Determinants of increased opioid-related mortality in the United States and Canada, 1990-2013: a systematic review

Social and economic determinants of drug overdose deaths: a systematic review of spatial relationships

PURPOSE

To synthesize the available evidence on the extent to which area-level socioeconomic conditions are associated with drug overdose deaths in the United States.

METHODS

We performed a systematic review (in MEDLINE, EMBASE, PsychINFO, Web of Science, EconLit) for papers published prior to July 2022. Eligible studies quantitatively estimated the association between an area-level measure of socioeconomic conditions and drug overdose deaths in the US, and were published in English. We assessed study quality using the Effective Public Health Practice Project Quality Assessment Tool. The protocol was preregistered at Prospero (CRD42019121317).

RESULTS

We identified 28 studies that estimated area-level effects of socioeconomic conditions on drug overdose deaths in the US. Studies were scored as having moderate to serious risk of bias attributed to both confounding and in analysis. Socioeconomic conditions and drug overdose death rates were moderately associated, and this was a consistent finding across a large number of measures and differences in study designs (e.g., cross-sectional versus longitudinal), years of data analyzed, and primary unit of analysis (e.g., ZIP code, county, state).

CONCLUSIONS

This review highlights the evidence for area-level socioeconomic conditions are an important factor underlying the geospatial distribution of drug overdose deaths in the US and the need to understand the mechanisms underlying these associations to inform future policy recommendations. The current evidence base suggests that, at least in the United States, employment, income, and poverty interventions may be effective targets for preventing drug overdose mortality rates.

Opioid characteristics and nonopioid interventions associated with successful opioid taper in patients with chronic noncancer pain

ABSTRACT

Current research indicates that tapering opioids may improve pain and function in patients with chronic noncancer pain. However, gaps in the literature remain regarding the choice of opioid and nonopioid interventions to support a successful taper. This study used an Australian primary care data set to identify a cohort of patients on long-term opioid therapy commencing opioid taper between January 2016 and September 2019. Using logistic regression analysis, we compared key clinical factors associated with differing taper outcomes. Of a total of 3371 patients who commenced taper, 1068 (31.7%) completed taper within 12 months. In the 3 months after commencement of taper, compared with those who did not complete taper, patients who successfully completed opioid taper were less likely to be prescribed buprenorphine (odds ratio [OR] 0.691; 95% CI: 0.530-0.901), fentanyl (OR, 0.429; 95% CI: 0.295-0.622), and long-acting (LA) opioids, including methadone (OR, 0.349; 95% CI: 0.157-0.774), oxycodone-naloxone (OR, 0.521; 95% CI: 0.407-0.669), and LA tapentadol (OR, 0.645; 95% CI: 0.461-0.902), but more likely to be prescribed codeine (OR, 1.308; 95% CI: 1.036-1.652). Compared with those who did not complete taper, patients who successfully tapered were less likely to be prescribed any formulations of oxycodone (short-acting [SA]: OR, 0.533; 95% CI: 0.422-0.672, LA: OR, 0.356; 95% CI: 0.240-0.530) and tramadol (SA: OR, 0.370; 95% CI: 0.218-0.628, LA: OR, 0.317; 95% CI: 0.234-0.428). The type of opioid prescribed in the months after commencement of taper seems to influence the taper outcomes. These findings may inform prospective studies on opioid taper.

Psychosocial factors associated with overdose subsequent to Illicit Drug use: a systematic review and narrative synthesis

BACKGROUND AND AIMS

Psychological and social status, and environmental context, may mediate the likelihood of experiencing overdose subsequent to illicit drug use. The aim of this systematic review was to identify and synthesise psychosocial factors associated with overdose among people who use drugs.

METHODS

This review was registered on Prospero (CRD42021242495). Systematic record searches were undertaken in databases of peer-reviewed literature (Medline, Embase, PsycINFO, and Cinahl) and grey literature sources (Google Scholar) for work published up to and including 14 February 2023. Reference lists of selected full-text papers were searched for additional records. Studies were eligible if they included people who use drugs with a focus on relationships between psychosocial factors and overdose subsequent to illicit drug use. Results were tabulated and narratively synthesised.

RESULTS

Twenty-six studies were included in the review, with 150,625 participants: of those 3,383-4072 (3%) experienced overdose. Twenty-one (81%) studies were conducted in North America and 23 (89%) reported polydrug use. Psychosocial factors associated with risk of overdose (n = 103) were identified and thematically organised into ten groups. These were: income; housing instability; incarceration; traumatic experiences; overdose risk perception and past experience; healthcare experiences; perception of own drug use and injecting skills; injecting setting; conditions with physical environment; and social network traits.

CONCLUSIONS

Global rates of overdose continue to increase, and many guidelines recommend psychosocial interventions for dependent drug use. The factors identified here provide useful targets for practitioners to focus on at the individual level, but many identified will require wider policy changes to affect positive change. Future research should seek to develop and trial interventions targeting factors identified, whilst advocacy for key policy reforms to reduce harm must continue.

Prevalence and Correlates of Opioid-Involved Suicides in Maryland

OBJECTIVE

Involvement of opioids in suicides has doubled during the past two decades, worsening a major public health concern. This study examined the characteristics of opioid-involved suicides.

METHODS

The sample of decedents (N = 12,038) in Maryland between 2006 and 2020 was used to compare the characteristics of opioid-involved suicides (n = 947) with suicides not involving opioids (n = 6,896) and accidental opioid deaths (n = 4,125). Direct comparisons were then made between opioid-involved suicides with and without the additional presence of non-opioid substances.

RESULTS

Opioid-involved suicides were significantly more likely than suicides not involving opioids to occur among those aged 18-64 years, non-Hispanic Whites, and unemployed or disabled individuals. Opioid-involved suicides were more likely than accidental opioid deaths to occur among females, those aged <18 years, non-Hispanic Whites, and employed individuals. Of all suicides involved opioids, 45% involved other non-opioid substances. Polysubstance opioid suicides were significantly more likely than suicides involving opioids only to occur among non-Hispanic Whites.

CONCLUSIONS

Significant differences were observed in the demographic groups most at risk for opioid-involved suicide than other suicide or accidental opioid death. Among opioid-involved suicides, polysubstance involvement also represents a distinct group. These findings may enhance the targeting of prevention efforts.

The contributions of avoidable causes of death to gender gap in life expectancy and life disparity in the US and Canada: 2001-2019

OBJECTIVES

This study measures public health policies' and healthcare system's influence, by assessing the contributions of avoidable deaths, on the gender gaps in life expectancy and disparity (GGLD and GGLD, respectively) in the United States (US) and Canada from 2001 to 2019.

METHODS

To estimate the GGLE and GGLD, we retrieved age- and sex-specific causes of death from the World Health Organization's mortality database. By employing the continuous-change model, we decomposed the GGLE and GGLD by age and cause of death for each year and over time using females as the reference group.

RESULTS

In Canada and the US, the GGLE (GGLD) narrowed (increased) by 0.9 (0.2) and 0.2 (0.3) years, respectively. Largest contributor to the GGLE was non-avoidable deaths in Canada and preventable deaths in the US. Preventable deaths had the largest contributions to the GGLD in both countries. Ischemic heart disease contributed to the narrowing GGLE/GGLD in both countries. Conversely, treatable causes of death increased the GGLE/GGLD in both countries. In Canada, "treatable & preventable" as well as preventable causes of death narrowed the GGLE while opposite was seen in the US. While lung cancer contributed to the narrowing GGLE/GGLD, drug-related death contributed to the widening GGLE/GGLD in both countries. Injury-related deaths contributed to the narrowing GGLE/GGLD in Canada but not in the US. The contributions of avoidable causes of death to the GGLE declined in the age groups 55-74 in Canada and 70-74 in the US, whereas the GGLE widened for ages 25-34 in the US.

CONCLUSION

Canada experienced larger reduction in the GGLE compared to the US attributed mainly to preventable causes of death. To narrow the GGLE and GGLD, the US needs to address injury deaths. Urgent interventions are required for drug-related death in both countries, particularly among males aged 15-44 years.

A Diagram of the Social-Ecological Conditions of Opioid Misuse and Overdose

The United States is experiencing a crisis of opioid misuse and overdose. To understand the underlying factors, researchers have begun looking upstream to identify social and structural determinants. However, no study has yet aggregated these into a comprehensive ecology of opioid overdose. We scoped 68 literature sources and compiled a master list of opioid misuse and overdose conditions. We grouped the conditions and used the Social Ecological Model to organize them into a diagram. We reviewed the diagram with nine subject matter experts (SMEs) who provided feedback on its content, design, and usefulness. From a literature search and SME interviews, we identified 80 unique conditions of opioid overdose and grouped them into 16 categories. In the final diagram, we incorporated 40 SME-recommended changes. In commenting on the diagram's usefulness, SMEs explained that the diagram could improve intervention planning by demonstrating the complexity of opioid overdose and highlighting structural factors. However, care is required to strike a balance between comprehensiveness and legibility. Multiple design formats may be useful, depending on the communication purpose and audience. This ecological diagram offers a visual perspective of the conditions of opioid overdose.

Developmental Approaches to Chronic Pain: A Narrative Review

Chronic pain, which can potentially develop from acute pain, subacute pain, or breakthrough pain, is generally defined as pain persisting for greater than three months with minimal relief. Chronic pain can be associated with a myriad of medical conditions. It is also one of the most common causes of disability, physical suffering, depression, and reduced quality of life. Treatment can vary depending on the underlying pathophysiology and can involve physical therapy, non-pharmaceutical approaches, pharmaceutical drugs, and invasive procedures. Currently available pharmaceutical agents have been effective for short-term management of chronic pain conditions, but few options address chronic pain with long-term efficacy. First-line pharmaceutical agents can potentially include over-the-counter (OTC) or prescription-strength non-steroidal anti-inflammatory drugs (NSAIDs), which have been linked to numerous side effects. If chronic pain persists, steroids are frequently used to provide longer relief. For more progressive or resistant chronic pain and/or in conjunction with invasive procedures, opioids have been utilized for acute treatment and for long-term maintenance. While these agents have proven to be effective for both acute and long-term use due to their modulation at various peripheral and central opioid receptors, they can be associated with numerous side effects and tied to the risk of addiction. As such, an unmet need exists to identify treatment modalities that provide opioid-like pain relief without opioid-induced adverse effects and the potential for addiction. This narrative review will provide an overview of the currently available treatment modalities for chronic pain and their adverse event profiles, as well as a review of therapies that are currently in development and/or preclinical trials for the management and treatment of chronic pain.

Socioeconomic marginalization and risk of overdose in a community-recruited cohort of people who use drugs: A longitudinal analysis

BACKGROUND

Poverty and socioeconomic disadvantage are important contributors to drug-related harm, but their precise role in overdose risk remains poorly understood. We sought to examine linkages between socioeconomic marginalization and non-fatal overdose risk in a community deeply affected by the ongoing drug poisoning crisis.

METHODS

This observational study used data derived from two community-recruited prospective cohorts of people who use drugs (PWUD) in Vancouver, British Columbia, Canada. Generalized linear mixed-effects models were used to assess longitudinal associations between multiple dimensions of socioeconomic disadvantage and self-reported non-fatal overdose.

RESULTS

Between 2014 and 2020, 1,493 participants (38.2% women; 59.6% white; 35.7% Indigenous) provided 9,968 interviews. Non-fatal overdose was reported by 32.5% of participants over the study period. In multivariable analyses, non-fatal overdose was independently associated with incarceration (adjusted odds ratios [AOR]: 1.42, 95% confidence interval [CI]: 1.08-1.88, p=0.012), homelessness (AOR: 1.57, 95%CI: 1.27-1.93, p<0.001), increased monthly income (AOR: 1.01, 95%CI: 1.00-1.01, p=0.029), and lower material security (AOR: 0.76, 95%CI: 0.67-0.88, p<0.001). We also observed differing strengths of association between illegal income generation and overdose in men (AOR: 1.84, 95%CI: 1.46-2.32, p<0.001) compared to women (AOR: 1.37, 95%CI: 1.06-1.78, p=0.016).

CONCLUSION

Non-fatal overdose was positively associated with incarceration, homelessness, higher monthly income, material insecurity, and engagement illegal income generating activities, underscoring the importance of addressing the socioeconomic production of overdose risk. These initiatives may include supportive housing interventions, alternative economic supports, and broader drug policy reform.

Leading consumption patterns of psychoactive substances in Colombia: A deep neural network-based clustering-oriented embedding approach

The number of health-related incidents caused using illegal and legal psychoactive substances (PAS) has dramatically increased over two decades worldwide. In Colombia, the use of illicit substances has increased up to 10.3%, while the consumption alcohol and tobacco has increased to 84% and 12%, respectively. It is well-known that identifying drug consumption patterns in the general population is essential in reducing overall drug consumption. However, existing approaches do not incorporate Machine Learning and/or Deep Data Mining methods in combination with spatial techniques. To enhance our understanding of mental health issues related to PAS and assist in the development of national policies, here we present a novel Deep Neural Network-based Clustering-oriented Embedding Algorithm that incorporates an autoencoder and spatial techniques. The primary goal of our model is to identify general and spatial patterns of drug consumption and abuse, while also extracting relevant features from the input data and identifying clusters during the learning process. As a test case, we used the largest publicly available database of legal and illegal PAS consumption comprising 49,600 Colombian households. We estimated and geographically represented the prevalence of consumption and/or abuse of both PAS and non-PAS, while achieving statistically significant goodness-of-fit values. Our results indicate that region, sex, housing type, socioeconomic status, age, and variables related to household finances contribute to explaining the patterns of consumption and/or abuse of PAS. Additionally, we identified three distinct patterns of PAS consumption and/or abuse. At the spatial level, these patterns indicate concentrations of drug consumption in specific regions of the country, which are closely related to specific geographic locations and the prevailing social and environmental contexts. These findings can provide valuable insights to facilitate decision-making and develop national policies targeting specific groups given their cultural, geographic, and social conditions.

Digital Therapeutics (DTx) Expand Multimodal Treatment Options for Chronic Low Back Pain: The Nexus of Precision Medicine, Patient Education, and Public Health

Digital therapeutics (DTx, software as a medical device) provide personalized treatments for chronic diseases and expand precision medicine beyond pharmacogenomics-based pharmacotherapies. In this perspective article, we describe how DTx for chronic low back pain (CLBP) can be integrated with pharmaceutical drugs (e.g., NSAIDs, opioids), physical therapy (PT), cognitive behavioral therapy (CBT), and patient empowerment. An example of an FDA-authorized DTx for CLBP is RelieVRx, a prescription virtual reality (VR) app that reduces pain severity as an adjunct treatment for moderate to severe low back pain. RelieVRx is an immersive VR system that delivers at-home pain management modalities, including relaxation, self-awareness, pain distraction, guided breathing, and patient education. The mechanism of action of DTx is aligned with recommendations from the American College of Physicians to use non-pharmacological modalities as the first-line therapy for CLBP. Herein, we discuss how DTx can provide multimodal therapy options integrating conventional treatments with exposome-responsive, just-in-time adaptive interventions (JITAI). Given the flexibility of software-based therapies to accommodate diverse digital content, we also suggest that music-induced analgesia can increase the clinical effectiveness of digital interventions for chronic pain. DTx offers opportunities to simultaneously address the chronic pain crisis and opioid epidemic while supporting patients and healthcare providers to improve therapy outcomes.

Testing the Decision Support Tool for Responsible Pain Management for Headache and Facial Pain Diagnosis with Opioid-Risk-Stratified Treatment

In primary and urgent care, headache and facial pain are common and challenging to diagnose and manage, especially with using opioids appropriately. We therefore developed the Decision Support Tool for Responsible Pain Management (DS-RPM) to assist healthcare providers in diagnosis (including multiple simultaneous diagnoses), workup (including triage), and opioid-risk-informed treatment. A primary goal was to supply sufficient explanations of DS-RPM's functions allowing critique. We describe the process of iteratively designing DS-RPM adding clinical content and testing/defect discovery. We tested DS-RPM remotely with 21 clinician-participants using three vignettes-cluster headache, migraine, and temporal arteritis-after first training to use DS-RPM with a trigeminal-neuralgia vignette. Their evaluation was both quantitative (usability/acceptability) and qualitative using semi-structured interviews. The quantitative evaluation used 12 Likert-type questions on a 1-5 scale, where 5 represented the highest rating. The mean ratings ranged from 4.48 to 4.95 (SDs ranging 0.22-1.03). Participants initially found structured data entry intimidating but adapted and appreciated its comprehensiveness and speed of data capture. They perceived DS-RPM as useful for teaching and clinical practice, making several enhancement suggestions. The DS-RPM was designed, created, and tested to facilitate best practice in management of patients with headaches and facial pain. Testing the DS-RPM with vignettes showed strong functionality and high usability/acceptability ratings from healthcare providers. Risk stratifying for opioid use disorder to develop a treatment plan for headache and facial pain is possible using vignettes. During testing, we considered the need to adapt usability/acceptability evaluation tools for clinical decision support, and future directions.

Supply-side predictors of fatal drug overdose in the Washington/Baltimore HIDTA region: 2016-2020

BACKGROUND

Rising rates of fentanyl- and polydrug-involved drug overdose deaths have prompted inquiry into the role of drug supply in fatal overdose outcomes in the United States. To date, however, there have been few empirical investigations of drug enforcement strategies on fatal overdose rates, despite knowledge that both drug use and supply are often geographically distributed. To address this limitation, we examined measures of drug enforcement as predictors of next-year fatal overdose rates in the Washington/Baltimore High Intensity Drug Trafficking Area (W/B HIDTA).

METHODS

We conducted mixed-effects models to examine the role of drug seizures and disruption in drug trafficking organizations (DTOs) and money laundering organizations (MLOs) on fatal overdose rates over a 5-year period (2016-2020) across 45 local jurisdictions in the W/B HIDTA region. Outcomes included any, opioid-involved, and fentanyl-involved fatal overdose.

RESULTS

Adjusting for covariates, both the total number of drug seizures and amount of cocaine seized (in dosage units per capita) positively predicted next-year opioid- and fentanyl-involved fatal overdose rates. Disruption to DTO and MLO operations did not significantly predict next-year fatal overdose rates for any outcome.

CONCLUSION

Supply-side enforcement activities alone may have limited impact on reducing fatal overdose rates, but may serve as important markers to identify communities at high risk of fatal overdose and facilitate targeted intervention. Our findings underscore the importance of comprehensive law enforcement approaches that extend beyond drug enforcement to integrate prevention, linkage to treatment, and harm reduction strategies as needed to address the overdose epidemic.

The spatial prevalence and associated factors of opioid overdose mortality in Milwaukee County, Wisconsin (2003-2018)

Mortality from opioid overdose has become the leading cause of non-natural death in Milwaukee County, Wisconsin in recent years. In order to better understand the opioid epidemic and formulate pro-active responses to the crisis at the local level, this study examines the spatial prevalence and associated factors of opioid overdoses that end in mortality in Milwaukee, WI using the spatial econometrics model. The social determinants of health framework is used to identify the potential related socioeconomic factors associated with opioid use and misuse. Using principal component analysis, 6 primary components are identified from the chosen social determinants and used as explanatory variables in the spatial econometric analysis. The age-adjusted standardized mortality rate is calculated for each census tract as the dependent variable in the analysis. Overall low socioeconomic status, labor-intensive occupations, income inequality, and the 20-34-year-old age group are identified as variables with a significant contribution to high overdose mortality rates, both directly and indirectly. A significant global spillover effect is also identified at the census tract level, indicating the severity of the opioid epidemic in Milwaukee County. This study reveals the overall contribution that socioeconomic factors have on the opioid epidemic and their associated feedback effects, providing targeted information on the opioid epidemic.

Opioid use for a first-incident upper extremity fracture in 220,440 patients without recent prior use in Ontario, Canada: a retrospective cohort study

To describe opioid use for a first upper extremity fracture in a cohort of patients who did not have recent opioid use.

Design

Descriptive epidemiological study.

Setting

Emergency Department, Hospital.

Patients/Participants

We obtained health administrative data records of adults presenting with a first adult upper extremity fracture from 2013 to 2017 in Ontario, Canada. We excluded patients with previous fractures, opioid prescription in the past 6 months or hospitalization >5 days after the fracture.

Intervention

Opioid prescription.

Main Outcome Measurements

We identified the proportion of patients filling an opioid prescription within 7 days of fracture. We described this based on different upper extremity fractures (ICD-10), Demographics (age, sex, rurality), comorbidity (Charlson Comorbidity Index, Rheumatoid arthritis, Diabetes), season of injury, and social marginalization (Ontario Marginalization Index-a data algorithm that combines a wide range of demographic indicators into 4 distinct dimensions of marginalization). We considered statistical differences (P< .01) that reached a standardized mean difference of 10% as being clinically important (standardized mean difference [SMD] ≥ 0.1).

Results

From 220,440 patients with a first upper extremity fracture (50% female, mean age 50), opioids were used by 34% of cases overall (32% in males, 36% in females, P< .001, SMD ≥ 0.1). Use varied by body region, with those with multiple or proximal fractures having the highest use: multiple shoulder 64%, multiple regions 62%, shoulder 62%, elbow 38%, wrist 31%, and hand 21%; and was higher in patients who had a nerve/tendon injury or hospitalization (P< .01, SMD ≥ 0.1). Social marginalization, comorbidity, and season of injury had clinically insignificant effects on opioid use.

Conclusions

More than one-third of patients who are recent-non-users will fill an opioid prescription within 7 days of a first upper extremity fracture, with usage highly influenced by fracture characteristics.Level of Evidence: Level II.

Long-term opioid use and mortality in patients with chronic non-cancer pain: Ten-year follow-up study in South Korea from 2010 through 2019

BACKGROUND

We aimed to investigate the prevalence and factors associated with long-term opioid use among patients with chronic non-cancer pain (CNCP).

METHODS

We extracted data from the National Health Insurance Service (NHIS) database in South Korea. As a nationwide database, the NHIS database contains information regarding all disease diagnoses and prescriptions for any drug and/or procedures. A total of 2.5% of adult patients (≥20 years of age) who were diagnosed with musculoskeletal diseases and CNCP from 2010 to 2019 were selected using a stratified random sampling technique and included in the analysis. Patients who were prescribed opioids continuously for ≥90 days were classified as long-term opioid users.

FINDINGS

A total of 19,645,161 patients with CNCP were included in the final analysis. The prevalence of long-term opioid use was 0.47% (95% confidence interval [CI]: 0.46%, 0.48%; 8421/1,808,043) in 2010, which gradually increased to 2.63% (95% CI: 2.61%, 2.66%; 49,846/1,892,913) in 2019. Among the 2010 cohort (n = 1,804,019), in multivariable logistic regression: old age, underlying disability, increased Charlson comorbidity index, use of benzodiazepine or Z-drug, rheumatoid arthritis, osteoarthritis, and low back pain were associated with an increased prevalence of long-term opioid use among patients with CNCP. In a multivariable Cox regression, the 10-year all-cause mortality in long-term opioid users was found to be 1·21-fold (hazard ratio: 1.21, 95% CI: 1.13, 1.31; P<0·001) higher than that in opioid-naive patients with CNCP.

INTERPRETATION

Long-term opioid use increased in patients with CNCP in South Korea from 2010 to 2019. Certain factors were potential risk factors for long-term opioid use. Moreover, long-term opioid use was associated with increased 10-year all-cause mortality among patients with CNCP.

FUNDING

None.

Oral Morphine as an Alternative Substitution Treatment for Opioid Use Disorder, a Rare but Non-risk-free Use

Background

National health monitoring agencies have reported the alternative use of morphine sulfate painkiller for maintenance treatment of opioid use disorder (OUD), associated with a potential increase in overdose risk.

Objectives

This study sought to assess the prevalence of regular and occasional legally prescribed morphine use in patients treated for OUD and compare their characteristics to those of patients receiving conventional opioid maintenance treatment (OMT), buprenorphine or methadone. Then, we assessed the factors associated with opioid overdose risk.

Methods

Data were extracted from the French national healthcare system database, covering the entire population in 2015. Diagnosis associated with hospital discharge and long-term disease codes were extracted to select the population and identify outcomes and covariates. OUD non-chronic pain patients were divided into regular (≤35 days between dispensing and ≥3 months of continuous treatment duration) morphine users, and occasional users. Their sociodemographic and health characteristics were compared to OMT controls. A multivariate logistic regression model was performed to determine factors associated with opioid overdose.

Results

In patients treated for OUD, 2,237 (2.2%) morphine users (1,288 regular and 949 occasional), 64,578 (63.7%) buprenorphine and 34,638 (34.1%) methadone controls were included. The prevalence of regular morphine use among patients treated for OUD regularly receiving an opioid was 1.3%. Compared to users who receive morphine regularly, occasional users had an increased risk of overdose [OR = 2.2 (1.5-3.3)], while the risk was reduced in the buprenorphine group [OR = 0.5 (0.4-0.7)] and not significantly different for methadone [OR = 1.0 (0.7-1.4)]. Other overdose risk factors were low-income, comorbidity, i.e., psychiatric conditions, alcohol use disorder or complications related to intravenous drug use, and coprescription with benzodiazepines or pregabalin. These factors were more frequent in morphine groups.

Conclusions

Patients that were prescribed oral morphine represented a small minority of the treated for OUD. The poorer health condition affected by numerous comorbidities and higher risk of opioid overdose in patients treated with oral morphine compared with OMT controls points toward the need to better supervise the practices of these patients, to strengthen multidisciplinary care and risk reduction measures.

Stepping up to the Canadian opioid crisis: a longitudinal analysis of the correlation between socioeconomic status and population rates of opioid-related mortality, hospitalization and emergency department visits (2000-2017)

INTRODUCTION

High levels of income inequality and increased opioid-related harm across Canada bring into question the role of socioeconomic status (SES) in the opioid epidemic. Only a few studies have examined this association, and most of those have analyzed this issue on a provincial level. This study examined the association between opioid-related health outcomes and SES, and investigated rate ratios over time.

METHODS

Administrative databases were used to identify opioid-related mortality, hospitalization and emergency department visits between 2000 and 2017. Patient's postal code was linked to the quintile of median household income at the forward sortation area level. Crude rates and age- and sex-adjusted rates in each quintile were calculated, as well as the adjusted rate ratio of average annual rates between the lowest and highest quintiles. The significance of the time trend of rate ratios for all outcomes was examined using linear regression.

RESULTS

A stepped gradient of opioid-related outcomes across all income quintiles emerged from these data. For mortality, hospitalization and emergency department visits, the average annual rate ratio between lowest quintile and highest quintile was 3.8, 4.3 and 4.9, respectively. These ratios were generally stable and consistent over the study period, albeit the opioid-related mortality SES gap decreased gradually (p < 0.01).

CONCLUSION

Area income quintile was found to be highly associated with opioid outcomes. Psychosocial factors (stress, unemployment, housing insecurity) that are typically concentrated in low SES areas may play a significant role in the opioid epidemic. Health policies should address these factors in order to provide effective solutions.

Opioid Literacy Among African Americans Living in Rural Alabama: Findings From a Social Determinants of Health (SDH) Framework

Limited research examining opioid literacy among African Americans (AAs) have been conducted. The current study examined the association between opioid literacy levels among AAs in rural Alabama using the social determinants of health framework. Three subscales in the Brief Opioid Overdose Knowledge questionnaire were used to measure opioid literacy. Among a sample of 253, limited opioid literacy was found. Social contact was found to be significantly associated with overall opioid literacy (B = .36, p < .05) and opioid general knowledge subscale (B = .14, p < .05). For the subscale of opioid overdose response knowledge, health insurance (B =−.59, p = .06) and social contact (B = .13, p = .07) emerged as marginally significant. The findings suggest that educational interventions are needed to increase opioid literacy among rural AAs, especially among those with limited social contact.

Effectiveness of Remote Intensive Counseling Versus Outpatient Counseling in Substance Use Disorders: A Retrospective Cohort Study

Background

Substance use disorders are a serious and persistent U.S. public health problem. Although a number of therapy modalities exist, few studies assessed the comparative effectiveness of specific therapies. This study empirically evaluated whether remote intensive counseling (RIC) is more effective than outpatient therapy (OT) in relapse prevention over the period of nine months in patients aged 18-45 years with a history of substance use.

Methods

The current study utilized a retrospective correlational cross-sectional cohort quantitative research design with multiple between-group comparisons and fixed effects. The sample (n=296) included adults of both sexes, of diverse racial/ethnic backgrounds, and of socioeconomic status (SES) between 18-45 years of age who had been using an illicit addictive substance(s) for at least six months prior and had never participated in any treatment program previously. Individuals with alcohol and/or nicotine co-dependence were excluded.

Result and conclusion

Remote intensive counseling (RIC) is more effective for patients aged 18-45 years with a history of substance use than outpatient therapy (OT). RIC works better for single or never married females younger than 30-year-old with higher education. The use of RIC for other age and racial/ethnic groups should be guided by whether patients belong to a younger age cohort and/or a specific race/ethnicity.

Mental disorder and opioid overdose: a systematic review

PURPOSE

This systematic review summarizes and presents the current state of research quantifying the relationship between mental disorder and overdose for people who use opioids.

METHODS

The protocol was published in Open Science Framework. We used the PECOS framework to frame the review question. Studies published between January 1, 2000, and January 4, 2021, from North America, Europe, the United Kingdom, Australia, and New Zealand were systematically identified and screened through searching electronic databases, citations, and by contacting experts. Risk of bias assessments were performed. Data were synthesized using the lumping technique.

RESULTS

Overall, 6512 records were screened and 38 were selected for inclusion. 37 of the 38 studies included in this review show a connection between at least one aspect of mental disorder and opioid overdose. The largest body of evidence exists for internalizing disorders generally and mood disorders specifically, followed by anxiety disorders, although there is also moderate evidence to support the relationship between thought disorders (e.g., schizophrenia, bipolar disorder) and opioid overdose. Moderate evidence also was found for the association between any disorder and overdose.

CONCLUSION

Nearly all reviewed studies found a connection between mental disorder and overdose, and the evidence suggests that having mental disorder is associated with experiencing fatal and non-fatal opioid overdose, but causal direction remains unclear.

Aggression towards clinicians within Opiate Substitution Treatment (OST) services: A survey of service providers

Background

High levels of aggression towards staff in healthcare settings have been reported. It seems likely that workers in Opioid Substitution Therapy (OST) would be at increased risk of adverse events and their consequences.

Objectives

This study aimed to establish if practitioners who provide OST are experiencing negative outcomes, specifically aggression, distress, and burnout, and to identify if workload and professional affiliation were associated with these risks.

Methods

A survey was conducted of OST practitioners in a single geographical region of New Zealand (population approx. 344,000). The survey asked for demographics (including caseloads), Perception of Patient Aggression Scale New Zealand Revision (POPAS-NZ), Kessler 10 (K10), Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), and Abbreviated Maslach Burnout Inventory (aMBI) and two qualitative questions asking about the best and worst aspects of working in OST.

Results

All recorded OST workers in the region (n = 181) were invited to participate, 95 practitioners responded to the survey (52.4%). This group included pharmacists, doctors, nurses, social workers and addiction workers. Results indicated aggression, distress, and burnout were being experienced by practitioners. Number of patients seen by a practitioner significantly increased risk of aggression (F(1,90) = 14.14, p < 0.001). Psychiatrists were the most at risk profession (p = 0.016). Burnout responses were high for around 20% of practitioners, with low numbers meeting criteria for distress and PTSD. Positive things about working in OST were relationships with patients, appreciating patient outcomes and positive team environments. Negative aspects were patient behaviours, maintaining empathy, and, administration tasks.

Conclusions

Aggression was a workplace hazard for OST clinicians. Low rates of distress and PTSD symptoms were reported and some evidence of practitioner burnout. Practitioners reported positive relationships, making a difference and teamwork may have been improving this area of mental health work.

Disparities in years of potential life lost to Drug-involved overdose deaths in South Carolina

INTRODUCTION

South Carolina has experienced a surge in fatal overdoses, primarily fueled by opioid-involved overdose deaths. This work aims to quantify the burden of premature mortality due to fatal opioid-involved overdoses in South Carolina while documenting the contribution of synthetic opioids to excess mortality, examining substance specific geographic and demographic patterns of mortality burden, and measuring the effect of fatal opioid and synthetic opioid-involved overdoses on average lifespan.

METHODS

We obtained death certificates for fatalities involving opioids, cocaine, benzodiazepines, and psychostimulants (N = 3,726) in South Carolina from 2014 to 2018. Years of Potential Life Lost (YPLL) was used to examine gender, racial, and geographic disparities in mortality burden. We assessed the contribution of synthetic opioid poisoning to the overall opioid mortality burden over time and calculated the effect of fatal opioid and synthetic opioid-involved overdoses on average lifespan.

RESULTS

From 2014 to 2018, opioid-involved overdose deaths resulted in 124,451 YPLL. The average age of fatal male and female opioid-involved overdoses decreased 2.8 and 3.9 years, respectively. Synthetic opioids increasingly contributed to opioid YPLL, accounting for 22% in 2014 to 64% in 2018. Mortality burden was not shared equally between races, sexes, or rural/urban counties. The largest change occurred in black male synthetic opioid-involved deaths (2234%). Rural counties comprised 44-48% of the population adjusted YPLL despite containing 34% of the population.

CONCLUSION

Opioid-involved overdoses account for a critical cause of mortality in South Carolina, demonstrate significant impact on YPLL and highlight mortality burden disparities in gender, race, and rural/urban settings.

Polysubstance use poisoning deaths in Canada: an analysis of trends from 2014 to 2017 using mortality data

Background

Over the past decade, rates of drug poisoning deaths have increased dramatically in Canada. Current evidence suggests that the non-medical use of synthetic opioids, stimulants and patterns of polysubstance use are major factors contributing to this increase.

Methods

Counts of substance poisoning deaths involving alcohol, opioids, other central nervous system (CNS) depressants, cocaine, and CNS stimulants excluding cocaine, were acquired from the Canadian Vital Statistics Death Database (CVSD) for the years 2014 to 2017. We used joinpoint regression analysis and the Cochrane-Armitage trend test for proportions to examine changes over time in crude mortality rates and proportions of poisoning deaths involving more than one substance.

Results

Between 2014 and 2017, the rate of substance poisoning deaths in Canada almost doubled from 6.4 to 11.5 deaths per 100,000 population (Average Annual Percent Change, AAPC: 23%, p < 0.05). Our analysis shows this was due to increased unintentional poisoning deaths (AAPC: 26.6%, p < 0.05) and polysubstance deaths (AAPC: 23.0%, p < 0.05). The proportion of unintentional poisoning deaths involving polysubstance use increased significantly from 38% to 58% among males (p < 0.0001) and 40% to 55% among females (p < 0.0001). Polysubstance use poisonings involving opioids and CNS stimulants (excluding cocaine) increased substantially during the study period (males AAPC: 133.1%, p < 0.01; females AAPC: 118.1%, p < 0.05).

Conclusions

Increases in substance-related poisoning deaths between 2014 and 2017 were associated with polysubstance use. Increased co-use of stimulants with opioids is a key factor contributing to the epidemic of opioid deaths in Canada.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12678-z.

Mapping the research addressing prescription drug monitoring programs: A scoping review

ISSUES

Prescription drug monitoring programs are a harm minimisation intervention and clinical decision support tool that address the public health concern surrounding prescription drug misuse. Given the large number of studies published to date and the ongoing implementation of these programs, it is important to map the literature and identify areas for further research to improve practice.

APPROACH

A scoping review was undertaken to identify the research on prescription drug monitoring programs published between January 2015 and April 2021.

KEY FINDINGS

A total of 153 citations were included in this scoping review. The majority of the studies originated from the USA and were quantitative. Results on program effectiveness are mixed and mainly examine their association with opioid-related outcomes. Unintended consequences are revealed in the literature and this review also highlights barriers to program use.

IMPLICATIONS

Overall, findings are mixed despite the large number of studies published to date. Mapping the literature identifies priority areas for further research that can advise policymakers and clinicians on practice improvement.

CONCLUSION

Results on prescription drug monitoring program effectiveness are mixed and mainly examine their association with opioid-related outcomes. This review highlights barriers to prescription drug monitoring program effectiveness related to program use and system integration. Further research is needed in these areas to improve prescription drug monitoring program use and patient outcomes.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States

IMPORTANCE

Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design.

OBJECTIVE

To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021.

EXPOSURES

Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type.

MAIN OUTCOMES AND MEASURES

The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification.

RESULTS

A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (β = 4.362), labor underutilization rate (β = 0.728), manufacturing employment (β = -0.056), homelessness rate (β = -0.125), percentage nonreligious (β = 0.041), non-Hispanic White race and ethnicity (β = 0.087), prescribed opioids for 30 days or more (β = 0.117), and percentage without health insurance (β = -0.013) and 5 factors associated with the suicide rate: percentage male (β = 1.046), military veteran (β = 0.747), rural (β = 0.031), firearm ownership (β = 0.030), and pain reliever misuse (β = 1.131).

CONCLUSIONS AND RELEVANCE

These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

Opioid-related emergency department visits and hospitalizations among patients with chronic gastrointestinal symptoms and disorders dually enrolled in the Department of Veterans Affairs and Medicare Part D

PURPOSE

We examined the prevalence of, and factors associated with, serious opioid-related adverse drug events (ORADEs) that led to an emergency department (ED) visit or hospitalization among patients with chronic gastrointestinal (GI) symptoms and disorders dually enrolled in the Department of Veterans Affairs (VA) and Medicare Part D.

METHODS

In this retrospective cohort study, we used linked national patient-level data (April 1, 2011, to October 31, 2014) from the VA and Centers for Medicare and Medicaid Services to identify serious ORADEs among dually enrolled veterans with a chronic GI symptom or disorder. Outcome measures included serious ORADEs, defined as an ED visit attributed to an ORADE or a hospitalization where the principal or secondary reason for admission involved an opioid. We used multiple logistic regression models to determine factors independently associated with a serious ORADE.

RESULTS

We identified 3,430 veterans who had a chronic GI symptom or disorder; were dually enrolled in the VA and Medicare Part D; and had a serious ORADE that led to an ED visit, hospitalization, or both. The period prevalence of having a serious ORADE was 2.4% overall and 4.4% among veterans with chronic opioid use (≥90 consecutive days). Veterans with serious ORADEs were more likely to be less than 40 years old, male, white, and to have chronic abdominal pain, functional GI disorders, chronic pancreatitis, or Crohn's disease. They were also more likely to have used opioids chronically and at higher daily doses.

CONCLUSION

There may be a considerable burden of serious ORADEs among patients with chronic GI symptoms and disorders. Future quality improvement efforts should target this vulnerable population.

Association Between Benzodiazepine and Opioid Prescription and Mortality Among Patients in a Large Healthcare System

OBJECTIVE

Coprescription of opioids and benzodiazepines (BDZ) is associated with adverse outcomes, including greater healthcare utilization and overdose risk. This study aims to examine opioid and BDZ coprescription, dosing, and mortality among patients with and without opioid use disorder (OUD) in a large healthcare system.

METHODS

Using data from the California state Prescription Drug Monitoring Program during 2010 to 2014 linked with a large healthcare system electronic health record database and mortality records from the Centers for Disease Control National Death Index, this study examined 5202 patients (1978 with OUD, 3224 controls). Multiple logistic regression analyses were conducted to examine relationships between most recent BDZ and opioid prescription, and their interaction with respect to mortality.

RESULTS

About 10.5% of the sample died on or before December 31, 2014. About 17.7% were prescribed BDZ during the final month of observation. Individuals with OUD were prescribed higher average BDZ and opioid doses than those without OUD. After adjusting for covariates, increased prescribed doses of BDZ (odds ratio [OR]=1.34, 95%CI: 1.15-1.55 per 10 mg/d increment) and opioids (OR = 1.04, 95%CI: 1.02-1.05 per 10 mg/d increment) were positively associated with mortality. Non-OUD patients who received both BDZ and opioid prescriptions had a higher mortality than those who received only BDZ or opioids (The ratio of odds ratio (ROR) = 3.83, 95%CI: 1.78-8.21).

CONCLUSIONS

Study findings highlight significant mortality associated with the coprescription of opioids and BDZ in a general healthcare setting. Further research is needed to elucidate factors associated with mortality among non-OUD patients who are co-prescribed opioids and BDZ.

Long-term follow-up assessment of opioid use outcomes among individuals with comorbid mental disorders and opioid use disorder treated with buprenorphine or methadone in a randomized clinical trial

AIMS

To investigate whether reduction in opioid use differs when treated by either buprenorphine-naloxone (BUP) or methadone (MET) among adults with comorbid opioid use disorder (OUD) and mental disorders.

DESIGN, SETTING AND PARTICIPANTS

In a randomized controlled trial, adults with OUD were randomized to 24 weeks of either BUP or MET treatment and were followed up in 3-yearly assessments. The present secondary analyses were based on 597 participants who completed all assessments.

MEASUREMENTS

The outcome measure was the number of days of using opioids per month during the follow-up period. The Mini-International Neuropsychiatric Interview (MINI) was used to classify participants into three groups: life-time mood disorder (n = 302), life-time mental disorder other than mood disorder (n = 114) and no mental disorder (n = 181). Medication treatment (BUP, MET, no treatment) during the follow-up period was a time-varying predictor.

FINDINGS

Based on zero-inflated Poisson (ZIP) mixed regression analysis, it was found that relative to no treatment, opioid use during the follow-up was significantly reduced by BUP [odds ratio (OR) = 0.12, 95% confidence interval (CI) = 0.07-0.21 for any use; risk ratio (RR) = 0.77, 95% CI =0.66-0.89 for days of use] and by MET [OR = 0.33, 95% CI = 0.25-0.45 for any use; RR = 0.78, 95% CI = 0.72-0.84 for days of use]. Relative to MET, BUP was associated with a lower likelihood of any opioid use among participants with mood disorders (OR = 0.52, 95% CI = 0.36-0.74) and for participants without mental disorder (OR = 0.37, 95% CI = 0.21-0.66) and fewer number of days using opioids (RR = 0.37, 95% CI = 0.25-0.56) among participants with other mental disorders.

CONCLUSIONS

Among adults with comorbid opioid use disorder and mental disorders, treatment with buprenorphine-naloxone produced greater reductions in opioid use than treatment with methadone.

Declining Life Expectancy in the United States: Missing the Trees for the Forest

In recent years, life expectancy in the United States has stagnated, followed by three consecutive years of decline. The decline is small in absolute terms but is unprecedented and has generated considerable research interest and theorizing about potential causes. Recent trends show that the decline has affected nearly all race/ethnic and gender groups, and the proximate causes of the decline are increases in opioid overdose deaths, suicide, homicide, and Alzheimer's disease. A slowdown in the long-term decline in mortality from cardiovascular diseases has also prevented life expectancy from improving further. Although a popular explanation for the decline is the cumulative decline in living standards across generations, recent trends suggest that distinct mechanisms for specific causes of death are more plausible explanations. Interventions to stem the increase in overdose deaths, reduce access to mechanisms that contribute to violent deaths, and decrease cardiovascular risk over the life course are urgently needed to improve mortality in the United States.

The leading neighborhood-level predictors of drug overdose: A mixed machine learning and spatial approach

BACKGROUND

Drug overdose is a leading cause of unintentional death in the United States and has contributed significantly to a decline in life expectancy during recent years. To combat this health issue, this study aims to identify the leading neighborhood-level predictors of drug overdose and develop a model to predict areas at the highest risk of drug overdose using geographic information systems and machine learning (ML) techniques.

METHOD

Neighborhood-level (block group) predictors were grouped into three domains: socio-demographic factors, drug use variables, and protective resources. We explored different ML algorithms, accounting for spatial dependency, to identify leading predictors in each domain. Using geographically weighted regression and the best-performing ML algorithm, we combined the output prediction of three domains to produce a final ensemble model. The model performance was validated using classification evaluation metrics, spatial cross-validation, and spatial autocorrelation testing.

RESULTS

The variables contributing most to the predictive model included the proportion of households with food stamps, households with an annual income below $35,000, opioid prescription rate, smoking accessories expenditures, and accessibility to opioid treatment programs and hospitals. Compared to the error estimated from normal cross-validation, the generalized error of the model did not increase considerably in spatial cross-validation. The ensemble model using ML outperformed the GWR method.

CONCLUSION

This study identified strong neighborhood-level predictors that place a community at risk of experiencing drug overdoses, as well as protective factors. Our findings may shed light on several specific avenues for targeted intervention in neighborhoods at risk for high drug overdose burdens.

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

OBJECTIVE

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

DESIGN

Retrospective cohort study.

SETTING

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

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Diversity inclusion in United States opioid pharmacological treatment trials: A systematic review

Pharmacological treatments for opioid use disorders (OUDs) may have mixed efficacy across diverse groups, i.e., sex/gender, race/ethnicity, and socioeconomic status (SES). The present systematic review aims to examine how diverse groups have been included in U.S. randomized clinical trials examining pharmacological treatments (i.e., methadone, buprenorphine, or naltrexone) for OUDs. PubMed was systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The initial search yielded 567 articles. After exclusion of ineligible articles, 50 remained for the present review. Of the included articles, 14.0% (n = 7) reported both full (i.e., accounting for all participants) sex/gender and race/ethnicity information; only two of those articles also included information about any SES indicators. Moreover, only 22.0% (n = 11) reported full sex/gender information, and 42.0% (n = 21) reported full racial/ethnic information. Furthermore, only 10.0% (n = 5) reported that their lack of subgroup analyses or diverse samples was a limitation to their studies. Particularly underrepresented were American Indian/Alaska Native (AI/AN), Asian, Native Hawaiian/Other Pacific Islander (NH/OPI), and multiracial individuals. These results also varied by medication type; Black individuals were underrepresented in buprenorphine randomized controlled trials (RCTs) but were well represented in RCTs for methadone and/or naltrexone. In conclusion, it is critical that all people receive efficacious pharmacological care for OUDs given the ongoing opioid epidemic. Findings from the present review, however, support that participants from diverse or marginalized backgrounds are underrepresented in treatment trials, despite being at increased risk for disparities related to OUDs. Suggestions for future research are advanced. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The iatrogenic opioid crisis: An example of 'institutional corruption of pharmaceuticals'?

RATIONALE

Prescribed opioids are major contributors to the international public health opioid crisis. Such widespread iatrogenic harms usually result from collective decision failures of healthcare organizations rather than solely of individual organizations or professionals. Findings from a system-wide safety analysis of the iatrogenic opioid crisis that includes roles of pertinent healthcare organizations may help avoid or mitigate similar future iatrogenic consequences. In this retrospective exploratory study, we report such an analysis.

METHODS

The study population encompassed the entire age spectrum and included those in whom opioids prescribed for chronic pain (unrelated to malignancy) were associated with death or morbidity. Root cause analysis, incorporating recent suggestions for improvement, was used to identify possible contributory factors from the literature. Based on their mandated roles and potential influences to prevent or mitigate the iatrogenic crisis, relevant organizations were grouped and stratified from most to least influential.

RESULTS

The analysis identified a chain of multiple interrelated causal factors within and between organizations. The most influential organizations were pharmaceutical, political, and drug regulatory; next: experts and their related societies, and publications. Less influential: accreditation, professional licensing and regulatory, academic and healthcare funding bodies. Collectively, their views and decisions influenced prescribing practices of frontline healthcare professionals and advocacy groups. Financial associations between pharmaceutical and most other organizations/groups were common. Ultimately, patients were adversely affected. There was a complex association with psychosocial variables.

LIMITATIONS

The analysis suggests associations not causality.

CONCLUSION

The iatrogenic crisis has multiple intricately linked roots. The major catalyst: pervasive pharma-linked financial conflicts of interest (CoIs) involving most other healthcare organizations. These extensive financial CoIs were likely triggers for a cascade of erroneous decisions and actions that adversely affected patients. The actions and decisions of pharma ranged from unethical to illegal. The iatrogenic opioid crisis may exemplify 'institutional corruption of pharmaceuticals'.

Association between opioid-related deaths and persistent opioid prescribing in primary care in England: a nested case-control study

AIM

This study aimed to evaluate the association between opioid-related deaths and persistent opioid utilisation in the United Kingdom (UK).

METHODS

This nested case-control study used the UK Clinical Practice Research Datalink, linking the Office for National Statistics death registration. Adult opioid users with recorded opioid-related death between 2000 and 2015 were included and matched to four opioid users (controls) based on a disease risk score. Persistent opioid utilisation (opioid prescriptions ≥3 quarters/year and oral morphine equivalent dose ≥4500 mg/year) and psychotropic prescriptions were identified annually during the three patient-years before the date of opioid-related death. Conditional logistic regression was used to assess the association between persistent opioid utilisation and opioid-related death, and the results were reported as adjusted odds ratios (aOR) and 95% confidence intervals (95%CI).

RESULTS

Of the 902,149 opioid users, 230 opioid-related deaths (cases) and 920 controls were identified. Persistent opioid utilisation was significantly associated with an increased risk of opioid-related deaths (aOR: 1.9; 95%CI: 1.2, 2.9) when persistent opioid utilisation was defined by both annual dose and number of quarters. Concurrent prescription of opioids and tricyclic antidepressants (aOR: 2.0; 95%CI: 1.2, 3.5) or higher dose of benzodiazepine (aOR: 6.5; 95%CI: 4.0, 10.4) or gabapentinoids (aOR: 6.2; 95%CI: 2.9, 13.5) were associated with opioid-related death.

CONCLUSION

Persistent opioid prescribing and concurrent prescribing of psychotropics were associated with a higher risk of opioid-related death and should be avoided in clinical practice. An evidence-based indicator to monitor the safety of prescribed opioids during opioid de-prescribing is needed.

High-Risk Opioid Prescribing Trends: Prescription Drug Monitoring Program Data From 2010 to 2018

OBJECTIVE

Deaths due to opioids have continued to increase in South Carolina, with 816 opioid-involved overdose deaths reported in 2018, a 9% increase from the prior year. The objective of the current study is to examine longitudinal trends (quarter [Q] 1 2010 through Q4 2018) of opioid prescribing volume and high-risk opioid prescribing behaviors in South Carolina using comprehensive dispensing data available in the South Carolina Prescription Drug Monitoring Program (SC PDMP).

DESIGN

Retrospective analyses of SC PDMP data were performed using general linear models to assess quarterly time trends and change in rate of each outcome Q1 2010 through Q4 2018.

PARTICIPANTS

Opioid analgesic prescription fills from SC state residents between Q1 2010 and Q4 2018.

MAIN OUTCOME MEASURES

High-risk prescribing behaviors included (1) opioid prescribing rate; (2) percentage of patients receiving opioids dispensed 90 or more average morphine milligram equivalents daily; (3) percentage of opioid prescribed days with overlapping opioid and benzodiazepine prescriptions; (4) rate per 100 000 residents of multiple provider episodes; and (5) percentage of patients prescribed extended release opioids who were opioid naive.

RESULTS

A total of 33 027 461 opioid prescriptions were filled by SC state residents within the time period of Q1 2010 through Q4 2018. A 41% decrease in the quarterly prescribing rate of opioids occurred from Q1 2010 to Q4 2018. The decrease in overall opioid prescribing was mirrored by significant decreases in all 4 high-risk prescribing behaviors.

CONCLUSION

PDMPs may represent the most complete data regarding the dispensing of opioid prescriptions and as such be valuable tools to inform and monitor the supply of licit opioids. Our results indicate that public health policy, legislative action, and multiple clinical interventions aimed at reducing high rates of opioid prescribing across the health care ecosystem appear to be succeeding in the state of South Carolina.

Applying principles of injury and infectious disease control to the opioid mortality epidemic in North America: critical intervention gaps

North America has been experiencing an acute and unprecedented public health crisis involving excessive and increasing levels of opioid-related overdose mortality. In the present commentary, we examine current interventions (as existent mainly in Canada) to date and compare them against established intervention frameworks and practices in other areas of public health, specifically injury and infectious disease control. We observe that current interventions focusing on opioid drug safety or exposure-specifically those that focus on distinctly potent and toxic opioid products driving major increases in overdose mortality-may be considered the equivalent of 'agent-' or 'vector'-based interventions. Such interventions have been largely neglected in favor of 'host' (e.g., drug user-oriented) or 'environmental' measures among strategies to reduce opioid-related overdose, likely contributing to the limited efficacy of current measures. We explore potential reasons, implications and remedies for these gaps in the overall public health strategy employed towards improved interventions to reduce opioid-related health harms.

Assessing the Relationships Between COVID-19 Stay-at-Home Orders and Opioid Overdoses in the State of Pennsylvania

COVID-19 is compounding opioid use disorder throughout the United States. While recent commentaries provide useful policy recommendations, few studies examine the intersection of COVID-19 policy responses and patterns of opioid overdose. We examine opioid overdoses prior to and following the Pennsylvania stay-at-home order implemented on April 1, 2020. Using data from the Pennsylvania Overdose Information Network, we measure change in monthly incidents of opioid-related overdose pre- versus post-April 1, and the significance of change by gender, age, race, drug class, and naloxone doses administered. Findings demonstrate statistically significant increases in overdose incidents among both men and women, White and Black groups, and several age groups, most notably the 30–39 and 40–49 ranges, following April 1. Significant increases were observed for overdoses involving heroin, fentanyl, fentanyl analogs or other synthetic opioids, pharmaceutical opioids, and carfentanil. The study emphasizes the need for opioid use to be addressed alongside efforts to mitigate and manage COVID-19 infection.

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

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

A qualitative study of emergency department patients who survived an opioid overdose: Perspectives on treatment and unmet needs

OBJECTIVE

Emergency medicine clinicians are uniquely positioned to deliver interventions to enhance linkage to evidence-based treatment for opioid use disorder (OUD) in the acute overdose period, yet little is known about patient perspectives to effectively engage patients immediately following opioid overdose. Our objective was to explore patients' perspectives on substance use treatment, perceived needs, and contextual factors that shape the choice of patients seen in the emergency department (ED) to engage with treatment and other patient support services in the acute post-opioid overdose period.

METHODS

We administered a brief quantitative survey and conducted semistructured interviews with 24 adult ED patients receiving care after an acute opioid overdose between June 2016 and August 2017 in an urban, academic ED. We used constant comparison method and thematic analysis to identify themes across four levels of a modified social ecologic model (individual, interpersonal, organizational, and structural).

RESULTS

The mean (±SD) age of the sample was 33.5 (±9.33) years; 83% were White and 12% were Black; 67% were male; and 83% were diagnosed with OUD, with a mean (±SD) of 3.25 (±2.64) self-reported lifetime opioid overdoses. Eight themes were identified as influencing participants' consideration of OUD treatment and other services: (1) perceptions about control of drug use, (2) personal experience with substance use treatment, (3) role of interpersonal relationships, (4) provider communication skills, (5) stigma, (6) availability of ED resources, (7) impact of treatment policies, and (8) support for unmet basic needs.

CONCLUSIONS

Patients receiving ED care following overdose in our ED are willing to discuss their opioid use and its treatment in the ED and report a variety of unmet needs. This work supports a role for ED-based research evaluating a patient-oriented approach to engage patients after opioid overdose.

Opioid Overdose in the Hospital Setting: A Systematic Review

OBJECTIVE

Our objective was to determine the percentage of opioid overdose events among medical and surgical inpatient admissions, and to identify risk factors associated with these events.

METHODS

We searched PubMed and CINAHL databases from inception through July 30, 2017 and identified additional studies from reference lists and other reviews. Articles were included if they reported original research on the rate of opioid overdoses or opioid-related adverse events, and the adverse events occurred in a general medical hospital during an inpatient stay. We extracted information on study population, design, results, and risk for bias using the Newcastle-Ottawa Quality Assessment Scale. We performed this review in accordance with recently suggested standards and report our findings as per the Meta-Analyses and Systematic Reviews of Observational Studies guidelines.

RESULTS

Thirteen studies met our eligibility criteria. The percentage of opioid overdoses ranged from 0.06% to 2.50% of hospitalizations. The majority of studies used only 1 method of event detection. Risk factors for overdose included older age, infancy, medical comorbidity, substance use disorder diagnosis, combining opioids with other sedatives, and admission to hospitals with higher opioid-prescribing rates.

CONCLUSIONS

Opioid overdose in the inpatient setting is a serious preventable harm and is likely underestimated in much of the current literature. Improved detection methods are needed to more accurately measure the rate of inpatient opioid overdose. Refined estimates of opioid overdose should be used to drive safety and quality improvement initiatives in hospitals.

Battlefield Acupuncture as a Treatment for Pain

This study evaluated both randomized and nonrandomized trials of battlefield acupuncture for the treatment of both acute and chronic pain. Studies published between May 2016 and November 2019 were found through PubMed, the Cochrane Library, or Scopus, concerned with the treatment of pain using auricular acupuncture in accordance with battlefield acupuncture protocol. Search terms were battlefield acupuncture AND pain or auricular acupuncture AND pain. Case reports, literature reviews, meta-analyses, and expert opinions were not included. Bias risk was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. We found 12 studies with a combined sample size of 12,326. All five of the included nonrandomized trials reported positive outcomes, while five of seven of the included randomized trials reached statistical significance in their primary outcome. Six of the randomized trials were considered to have a high risk of bias resulting from the lack of blinding. The one randomized trial with moderate bias risk was a positive study. No severe adverse events were reported. Clinicians may consider battlefield acupuncture as a safe treatment for pain while the evidence base grows; however, we conclude that widespread adoption of battlefield acupuncture will require further high-quality studies drawing from diverse settings and patient populations. In addition, future studies should attempt to achieve blinding.

"They're not doing enough.": women's experiences with opioids and naloxone in Toronto

BACKGROUND

Amid increasing opioid overdose deaths in Canada since 2010 and a changing naloxone access landscape, there is a need for up-to-date research on Canadian women's experiences with opioids. Studies on Canadian take-home naloxone programs are promising, but research beyond these programs is limited. Our study is the first to focus on women's experiences and perspectives on the opioid crisis in Ontario, Canada's most populous province, since the opioid crisis began in 2010.

OBJECTIVE

Our objective was to address research knowledge gaps involving Canadian women with criminal justice involvement who use opioids, and identify flaws in current policies, responses, and practices. While the opioid overdose crisis persists, this lack of research inhibits our ability to determine whether overdose prevention efforts, especially involving naloxone, are meeting their needs.

METHODS

We conducted semi-structured, qualitative interviews from January to April 2018 with 10 women with experience of opioid use. They were recruited through the study's community partner in Toronto. Participants provided demographic information, experiences with opioids and naloxone, and their perceptions of the Canadian government's responses to the opioid crisis. Interviews were transcribed verbatim and inductive thematic analysis was conducted to determine major themes within the data.

RESULTS

Thematic analysis identified seven major concerns despite significant differences in participant life and opioid use experiences. Participants who had used illicit opioids since naloxone became available over-the-counter in 2016 were much more knowledgeable about naloxone than participants who had only used opioids prior to 2016. The portability, dosage form, and effects of naloxone are important considerations for women who use opioids. Social alienation, violence, and isolation affect the wellbeing of women who use opioids. The Canadian government's response to the opioid crisis was perceived as inadequate. Participants demonstrated differing needs and views on ideal harm reduction approaches, despite facing similar structural issues surrounding stigma, addiction management, and housing.

CONCLUSIONS

Participants experienced with naloxone use found it to be useful in preventing fatal overdose, however many of their needs with regards to physical, mental, and social health, housing, harm reduction, and access to opioid treatment remained unmet.

Top Ten Tips Palliative Care Clinicians Should Know About End-Stage Liver Disease

End-stage liver disease (ESLD) is an increasingly prevalent condition with high morbidity and mortality, especially for those ineligible for liver transplantation. Patients with ESLD, along with their family caregivers, have significant needs related to their quality of life, and there is increasing attention being paid to integration of palliative care (PC) principles into routine care throughout the disease spectrum. To provide upstream care for these patients and their family caregivers, it is essential for PC providers to understand their complex psychosocial and physical needs and to be aware of the unique challenges around medical decision making and end-of-life care for this patient population. This article, written by a team of liver and PC experts, shares 10 high-yield tips to help PC clinicians provide better care for patients with advanced liver disease.

Determining the influence of the Workers Compensation Board of Manitoba's opioid policy on prescription opioid use amongst WCB recipients

Background

Opioid medications are commonly used by Workers Compensation Board (WCB) claimants following workplace injuries. The purpose of this study is to describe the impact of an opioid management policy on opioid prescriptions amongst a WCB‐covered population compared to changes in the use of these medications in the general population of a Canadian province.

Methods

We linked WCB claims data from 2006 to 2016 (13,155 claims, 11,905 individuals) to Manitoba provincial health records and compared opioid use amongst this group to 478,606 individuals aged 18–65. Linear regression was performed to examine the change over time in number of individuals being prescribed opioids for various durations and dosages of 50 or more, and 120 or more morphine equivalents (ME)/day for both the WCB and Manitoba population.

Results

WCB claimants totaled 2.5% of Manitoba residents aged 18–65 who were prescribed opioids for non‐cancer pain. After the introduction of the opioid use policy for the WCB population in November 2011, the number of people prescribed opioids declined 49.4% in the WCB group, while increasing 10.8% in the province as a whole. The number of individuals using 50 ME/day or more declined 43.1% in the WCB group and increased 5.8% in the province.

Conclusions

Opioid management programs organized by a compensation board can lead to a substantial reduction in the prescription of opioid medications to a WCB client population, including individuals who were prescribed higher doses of these medications when compared with general trends in the community.

The association between loneliness and medication use in older adults

BACKGROUND

Loneliness is common in older adults, and it is associated with unhealthy behaviours, including substance use. We evaluated the association between loneliness and self-reported use of opioids and benzodiazepines in older adults.

METHODS

We used data from the Canadian Community Health Survey's 'Healthy Aging' sub-survey and included adults 65 years or older who administered their own medications. We classified individuals as lonely if they scored 6 or more on the three -item University of California, Los Angeles's Loneliness Scale. We used multinomial logistic regression models, adjusting for demographics and self-reported comorbidities, to describe the association between loneliness and daily or occasional use of opioids, benzodiazepines and non-opioid analgesics. We also explored the association between loneliness and polypharmacy.

RESULTS

Our cohort included 15,302 older adults, of whom 2,096 (13.7%) were classified as lonely. Daily use of opioids (4.1%) and benzodiazepines (1.7%) were less common than daily use of non-opioid analgesics (33.9%). Lonely older adults had higher daily use of opioids (odds ratio [OR] 1.61, 1.31-1.98) and benzodiazepines (OR 1.66, 1.21-2.28), but not non-opioid analgesics (OR 1.05, 0.92-1.19). Loneliness was not associated with occasional use of opioids, benzodiazepines or non-opioid analgesics in older adults, but was associated with polypharmacy (OR 1.27, 1.06-1.52).

CONCLUSIONS

Loneliness in older adults is associated with increased daily use of opioids and benzodiazepines. Further research should evaluate patient- and physician-level factors that mediate this association, and develop strategies to mitigate loneliness and its attendant adverse outcomes.

"Stories of starting": Understanding the complex contexts of opioid misuse initiation

Background: The impacts of opioid use disorder and opioid-involved overdose are known, but less is known about the contexts in which people first misuse opioids, and the motivations for continued misuse. Methods: In-depth interviews with 26 individuals in Allegheny County, Pennsylvania with current or past histories of opioid misuse were conducted. Narratives were analyzed to understand the circumstances and influences contributing to initial and continued misuse of opioids. Results: Participants described social and familial contexts that normalized or accepted opioid misuse-this often included their own use of other illicit substances prior to initiating opioids. Participants also described initial use of opioids as related to efforts to cope with physical pain. They also described recognizing and then seeking psychological/emotional benefits from opioids. All three of these themes often overlapped and intersected in these stories of starting opioid misuse. Conclusions: Opioid misuse stemmed from complex interacting influences involving coping with physical and psychological pain, perception that opioids are needed to feel "normal", and acceptance or normalization of opioid use. This suggests a multi-pronged approach to both prevention and treatment are needed.

Why comparative epidemiological indicators suggest that New Zealand is unlikely to experience a severe opioid epidemic

North America (i.e., the United States and Canada) and select other wealthy Commonwealth countries (e.g., Australia, the UK) have been experiencing marked 'opioid epidemics', consisting of elevated opioid use and related (e.g., mortality and morbidity) harms involving both prescription and, increasingly, illicit opioid substances. Multiple commentators have alerted to the possibility of New Zealand becoming home to a similar opioid crisis. In this article, we briefly examine and compare key system-level epidemiological indicators for New Zealand in regards to this situation and prospect. These data suggest that, comparatively, population-level (medical) opioid use, exposure and supply in New Zealand have been low and moderate, mostly involving restrained and lower-risk (e.g., short-duration, few long-acting/high-potency formulations, restricted settings) medical opioid availability, with limited over-time increases and absent the major oscillations in opioid dispensing observed elsewhere. Similarly, illicit opioids have been rather low in availability and use, and do not form primary substances in illicit drug scenes or markets. Correspondingly, opioid-related mortality in New Zealand has been somewhat increasing over-time albeit at comparably low levels, and principally involves methadone, morphine and codeine, i.e. the main opioids medically prescribed. Synthesizing the evidence, New Zealand has not featured the distinct characteristics or system-level drivers that have facilitated the opioid epidemics as have unfolded in other jurisdictions. It appears that New Zealand may have all along engaged in the more measured opioid use practices that other jurisdictions have attempted to revert to post-hoc (but largely when too late) while experiencing extensive adverse consequences related to opioids. On this basis, New Zealand provides for a worthwhile comparative case study towards more moderate opioid utilization and control entailing relatively limited collateral harms (e.g., opioid mortality) on public health compared to elsewhere. Details and characteristics of New Zealand's approach to and experience with opioids should be further examined for future and other jurisdictions' benefit.

Changes in opioid prescribing after implementation of mandatory registration and proactive reports within California's prescription drug monitoring program

BACKGROUND

In 2016, California updated its prescription drug monitoring program (PDMP), adding two key features: automated proactive reports to prescribers and mandatory registration for prescribers and pharmacists. The effects of these changes on prescribing patterns have not yet been examined. We aimed to evaluate the joint effect of these two PDMP features on county-level prescribing practices in California.

METHODS

Using county-level quarterly data from 2012 to 2017, we estimated the absolute change associated with the implementation of these two PDMP features in seven prescribing indicators in California versus a control group comprising counties in Florida and Washington: opioid prescription rate per 1000 residents; patients' mean daily opioid dosage in milligrams of morphine equivalents[MME]; prescribers' mean daily MME prescribed; prescribers' mean number of opioid prescriptions per day; percentage of patients getting >90 MME/day; percentage of days with overlapping prescriptions for opioids and benzodiazepines; multiple opioid provider episodes per 100,000 residents.

RESULTS

Proactive reports and mandatory registration were associated with a 7.7 MME decrease in patients' mean daily opioid dose (95 %CI: -11.4, -2.9); a 1.8 decrease in the percentage of patients prescribed high-dose opioids (95 %CI: -2.3, -0.9); and a 6.3 MME decrease in prescribers' mean daily dose prescribed (95 %CI: -10.0, -1.3).

CONCLUSIONS

California's implementation of these two PDMP features was associated with decreases in the total quantity of opioid MMEs prescribed, and indicators of patients prescribed high-dose opioids compared to states that had PDMP's without these features. Rates of opioid prescribing and other high-risk prescribing patterns remained unchanged.

Impact of an emergency department opioid prescribing guideline on emergency physician behaviour and incidence of overdose in the Saskatoon Health Region: a retrospective pre-post implementation analysis

BACKGROUND

Deaths related to opioid overdoses are increasing in North America, with the emergency department being identified as a potential contributor toward this epidemic. Our goal was to determine whether a departmental guideline for the prescribing of restricted medications resulted in a reduction in opioids prescribed in a Canadian setting, with a secondary objective of determining the impact on local overdose frequency.

METHODS

We conducted a retrospective analysis of the prescribing habits of emergency department physicians in 3 hospitals in the Saskatoon Health Region, Saskatchewan, before (Nov. 1, 2015, to Apr. 30, 2016) and after (Nov. 1, 2016, to Apr. 30, 2017) implementation of a guideline in September 2016 for the prescribing of restricted medications. We quantified opioids prescribed per hour worked and per patient seen. We performed Student paired 2-tailed t tests for both individual drug formulations and the combined total morphine equivalents.

RESULTS

Thirty-two emergency department physicians were included. We found a decrease of 31.1% in opioids prescribed, from 10.36 morphine milligram equivalents (MME) per patient seen to 7.14 MME per patient seen (absolute change -3.22 MME, 95% confidence interval -4.81 to -1.63 MME). Over the same period, we found no change in prehospital naloxone use and a modest increase in the amount of naloxone dispensed by emergency department pharmacies. There was no decrease in the number of overdoses after guideline implementation.

INTERPRETATION

Implementation of a guideline for the prescribing of restricted medications in a Canadian emergency department setting was associated with a decrease in the quantity of opioids prescribed but not in the number of overdoses. This finding suggests that the emergency department is unlikely the source of opioids used in acute overdose, although emergency department opioid prescriptions cannot be ruled out as a risk factor for opioid use disorder.

Comparison of Crude Population-Level Indicators of Opioid Use and Related Harm in New Zealand and Ontario (Canada)

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.