A statewide evaluation of seven strategies to reduce opioid overdose in North Carolina

Claims data analysis of provider-to-provider tele-mentoring program impact on opioid prescribing in Missouri

OBJECTIVE

The objective of this study was to assess opioid prescribing patterns of primary care providers (PCPs) participating in a virtual tele-mentoring program for patients with chronic pain as compared to nonparticipants.

DESIGN

We utilized Missouri Medicaid claims from 2013 to 2021 to compare opioid prescription dosages and daily supply of opioids prescribed by PCPs. Participants and nonparticipants were matched using propensity score matching.

SETTING

Missouri Medicaid data were received through partnership with the Center for Health Policy's MO HealthNet Data Project, the state's leading provider of Medicaid data.

PARTICIPANTS

Missouri-based prescribers.

INTERVENTION

Show-Me Project Extension for Community Healthcare Outcomes (ECHO), an evidence-based provider-to-provider telehealth intervention that connects PCPs with a team of specialists.

MAIN OUTCOME MEASURES

We compared the rate of prescription opioid >50 morphine milligram equivalents (MMEs), mean MMEs/day, and mean number of daily supply to understand the impact of the ECHO model on providers' opioid prescribing.

RESULTS

Patients treated by ECHO providers have 33 percent lower odds of being prescribed opioid dose >50 MME/day (p < 0.001) compared to non-ECHO providers. There is also a 14 percent reduction in the average opioid dose prescribed to patients of ECHO providers (p < 0.001). We observed a 3 percent (p < 0.001) reduction in average daily supply of opioids among patients of ECHO providers compared to the comparison group.

CONCLUSIONS

Pain Management ECHO supports PCPs with needed education and skills to provide specialty care in the management of pain conditions and safe prescribing of opioid medications.

Impact of the COVID-19 pandemic on adult mental health-related admissions at a large university health system in North Carolina - one year into the pandemic

OBJECTIVE

Pandemic-associated stress may have exacerbated preexisting mental health and substance use disorders (MH/SUD) and caused new MH/SUD diagnoses which would be expected to lead to an increase in visits to emergency departments and hospital admissions for these conditions. This study assessed whether the proportion of hospital and emergency department encounters for MH/SUD diagnoses increased during the first year of the COVID-19 pandemic in the United States.

METHODS

We conducted a longitudinal (interrupted time series) analysis of 994,724 eligible encounters identified by electronic query between January 1, 2016 and March 31, 2021. Of these, 55,574 encounters involved MH/SUD diagnosis. The pre-pandemic period was defined as January 1, 2016 to March 31, 2020, and the pandemic period was defined as April 1, 2020 to March 31, 2021. All statistical analyses were performed with R.

RESULTS

No significant trend in MH/SUD encounters at baseline (rate ratio 1.00, 95% CI 0.99-1.01, p = 0.75) was observed. However, the onset of the pandemic was temporally associated with a significant level increase in the proportion of MH/SUD encounters relative to overall encounters (rate ratio 1.14, 95% CI 1.06-1.21, p<0.001) with no change in the overall trend (rate ratio 0.99, 95% CI 0.90-1.10, p = 0.89).

CONCLUSIONS

The significant pandemic-associated increase in the proportion of MH/SUD encounters relative to overall encounters was driven largely by sustained numbers of MH/ SUD encounters despite a decrease in total encounters. Increased support for mental health care is needed for these vulnerable patients during pandemics.

Supporting community overdose response planning in Ontario, Canada: Findings from a situational assessment

Background

Many communities across North America are coming together to develop comprehensive plans to address and respond to the escalating overdose crisis, largely driven by an increasingly toxic unregulated drug supply. As there is a need to build capacity for successful implementation, the objective of our mixed methods study was to identify the current planning and implementation practices, needs, and priority areas of support for community overdose response plans in Ontario, Canada.

Methods

We used a situational assessment methodology to collect data on current planning and implementation practices, needs, and challenges related to community overdose response plans in Ontario, consisting of three components. Between November 2019 to February 2020, we conducted ten semi-structured key informant interviews, three focus groups with 25 participants, and administered an online survey (N = 66). Purposeful sampling was used to identify professionals involved in coordinating, supporting, or partnering on community overdose response plans in jurisdictions with relevant information for Ontario including other Canadian provinces and American states. Key informants included evaluators, representatives involved in centralised supports, as well as coordinators and partners on community overdose response plans. Focus group participants were coordinators or leads of community overdose response plans in Ontario.

Results

Sixty-six professionals participated in the study. The current planning and implementation practices of community overdose response plans varied in Ontario. Our analysis generated four overarching areas for needs and support for the planning and implementation of community overdose response plans: 1) data and information; 2) evidence and practice; 3) implementation/operational factors; and 4) partnership, engagement, and collaboration. Addressing stigma and equity within planning and implementation of community overdose response plans was a cross-cutting theme that included meaningful engagement of people with living and lived expertise and meeting the service needs of different populations and communities.

Conclusions

Through exploring the needs and related supports for community overdose response plans in Ontario, we have identified key priority areas for building local capacity building to address overdose-related harms. Ongoing development and refinement, community partnership, and evaluation of our project will highlight the influence of our supports to advance the capacity, motivation, and opportunities of community overdose response plans.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13762-0.

Retrospective analysis of patterns of opioid overdose and interventions delivered at a tertiary hospital emergency department: impact of COVID-19

Background

Opioid-related overdoses cause substantial numbers of preventable deaths. Naloxone is an opioid antagonist available in take-home naloxone (THN) kits as a lifesaving measure for opioid overdose. As the emergency department (ED) is a primary point of contact for patients with high-risk opioid use, evidence-based recommendations from the Society of Hospital Pharmacists of Australia THN practice guidelines include the provision of THN, accompanied by psychosocial interventions. However, implementation of these guidelines in practice is unknown. This study investigated ED opioid-related overdose presentations, concordance of post-overdose interventions with the THN practice guidelines, and the impact, if any, of the SARS-CoV-2 (COVID-19) pandemic on case presentations.

Methods

A single-centre retrospective audit was conducted at a major tertiary hospital of patients presenting with overdoses involving opioids and non-opioids between March to August 2019 and March to August 2020. Patient presentations and interventions delivered by the paramedics, ED and upon discharge from the ED were collated from medical records and analysed using descriptive statistics, chi square and independent T-tests.

Results

The majority (66.2%) of patients presented to hospital with mixed drug overdoses involving opioids and non-opioids. Pharmaceutical opioids were implicated in a greater proportion (72.1%) of overdoses than illicit opioids. Fewer patients presented in March to August 2020 as compared with 2019 (26 vs. 42), and mixed drug overdoses were more frequent in 2020 than 2019 (80.8% vs. 57.1%). Referral to outpatient psychology (22.0%) and drug and alcohol services (20.3%) were amongst the most common post-discharge interventions. Naloxone was provided to 28 patients (41.2%) by the paramedics and/or ED. No patients received THN upon discharge.

Conclusions

This study highlights opportunities to improve ED provision of THN and other interventions post-opioid overdose. Large-scale multi-centre studies are required to ascertain the capacity of EDs to provide THN and the impact of COVID-19 on opioid overdose presentations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00604-w.

How do naloxone-based interventions work to reduce overdose deaths: a realist review

BACKGROUND

Naloxone-based interventions as part of health systems can reverse an opioid overdose. Previous systematic reviews have identified the effectiveness of naloxone; however, the role of context and mechanisms for its use has not been explored. This realist systematic review aims to identify a theory of how naloxone works based on the contexts and mechanisms that contribute to the success of the intervention for improved outcomes.

METHODS

Pre-registered at PROSPERO, this realist review followed RAMESES standards of reporting. Keywords included 'naloxone' and ' opioid overdose'. All study designs were included. Data extraction using 55 relevant outputs based on realist logic produced evidence of two middle-range theories: Naloxone Bystander Intervention Theory and Skills Transfer Theory.

RESULTS

Harm reduction and/or low threshold contexts provide a non-judgemental approach which support in-group norms of helping and empower the social identity of the trained and untrained bystander. This context also creates the conditions necessary for skills transfer and diffusion of the intervention into social networks. Stigma and negative attitudes held by first responders and stakeholders involved in the implementation process, such as police or GPs, can prohibit the bystander response by inducing fear in responding. This interferes with skills transfer, naloxone use and carriage of naloxone kits.

CONCLUSIONS

The findings provide theoretically informed guidance regarding the harm reduction contexts that are essential for the successful implementation of naloxone-based interventions. Peer-to-peer models of training are helpful as it reinforces social identity and successful skills transfer between bystanders. Health systems may want to assess the prevalence of, and take steps to reduce opioid-related stigma with key stakeholders in contexts using a low threshold training approach to build an environment  to support positive naloxone outcomes.

TRIAL REGISTRATION

PROSPERO 2019 CRD42019141003.

Gaps in hepatitis C virus prevention and care for HIV-hepatitis C virus co-infected people who inject drugs in Canada

BACKGROUND

People who inject drugs (PWID) living with HIV are a priority population for eliminating hepatitis C virus (HCV) as a public health threat. Maximizing access to HCV prevention and treatment strategies are key steps towards elimination. We aimed to evaluate engagement in harm reduction programs and HCV treatment, and to describe injection practices among HIV-HCV co-infected PWID in Canada from 2003 to 2019.

METHODS

We included Canadian Coinfection Cohort study participants who reported injecting drugs between 2003 and 2019 in Quebec, Ontario, Saskatchewan, and British Columbia, Canada. We investigated temporal trends in HCV treatment uptake, efficacy, and effectiveness; injection practices; and engagement in harm reduction programs in three time periods based on HCV treatment availability: 1) interferon/ribavirin (2003-2010); 2) first-generation direct acting antivirals (DAAs) (2011-2013); 3) second-generation DAAs (2014-2019). Harm reduction services assessed included needle and syringe programs (NSP), opioid agonist therapy (OAT), and supervised injection sites (SIS).

RESULTS

Median age of participants (N = 1,077) at cohort entry was 44 years; 69% were males. Province-specific HCV treatment rates increased among HCV RNA-positive PWID, reaching 16 to 31 per 100 person-years in 2014-2019. Treatment efficacy improved from a 50 to 70% range in 2003-2010 to >90% across provinces in 2014-2019. Drug injecting patterns among active PWID varied by province, with an overall decrease in cocaine injection frequency and increasing opioid injections. In the most recent time period (2014-2019), needle/syringe sharing was reported at 8-22% of visits. Gaps remained in engagement in harm reduction programs: NSP use decreased (58-70% of visits), OAT engagement among opioid users was low (8-26% of visits), and participants rarely used SIS (1-15% of visits).

CONCLUSION

HCV treatment uptake and outcomes have improved among HIV-HCV coinfected PWID. Yet, this population remains exposed to drug-related harms, highlighting the need to tie HCV elimination strategies with enhanced harm reduction programs to improve overall health for this population.

Implementation of a New Hampshire community-initiated response to the opioid crisis: A mixed-methods process evaluation of Safe Station

BACKGROUND

New Hampshire (NH) ranked first for fentanyl- and all opioid-related overdose deaths per capita from 2014 to 2016 and third in 2017 with no rate reduction from the previous year relative to all other states in the US. In response to the opioid crisis in NH, Manchester Fire Department (MFD), the state's largest city fire department, launched the Safe Station program in 2016 in partnership with other community organizations. This community-based response to the crisis-described as a connection to recovery-focuses on reducing barriers to accessing resources for people with substance use and related problems. The study aim is to characterize the multi-organizational partnerships and workflow of the Safe Station model and identify key components that are engaging, effective, replicable, and sustainable.

METHODS

A mixed-methods design included: semi-structured qualitative interviews conducted with 110 stakeholders from six groups of community partners (Safe Station clients, MFD staff and leadership, and local emergency department, ambulance, and treatment partner staff); implementation and sustainability surveys (completed by MFD stakeholders); and ethnographic observations conducted at MFD. Qualitative data were content analyzed and coded using the Consolidated Framework for Implementation Research. Survey subscales were scored and evaluated to corroborate the qualitative findings.

RESULTS

Community partners identified key program characteristics including firefighter compassion, low-threshold access, and immediacy of service linkage. Implementation and sustainability survey data corroborate the qualitative interview and observation data in these areas. All participants agreed that community partnerships are key to the program's success. There were mixed evaluations of the quality of communication among the organizations.

CONCLUSION

Safe Station is a novel response to the opioid crisis in New Hampshire that offers immediate, non-judgmental access to services for persons with opioid use disorders requiring community-wide engagement and communication. Data convergence provides guidance to the sustainability and replicability of the program.

Academic detailing increases prescription drug monitoring program use among primary care practices

OBJECTIVE

Clinical review of a prescription drug monitoring program (PDMP) is considered a valuable tool for opioid prescribing risk mitigation; however, PDMP use is often low, even in states with mandatory registration and use policies. The objective was to evaluate the impact of an academic detailing (AD) outreach intervention on PDMP use among primary care prescribers.

METHODS

AD intervention was delivered to primary care based controlled substance prescribers (N = 87) and their associated PDMP delegates (n = 42) by a clinical pharmacist as 1 component of a large-scale, statewide initiative to improve opioid prescribing safety. Prescriber PDMP use behavior was assessed by prescriber self-report and analysis of objective 2016-2018 PDMP data regarding the number of monthly report requests. We compared means between pre- and postintervention using a paired t test and plotted the monthly average reports over time to assess the trend of mean reports over time. Generalized linear mixed model with a negative binomial distribution was used to assess the difference in the trend and magnitude of the combined count of reports for the entire sample and prescriber subsets that were segmented on the basis of the adoption status of PDMP.

RESULTS

The monthly mean of reports by combined prescribers and delegates significantly increased after the AD intervention (mean 28.1 pre vs. 53.0 post; P < 0.001), with the increase in delegate reports (mean 17.1 pre vs. 60.0 post; P < 0.001) driving the overall increase. Reports were requested 40.4 times more often than in the preintervention period (P < 0.001). Patterns of pre- to postchanges in mean monthly report requests differed by baseline PDMP adoption status.

CONCLUSION

The AD intervention was transformative in facilitating practice change to use delegates to run reports. Visits with both prescribers and delegates, including hands-on PDMP training and registration assistance, can be viewed as beneficial for practice facilitation.

Association between supportive interventions and healthcare utilization and outcomes in patients on long-term prescribed opioid therapy presenting to acute healthcare settings: a systematic review and meta-analysis

BACKGROUND

Long-term prescription of opioids by healthcare professionals has been linked to poor individual patient outcomes and high resource utilization. Supportive strategies in this population regarding acute healthcare settings may have substantial impact.

METHODS

We performed a systematic review and meta-analysis of primary studies. The studies were included according to the following criteria: 1) age 18 and older; 2) long-term prescribed opioid therapy; 3) acute healthcare setting presentation from a complication of opioid therapy; 4) evaluating a supportive strategy; 5) comparing the effectiveness of different interventions; 6) addressing patient or healthcare related outcomes. We performed a qualitative analysis of supportive strategies identified. We pooled patient and system related outcome data for each supportive strategy.

RESULTS

A total of 5664 studies were screened and 19 studies were included. A total of 9 broad categories of supportive strategies were identified. Meta-analysis was performed for the "supports for patients in pain" supportive strategy on two system-related outcomes using a ratio of means. The number of emergency department (ED) visits were significantly reduced for cohort studies (n = 6, 0.36, 95% CI [0.20-0.62], I2 = 87%) and randomized controlled trials (RCTs) (n = 3, 0.71, 95% CI [0.61-0.82], I2 = 0%). The number of opioid prescriptions at ED discharge was significantly reduced for RCTs (n = 3, 0.34, 95% CI [0.14-0.82], I2 = 78%).

CONCLUSION

For patients presenting to acute healthcare settings with complications related to long-term opioid therapy, the intervention with the most robust data is "supports for patients in pain".

Implementing harm reduction in non-urban communities affected by opioids and polysubstance use: A qualitative study exploring challenges and mitigating strategies

BACKGROUND

Harm reduction services, which typically provide overdose education and prevention with distribution of naloxone and other supplies related to safer drug use, help reduce opioid-related overdose and infectious disease transmission. However, structural stigma and the ongoing criminalization of drug use have limited the expansion of harm reduction services into many non-urban communities in the United States that have been increasingly affected by the health consequences of opioid and polysubstance use.

METHODS

We conducted qualitative interviews with 22 professionals working with people who use drugs in cities and towns across Rhode Island and Massachusetts to understand challenges and strategies for engaging communities in accepting harm reduction perspectives and services.

RESULTS

Our thematic analysis identified several interrelated challenges to implementing harm reduction services in non-urban communities, including: (1) limited understandings of harm reduction practice and preferential focus on substance use treatment and primary prevention, (2) community-level stigma against people who use drugs as well as the agencies supporting them, (3) data reporting and aggregating leading to inaccurate perceptions about local patterns of substance use and related health consequences, and (4) a "prosecutorial mindset" against drug use and harm reduction. From key informants' narratives, we also identified specific strategies that communities could use to address these challenges, including: (1) identifying local champions to advocate for harm reduction strategies, (2) proactively educating communities about harm reduction approaches before they are implemented, (3) improving the visibility of harm reduction services within communities, and (4) obtaining "buy-in" from a wide range of local stakeholders including law enforcement and local government.

CONCLUSION

These findings carry important implications for expanding harm reduction services, including syringe service programs and safe injection sites, into non-urban communities that have a demonstrated need for evidence-based interventions to reduce drug-related overdose and infectious disease transmission.

Community engagement to implement evidence-based practices in the HEALing communities study

BACKGROUND

The implementation of evidence-based practices to reduce opioid overdose deaths within communities remains suboptimal. Community engagement can improve the uptake and sustainability of evidence-based practices. The HEALing Communities Study (HCS) aims to reduce opioid overdose deaths through the Communities That HEAL (CTH) intervention, a community-engaged, data-driven planning process that will be implemented in 67 communities across four states.

METHODS

An iterative process was used in the development of the community engagement component of the CTH. The resulting community engagement process uses phased planning steeped in the principles of community based participatory research. Phases include: 0) Preparation, 1) Getting Started, 2) Getting Organized, 3) Community Profiles and Data Dashboards, 4) Community Action Planning, 5) Implementation and Monitoring, and 6) Sustainability Planning.

DISCUSSION

The CTH protocol provides a common structure across the four states for the community-engaged intervention and allows for tailored approaches that meet the unique needs or sociocultural context of each community. Challenges inherent to community engagement work emerged early in the process are discussed.

CONCLUSION

HCS will show how community engagement can support the implementation of evidence-based practices for addressing the opioid crisis in highly impacted communities. Findings from this study have the potential to provide communities across the country with an evidence-based approach to address their local opioid crisis; advance community engaged research; and contribute to the implementation, sustainability, and adoption of evidence-based practices.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04111939).

A Rapid Review of the Impact of Systems-Level Policies and Interventions on Population-Level Outcomes Related to the Opioid Epidemic, United States and Canada, 2014-2018

OBJECTIVES

In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies.

METHODS

We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings.

RESULTS

The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed.

CONCLUSIONS

Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.

Association between opioid analgesic therapy and initiation of buprenorphine management: An analysis of prescription drug monitoring program data

BACKGROUND

In the US, medication assisted treatment, particularly with office-based buprenorphine, has been an important component of opioid dependence treatment among patients with iatrogenic addiction to opioid analgesics. The predictors of initiating buprenorphine for addiction among opioid analgesic patients have not been well-described.

METHODS

We conducted a time-to-event analysis using data from the North Carolina (NC) Prescription Drug Monitoring Program (PDMP). Our outcome of interest was time-to-initiation of sublingual buprenorphine. Our study population was a prospective cohort of all state residents receiving a full-agonist opioid analgesic between 2011 and 2015. Predictors of initiation of sublingual buprenorphine examined included: age, gender, cumulative pharmacies and prescribers utilized, cumulative opioid intensity (defined as cumulative opioid exposure divided by duration of opioid exposure), and benzodiazepine dispensing.

FINDINGS

Of 4.3 million patients receiving opioid analgesics in NC between 2011 and 2015 (accumulated 8.30 million person-years of follow-up), and a total of 28,904 patients initiated buprenorphine formulations intended for addiction treatment (overall rate 3.48 per 1,000 person-years). In adjusted multivariate models, the utilization of 3 or more pharmacies (HR: 2.93; 95% CI: 2.82, 3.05) or 6 or more controlled substance prescribers (HR: 12.09; 95% CI: 10.76, 13.57) was associated with buprenorphine initiation. A dose-response relationship was observed for cumulative opioid intensity (HR in highest decile relative to lowest decile: 5.05; 95% CI: 4.70, 5.42). Benzodiazepine dispensing was negatively associated with buprenorphine initiation (HR: 0.63; 95% CI: 0.61, 0.65).

CONCLUSIONS

Opioid analgesic patients utilizing multiple prescribers or pharmacies are more likely to initiate sublingual buprenorphine. This finding suggests that patients with multiple healthcare interactions are more likely to be treated for high-risk opioid use, or may be more likely to be identified and treated for addiction. Future research should utilize prescription monitoring program data linked to electronic health records to include diagnosis information in analytic models.

Evidence for state, community and systems-level prevention strategies to address the opioid crisis

BACKGROUND

Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.

METHODS

We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.

RESULTS

The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.

CONCLUSIONS

Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

Evidence for state, community and systems-level prevention strategies to address the opioid crisis

BACKGROUND

Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.

METHODS

We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.

RESULTS

The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.

CONCLUSIONS

Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

Touchpoints - Opportunities to predict and prevent opioid overdose: A cohort study

BACKGROUND

Medical care, public health, and criminal justice systems encounters could serve as touchpoints to identify and intervene with individuals at high-risk of opioid overdose death. The relative risk of opioid overdose death and proportion of deaths that could be averted at such touchpoints are unknown.

METHODS

We used 8 individually linked data sets from Massachusetts government agencies to perform a retrospective cohort study of Massachusetts residents ages 11 and older. For each month in 2014, we identified past 12-month exposure to 4 opioid prescription touchpoints (high dosage, benzodiazepine co-prescribing, multiple prescribers, or multiple pharmacies) and 4 critical encounter touchpoints (opioid detoxification, nonfatal opioid overdose, injection-related infection, and release from incarceration). The outcome was opioid overdose death. We calculated Standardized Mortality Ratios (SMRs) and Population Attributable Fractions (PAFs) associated with touchpoint exposure.

RESULTS

The cohort consisted of 6,717,390 person-years of follow-up with 1315 opioid overdose deaths. We identified past 12-month exposure to any touchpoint in 2.7% of person-months and for 51.8% of opioid overdose deaths. Opioid overdose SMRs were 12.6 (95% CI: 11.1, 14.1) for opioid prescription and 68.4 (95% CI: 62.4, 74.5) for critical encounter touchpoints. Fatal opioid overdose PAFs were 0.19 (95% CI: 0.17, 0.21) for opioid prescription and 0.37 (95% CI: 0.34, 0.39) for critical encounter touchpoints.

CONCLUSIONS

Using public health data, we found eight candidate touchpoints were associated with increased risk of fatal opioid overdose, and collectively identified more than half of opioid overdose decedents. These touchpoints are potential targets for development of overdose prevention interventions.

'Communities are attempting to tackle the crisis': a scoping review on community plans to prevent and reduce opioid-related harms

OBJECTIVES

We sought to understand the implementation of multifaceted community plans to address opioid-related harms.

DESIGN

Our scoping review examined the extent of the literature on community plans to prevent and reduce opioid-related harms, characterise the key components, and identify gaps.

DATA SOURCES

We searched MEDLINE, Embase, PsycINFO, CINHAL, SocINDEX and Academic Search Primer, and three search engines for English language peer-reviewed and grey literature from the past 10 years.

ELIGIBILITY CRITERIA

Eligible records addressed opioid-related harms or overdose, used two or more intervention approaches (eg, prevention, treatment, harm reduction, enforcement and justice), involved two or more partners and occurred in an Organisation for Economic Co-operation and Development country.

DATA EXTRACTION AND SYNTHESIS

Qualitative thematic and quantitative analysis was conducted on the charted data. Stakeholders were engaged through fourteen interviews, three focus groups and one workshop.

RESULTS

We identified 108 records that described 100 community plans in Canada and the USA; four had been evaluated. Most plans were provincially or state funded, led by public health and involved an average of seven partners. Commonly, plans used individual training to implement interventions. Actions focused on treatment and harm reduction, largely to increase access to addiction services and naloxone. Among specific groups, people in conflict with the law were addressed most frequently. Community plans typically engaged the public through in-person forums. Stakeholders identified three key implications to our findings: addressing equity and stigma-related barriers towards people with lived experience of substance use; improving data collection to facilitate evaluation; and enhancing community partnerships by involving people with lived experience of substance use.

CONCLUSION

Current understanding of the implementation and context of community opioid-related plans demonstrates a need for evaluation to advance the evidence base. Partnership with people who have lived experience of substance use is underdeveloped and may strengthen responsive public health decision making.

Association between harm reduction strategies and healthcare utilization in patients on long-term prescribed opioid therapy presenting to acute healthcare settings: a protocol for a systematic review and meta-analysis

INTRODUCTION

Opioids are routinely used to treat a variety of chronic conditions associated with pain. However, they are a class of medications with a significant potential for adverse health effects, with and without misuse. Opioid misuse, as defined as inappropriate use of appropriately prescribed opioids, is becoming more well-recognized publicly but does not have clear treatment options. Opioid misuse has been linked to variety of poor outcomes and its consequences have a significant impact on healthcare resource utilization. The evidence on harm reduction strategies to mitigate adverse events prompting presentation to acute care settings for patients presenting with long-term opioid use is sparse.

METHODS AND ANALYSIS

We will perform a systematic review and meta-analysis to catalog effective harm reduction strategies and identify the most effective ones to reduce avoidable healthcare utilization in patients on long-term opioid therapy who present to acute health care settings with complications attributed to opioid misuse. A search strategy will be developed and executed by an information specialist; electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library) and additional sources will be searched. Search themes will include opioids, chronic drug use, and acute healthcare settings. Citation screening, selection, quality assessment, and data abstraction will be performed in duplicate. A comprehensive inventory of harm reduction strategies will be developed. Data will be collected on patient-related outcomes associated with each identified harm reduction strategy. When sufficiently homogeneous data on interventions, population, and outcomes is available, it will be pooled for aggregate analysis. Evaluation of the methodological quality of individual studies and of the quality of the body of evidence will be performed. Our primary objective will be to identify harm reduction strategies that have been shown to result in clinically relevant and statistically significant improvements in patient outcomes and/or decreased healthcare utilization.

DISCUSSION

This study will better characterize harm reduction strategies for patients on long-term prescribed opioids presenting to acute healthcare settings. It will also add new knowledge and generate greater understanding of key knowledge gaps of the long-term prescribed opioid use and its impact on healthcare utilization.

SYSTEMATIC REVIEW REGISTRATION

CRD42018088962 .

Training experiences regarding pain management, addiction, and drug diversion of dentists enrolled in the National Dental Practice-Based Research Network

Background: The purpose of this study was to describe dentists' training experiences relevant to pain management, addiction, and prescription opioid drug diversion and examine associations between these training experiences and dentists' opioid prescribing practices. Methods: A Web-based, cross-sectional survey was conducted among practicing dentist members of the National Dental Practice-Based Research Network (PBRN; N = 822). The survey assessed pain management prescribing practices and training experiences related to pain management and assessment for addiction and drug diversion. Survey data were linked with National Dental PBRN Enrollment Questionnaire data regarding practitioner demographics and practice characteristics. Results: The majority of dentists (67%) reported prior training in pain management; however, a minority of dentists reported prior training regarding identification and assessment of drug abuse or addiction (48%) or identification of prescription drug diversion (25%). The majority of training experiences across all topics occurred through continuing dental education participation. Dental school training relevant to pain management, addiction, and identification of drug diversion was more prevalent among more recent dental school graduates. Training experiences were associated with prescribing practices. Conclusions: Results suggest that across multiple levels of training, many dentists are not receiving training specific to addiction assessment and identification of drug diversion. Such training is associated with greater consistency of risk mitigation implementation in practice.

Army and Navy ECHO Pain Telementoring Improves Clinician Opioid Prescribing for Military Patients: an Observational Cohort Study

BACKGROUND

Opioid overdose deaths occur in civilian and military populations and are the leading cause of accidental death in the USA.

OBJECTIVE

To determine whether ECHO Pain telementoring regarding best practices in pain management and safe opioid prescribing yielded significant declines in opioid prescribing.

DESIGN

A 4-year observational cohort study at military medical treatment facilities worldwide.

PARTICIPANTS

Patients included 54.6% females and 46.4% males whose primary care clinicians (PCCs) opted to participate in ECHO Pain; the comparison group included 39.9% females and 60.1% males whose PCCs opted not to participate in ECHO Pain.

INTERVENTION

PCCs attended 2-h weekly Chronic Pain and Opioid Management TeleECHO Clinic (ECHO Pain), which included pain and addiction didactics, case-based learning, and evidence-based recommendations. ECHO Pain sessions were offered 46 weeks per year. Attendance ranged from 1 to 3 sessions (47.7%), 4-19 (32.1%, or > 20 (20.2%).

MAIN MEASURES

This study assessed whether clinician participation in Army and Navy Chronic Pain and Opioid Management TeleECHO Clinic (ECHO Pain) resulted in decreased prescription rates of opioid analgesics and co-prescribing of opioids and benzodiazepines. Measures included opioid prescriptions, morphine milligram equivalents (MME), and days of opioid and benzodiazepine co-prescribing per patient per year.

KEY RESULTS

PCCs participating in ECHO Pain had greater percent declines than the comparison group in (a) annual opioid prescriptions per patient (- 23% vs. - 9%, P < 0.001), (b) average MME prescribed per patient/year (-28% vs. -7%, p < .02), (c) days of co-prescribed opioid and benzodiazepine per opioid user per year (-53% vs. -1%, p < .001), and (d) the number of opioid users (-20.2% vs. -8%, p < .001). Propensity scoring transformation-adjusted results were consistent with the opioid prescribing and MME results.

CONCLUSIONS

Patients treated by PCCs who opted to participate in ECHO Pain had greater declines in opioid-related prescriptions than patients whose PCCs opted not to participate.

Causal inference for evaluating prescription opioid abuse using trend-in-trend design

PURPOSE

One response to the opioid crisis in the United States has been the development of opioid analgesics with properties intended to reduce non-oral use. Previous evaluations of abuse in the community have relied on population averaged interrupted time series Poisson models with utilization offsets. However, competing interventions and secular trends complicate interpretation of time-series analyses. An alternative research design, trend-in-trend, accounts for heterogeneity in per capita opioid dispensing and unmeasured time-varying confounding, which provides a causal evaluation, provided that underlying assumptions are met.

METHODS

Trend-in-trend can be modeled using a logistic regression framework. In logistic regression, exposure was any product-specific outpatient dispensing by three-digit ZIP code and calendar quarter, for 22 opioids. The outcome was any product-specific abuse case ascertained from poison centers and drug treatment programs, covering 94% of the US population, between July 2009 and December 2016. Product-specific odds ratios compared places without dispensing with places with any dispensing; the causal contrast represents the odds of product-specific abuse in the community given exposure.

RESULTS

Dispensing of new and low-volume opioids varied considerably across the country, with no region showing high of all products. Of 22 opioids analyzed, the three with approved labeling as intended to deter abuse ranked near the lowest in both absolute (population-adjusted rates: 1.7, 0.9, and 8.2 per million people per quarter, respectively) and relative measures (trend-in-trend ORs: 1.96, 1.79, 1.69, respectively).

CONCLUSIONS

Postmarketing studies of prescription opioid abuse may benefit by evolving from unadjusted surveillance rates to a causal inference approach.

Associations between implementation of Project Lazarus and opioid analgesic dispensing and buprenorphine utilization in North Carolina, 2009-2014

Background

Project Lazarus (PL) is a seven-strategy, community-coalition-based intervention designed to reduce opioid overdose and dependence. The seven strategies include: community education, provider education, hospital emergency department policy change, diversion control, support programs for patients with pain, naloxone policies, and addiction treatment expansion. PL was originally developed in Wilkes County, NC. It was made available to all counties in North Carolina starting in March 2013 with funding of up to $34,400 per county per year. We examined the association between PL implementation and 1) overall dispensing rate of opioid analgesics, and 2) utilization of buprenorphine. Buprenorphine is often used in connection with medication assisted treatment (MAT) for opioid dependence.

Methods

Observational interrupted time series analysis of 100 counties over 2009–2014 (n = 7200 county-months) in North Carolina. The intervention period was March 2013–December 2014. 74 of 100 counties implemented the intervention. Exposure data sources comprised process surveys, training records, Prescription Drug Monitoring Program (PDMP) data, and methadone treatment program quality data. Outcomes were PDMP-derived counts of opioid prescriptions and buprenorphine patients. Incidence Rate Ratios were estimated with adjusted GEE Poisson regression models of all seven PL strategies.

Results

In adjusted models, diversion control efforts were positively associated with increased dispensing of opioid analgesics (IRR: 1.06; 95% CI: 1.03, 1.09). None of the other PL strategies were associated with reduced prescribing of opioid analgesics. Support programs for patients with pain were associated with a non-significant decrease in buprenorphine utilization (IRR: 0.93; 95% CI: 0.85, 1.02), but addiction treatment expansion efforts were associated with no change in buprenorphine utilization (IRR: 0.98; 95% CI: 0.91, 1.06).

Conclusions

Implementation of PL strategies did not appreciably reduce opioid dispensing and did not increase buprenorphine utilization. These results are consistent with previous findings of limited impact of PL strategies on overdose morbidity and mortality. Future studies should analyze the uptake of MAT using a more expansive view of institutional barriers, treating community coalition activity around MAT as an effect modifier.

Management of Pain in the United States-A Brief History and Implications for the Opioid Epidemic

Pain management in the United States reflects attitudes to those in pain. Increased numbers of disabled veterans in the 1940s to 1960s led to an increased focus on pain and its treatment. The view of the person in pain has moved back and forth between a physiological construct to an individual with pain where perception may be related to social, emotional, and cultural factors. Conceptually, pain has both a medical basis and a political context, moving between, for example, objective evidence of disability due to pain and subjective concerns of malingering. In the 20th century, pain management became predominately pharmacologic. Perceptions of undertreatment led to increased use of opioids, at first for those with cancer-related pain and then later for noncancer pain without the multidimensional care that was intended. The increased use was related to exaggerated claims in the medical literature and by the pharmaceutical industry, of a lack of addiction in the setting of noncancer pain for these medications-a claim that was subsequently found to be false and deliberatively deceptive; an epidemic of opioid prescribing began in the 1990s. An alarming rise in deaths due to opioids has led to several efforts to decrease use, both in patients with noncancer conditions and in those with cancer and survivors of cancer.

Opioid Crisis: No Easy Fix to Its Social and Economic Determinants

The accepted wisdom about the US overdose crisis singles out prescribing as the causative vector. Although drug supply is a key factor, we posit that the crisis is fundamentally fueled by economic and social upheaval, its etiology closely linked to the role of opioids as a refuge from physical and psychological trauma, concentrated disadvantage, isolation, and hopelessness. Overreliance on opioid medications is emblematic of a health care system that incentivizes quick, simplistic answers to complex physical and mental health needs. In an analogous way, simplistic measures to cut access to opioids offer illusory solutions to this multidimensional societal challenge. We trace the crisis' trajectory through the intertwined use of opioid analgesics, heroin, and fentanyl analogs, and we urge engaging the structural determinants lens to address this formidable public health emergency. A broad focus on suffering should guide both patient- and community-level interventions.