversity of South AustraliaAdelaideSAAustralia
| | - Maarit Jaana Korhonen
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, SciencesMonash UniversityMelbourneVICAustralia
- Institute of BiomedicineUniversity of TurkuTurkuFinland
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW SydneySydneyNSWAustralia
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31
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Larance B, Gisev N, Cama E, Nelson EC, Darke S, Larney S, Degenhardt L. Predictors of transitions across stages of heroin use and dependence prior to treatment-seeking among people in treatment for opioid dependence. Drug Alcohol Depend 2018; 191:145-151. [PMID: 30107320 PMCID: PMC6698181 DOI: 10.1016/j.drugalcdep.2018.03.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 03/30/2018] [Accepted: 03/31/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIMS Little is known about transition pathways among heroin users prior to treatment. This study examined the demographic and clinical predictors of transition speed from heroin use, to dependence, to first treatment episode. METHODS 1149 heroin-dependent participants recruited from opioid agonist treatment clinics in Sydney, Australia, underwent a structured interview. Age of onset (AOO) was collected for heroin use, dependence and treatment-seeking, childhood maltreatment, psychiatric history and other substance dependence. Discrete-time survival analyses modelled years from onset of use to dependence, and from dependence to treatment-seeking, including demographic and clinical covariates. FINDINGS Median AOO for first heroin use, dependence and treatment-seeking was 18 years (inter-quartile range, or IQR = 6), 21 years (IQR = 7), and 24 years (IQR = 10) respectively. In adjusted models, younger birth cohorts (vs. born <1960), greater childhood maltreatment and later AAO of first heroin use were associated with more rapid transitions from heroin use to dependence. Living independently, parental violence, and alcohol dependence were associated with slower transitions. Earlier treatment-seeking was associated with younger birth cohorts, having dependent children and later AOO of dependence. Delayed treatment-seeking was associated with <10 years school education, living independently, depression and alcohol dependence. CONCLUSIONS In this treatment sample, onset of heroin use occurred during late adolescence, suggesting the need for targeted interventions in mid-adolescence. Transitions to heroin dependence, then treatment-seeking, occurred during early adulthood. Rapid transitions from use to dependence were associated with younger birth cohorts, greater exposure to childhood maltreatment, and later onset of use.
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Affiliation(s)
- Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King Street Randwick, Sydney, NSW, 2052, Australia.
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King Street Randwick, Sydney, NSW 2052, Australia
| | - Elena Cama
- National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King Street Randwick, Sydney, NSW 2052, Australia
| | - Elliot C. Nelson
- Washington University, School of Medicine, Department of Psychiatry, 660 South Euclid Avenue, Campus Box 8134, St. Louis, MO 63110, USA
| | - Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King Street Randwick, Sydney, NSW 2052, Australia
| | - Sarah Larney
- National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King Street Randwick, Sydney, NSW 2052, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King Street Randwick, Sydney, NSW 2052, Australia
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32
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Herrmann ES, Jarvis BP, Sparks AC, Cohn AM, Koszowski B, Rosenberry ZR, Coleman-Cowger VH, Pickworth WB, Peters EN. Sweet flowers are slow, and weeds make haste: leveraging methodology from research on tobacco, alcohol, and opioid analgesics to make rapid and policy-relevant advances in cannabis science. Int Rev Psychiatry 2018; 30:238-250. [PMID: 30179535 PMCID: PMC6396691 DOI: 10.1080/09540261.2018.1465400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The legalization of medical and recreational cannabis use has occurred ahead of science. The current evidence base has poor utility for determining if cannabis products can meet the standards of safety, efficacy, and quality intrinsic to modern medicine, and for informing regulation of cannabis as a legal intoxicant. Individual jurisdictions that pass cannabis reforms may not have adequate resources to support the level of new scientific research needed to inform regulatory actions; this could make it difficult to keep a rapidly growing multi-billion-dollar cannabis industry in check. Further, the present lack of evidence-based regulatory oversight for cannabis parallels the climates that gave rise to the tobacco and prescription opioid epidemics, suggesting that continued omission may result in negative public health consequences. However, translating a methodological framework developed through research on these compounds may promote rapid advances in cannabis science germane to regulatory knowledge gaps. The present review highlights specific advancements in these areas, as well as in alcohol regulation, that are prime for informing policy-relevant cannabis science, and also offers some recommendations for evidence-based regulatory policy. Resulting progress may directly inform both regulation of cannabis in both medical and licit recreational drug frameworks, and new cannabis-related public health initiatives.
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Affiliation(s)
- Evan S. Herrmann
- Individual and Population Health, Battelle, Baltimore, MD, USA,CONTACT: Evan S. Herrmann Individual and Population Health, Battelle, Baltimore, MD, 21209, USA[TQ1]
| | | | | | - Amy M. Cohn
- Individual and Population Health, Battelle, Baltimore, MD, USA
| | | | | | | | | | - Erica N. Peters
- Individual and Population Health, Battelle, Baltimore, MD, USA
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