Bystander-application of a novel nasal swab optimized for drug delivery is safe and non-traumatic for the general population

OBJECTIVE

The PN Naloxone Nasal Swab (Pocket Naloxone Corp., Bethesda, MD) is a swab optimized for drug delivery and intended for use by non-medical personnel for the emergency treatment of opioid overdose. The aim of this study (PNC-20-003) is to determine the safety of this nasal swab in a real-world environment.

METHODS

This was a single-institution, quantitative-qualitative prospective trial performed at an outpatient clinic. Patients with normal or abnormal nasal structure were recruited. A non-medically trained individual placed the nasal (soaked in fluorescein dye) on each side of the patient's nose. Endoscopy with recording was performed before and after swab placement. An independent reviewer rated degree of staining, mucosal bleeding, and trauma at nasal subsites.

RESULTS

Videos from 32 nasal cavities (16 participants) were reviewed. All cavities had high intensity staining at the septum and the inferior turbinate. No patients had staining within the middle meatus, agger nasi, or olfactory regions. In patients with normal anatomy, obstructive nasal anatomy or prior nasal surgery, all cavities had staining near the nasal septum. Only 7 cavities (22 %) had minor bleeding defined as ooze that stopped in 1-2min, and 3 (9 %) had minor trauma defined as mucosal disruption less than 5mm. There were no significant differences in comparing pre- and post-swab nasal cavity, trauma, or bleeding exams.

CONCLUSIONS

These study results showed that this swab is atraumatic to the nasal mucosal membranes when administered by non-medical personnel. Analysis suggests contact with targeted sites for drug absorption regardless of anatomy.

Fentanyl dysregulates neuroinflammation and disrupts blood-brain barrier integrity in HIV-1 Tat transgenic mice

Opioid overdose deaths have dramatically increased by 781% from 1999 to 2021. In the setting of HIV, opioid drug abuse exacerbates neurotoxic effects of HIV in the brain, as opioids enhance viral replication, promote neuronal dysfunction and injury, and dysregulate an already compromised inflammatory response. Despite the rise in fentanyl abuse and the close association between opioid abuse and HIV infection, the interactive comorbidity between fentanyl abuse and HIV has yet to be examined in vivo. The HIV-1 Tat-transgenic mouse model was used to understand the interactive effects between fentanyl and HIV. Tat is an essential protein produced during HIV that drives the transcription of new virions and exerts neurotoxic effects within the brain. The Tat-transgenic mouse model uses a glial fibrillary acidic protein (GFAP)-driven tetracycline promoter which limits Tat production to the brain and this model is well used for examining mechanisms related to neuroHIV. After 7 days of fentanyl exposure, brains were harvested. Tight junction proteins, the vascular cell adhesion molecule, and platelet-derived growth factor receptor-β were measured to examine the integrity of the blood brain barrier. The immune response was assessed using a mouse-specific multiplex chemokine assay. For the first time in vivo, we demonstrate that fentanyl by itself can severely disrupt the blood-brain barrier and dysregulate the immune response. In addition, we reveal associations between inflammatory markers and tight junction proteins at the blood-brain barrier.

Development and Usability Evaluation of an Opioid Management App

We describe the development and usability evaluation of a novel patient engagement tool (OPY) in its early stage from perspectives of both experts and end-users. The tool is aimed at engaging patients in positive behaviors surrounding the use, weaning, and disposal of opioid medications in the post-surgical setting. The messaging and design of the application were created through a behavioral economics lens. Expert-based heuristic analysis and user testing were conducted and demonstrated that while patients found the tool to be easy to use and subjectively somewhat useful, additional work to enhance the user interface and features is needed in close partnership with developers and stakeholders.

Opioid prescription and opioid disorders in burns: A large database analysis from 1990 to 2019

BACKGROUND

Opioids remain crucial in the management of burn pain. A comprehensive analysis of opioid use in burns and their complications has not been investigated.

METHODS

Data were collected from TriNetX, a large multicenter database with de-identified patient information. The population included patients prescribed opioids on or following burn injury from January 1st, 1990, to December 31st, 2019. Opioid prescription use was analyzed after cohort stratification by decades: 1990-1999, 2000-2009, and 2010-2019. Outcomes for opioid-related disorders, opioid dependence, opioid abuse, intentional self-harm, and mental and behavioral disorders from psychoactive substance use were investigated.

RESULTS

Hydrocodone was the most frequently prescribed opioid in 1990-1999 and 2000-2009, with oxycodone taking the lead in 2010-2019 (p < 0.0001). During 1990-1999, patients had a decreased risk of recorded opioid-related disorders (RR=0.52), opioid dependence (RR=0.46), opioid abuse (RR=0.55), mental and behavioral disorders (RR=0.88), and intentional self-harm (RR=0.37) when compared to 2000-2009. A comparison of the 2000-2009-2010-2019 cohorts showed an increased risk of recorded opioid-related disorders (RR= 1.91), opioid dependence (RR=1.56), opioid abuse (RR=1.67), mental and behavioral disorders (RR =1.73), and intentional self-harm (RR=2.02).

CONCLUSIONS

The risk of opioid-related disorders has nearly doubled since the year 2000 warranting precautions when prescribing pain medications to burn patients.

Opioid abuse and SIV infection in non-human primates

Human immunodeficiency virus (HIV) and drug abuse are intertwined epidemics, leading to compromised adherence to combined antiretroviral therapy (cART) and exacerbation of NeuroHIV. As opioid abuse causes increased viral replication and load, leading to a further compromised immune system in people living with HIV (PLWH), it is paramount to address this comorbidity to reduce the NeuroHIV pathogenesis. Non-human primates are well-suited models to study mechanisms involved in HIV neuropathogenesis and provide a better understanding of the underlying mechanisms involved in the comorbidity of HIV and drug abuse, leading to the development of more effective treatments for PLWH. Additionally, using broader behavioral tests in these models can mimic mild NeuroHIV and aid in studying other neurocognitive diseases without encephalitis. The simian immunodeficiency virus (SIV)-infected rhesus macaque model is instrumental in studying the effects of opioid abuse on PLWH due to its similarity to HIV infection. The review highlights the importance of using non-human primate models to study the comorbidity of opioid abuse and HIV infection. It also emphasizes the need to consider modifiable risk factors such as gut homeostasis and pulmonary pathogenesis associated with SIV infection and opioid abuse in this model. Moreover, the review suggests that these non-human primate models can also be used in developing effective treatment strategies for NeuroHIV and opioid addiction. Therefore, non-human primate models can significantly contribute to understanding the complex interplay between HIV infection, opioid abuse, and associated comorbidities.

Efficacy and safety of oliceridine treatment in patients with postoperative pain: a systematic review and meta-analysis of randomized controlled trials

AIM

Our aim was to conduct a systematic review and meta-analysis to examine the efficacy and safety of oliceridine in patients with postoperative pain.

METHODS

Four databases were searched from the beginning of the database to the present. We included all randomized controlled trials (RCT) that evaluated the efficacy and safety of oliceridine in patients with postoperative pain. Our endpoints were the proportion of treatment responders to the oliceridine regimen and the incidence of adverse effects such as nausea and vomiting.

RESULTS

The analysis showed that more patients responded significantly with oliceridine compared to placebo. The proportion of treatment responders to oliceridine was comparable to that of morphine. Oliceridine had analgesia effects similar to morphine compared to placebo. The incidence of respiratory safety events was significantly lower with oliceridine compared to morphine. Oliceridine was significantly associated with more adverse events such as nausea and vomiting compared to placebo. The safety profile of oliceridine was superior to morphine compared to morphine.

CONCLUSIONS

Our systematic review and meta-analysis showed that oliceridine is an effective and safe intravenous analgesic in patients with postoperative pain, producing rapid postoperative analgesic and usually well tolerated, and reducing incidence of adverse events compared to morphine.

PROSPERO REGISTRATION

CRD42023391581.

Modeling Opioid Abuse: A Case Study of the Opioid Crisis in New England

For the past two decades, the USA has been embroiled in a growing prescription drug epidemic. The ripples of this epidemic have been especially apparent in the state of Maine, which has fought hard to mitigate the damage caused by addiction to pharmaceutical and illicit opioids. In this study, we construct a mathematical model of the opioid epidemic incorporating novel features important to better understanding opioid abuse dynamics. These features include demographic differences in population susceptibility, general transmission expressions, and combined consideration of pharmaceutical opioid and heroin abuse. We demonstrate the usefulness of this model by calibrating it with data for the state of Maine. Model calibration is accompanied by sensitivity and uncertainty analysis to quantify potential error in parameter estimates and forecasts. The model is analyzed to determine the mechanisms most influential to the number of opioid abusers and to find effective ways of controlling opioid abuse prevalence. We found that the mechanisms most influential to the overall number of abusers in Maine are those involved in illicit pharmaceutical opioid abuse transmission. Consequently, preventative strategies that controlled for illicit transmission were more effective over alternative approaches, such as treatment. These results are presented with the hope of helping to inform public policy as to the most effective means of intervention.

Algorithms to Identify Nonmedical Opioid Use

The rise in nonmedical opioid overdoses over the last two decades necessitates improved detection technologies. Manual opioid screening exams can exhibit excellent sensitivity for identifying the risk of opioid misuse but can be time-consuming. Algorithms can help doctors identify at-risk people. In the past, electronic health record (EHR)-based neural networks outperformed Drug Abuse Manual Screenings in sparse studies; however, recent data shows that it may perform as well or less than manual screenings. Herein, a discussion of several different manual screenings and recommendations is contained, along with suggestions for practice. A multi-algorithm approach using EHR yielded strong predictive values of opioid use disorder (OUD) over a large sample size. A POR (Proove Opiate Risk) algorithm provided a high sensitivity for categorizing the risk of opioid abuse within a small sample size. All established screening methods and algorithms reflected high sensitivity and positive predictive values. Neural networks based on EHR also showed significant effectiveness when corroborated with Drug Abuse Manual Screenings. This review highlights the potential of algorithms for reducing provider costs and improving the quality of care by identifying nonmedical opioid use (NMOU) and OUD. These tools can be combined with traditional clinical interviewing, and neural networks can be further refined while expanding EHR.

Characterizing OPRM1 DNA methylation in prescription opioid users with chronic musculoskeletal pain

Introduction

Many patients with chronic pain use prescription opioids. Epigenetic modification of the μ-opioid receptor 1 (OPRM1) gene, which codes for the target protein of opioids, may influence vulnerability to opioid abuse and response to opioid pharmacotherapy, potentially affecting pain outcomes.

Objective

Our objective was to investigate associations of clinical and sociodemographic factors with OPRM1 DNA methylation in patients with chronic musculoskeletal pain on long-term prescription opioids.

Methods

Sociodemographic variables, survey data (Rapid Estimate of Adult Health Literacy in Medicine-Short Form, Functional Comorbidity Index [FCI], PROMIS 43v2.1 Profile, Opioid Risk Tool, and PROMIS Prescription Pain Medication Misuse), and saliva samples were collected. The genomic DNA extracted from saliva samples were bisulfite converted, amplified by polymerase chain reaction, and processed for OPRM1-targeted DNA methylation analysis on a Pyrosequencing instrument (Qiagen Inc, Valencia, CA). General linear models were used to examine the relationships between the predictors and OPRM1 DNA methylation.

Results

Data from 112 patients were analyzed. The best-fitted multivariable model indicated, compared with their counterparts, patients with > eighth grade reading level, degenerative disk disease, substance abuse comorbidity, and opioid use < 1 year (compared with >5 years), had average methylation levels that were 7.7% (95% confidence interval [CI] 0.95%, 14.4%), 11.7% (95% CI 2.7%, 21.1%), 21.7% (95% CI 10.7%, 32.5%), and 16.1% (95% CI 3.3%, 28.8%) higher than the reference groups, respectively. Methylation levels were 2.2% (95% CI 0.64%, 3.7%) lower for every 1 unit increase in FCI and greater by 0.45% (95% CI 0.08%, 0.82%) for every fatigue T score unit increase.

Conclusions

OPRM1 methylation levels varied by several patient factors. Further studies are warranted to replicate these findings and determine potential clinical utility.

Minimally invasive, benign foregut surgery is not associated with long-term, persistent opioid use postoperatively: an analysis of the IBM® MarketScan® database

BACKGROUND

It is unknown if opioid naïve patients who undergo minimally invasive, benign foregut operations are at risk for progressing to persistent postoperative opioid use. The purpose of our study was to determine if opioid naïve patients who undergo minimally invasive, benign foregut operations progress to persistent postoperative opioid use and to identify any patient- and surgery-specific factors associated with persistent postoperative opioid use.

METHODS

Opioid-naïve, adult patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018 were identified within the IBM® MarketScan® Commercial Claims and Encounters Database. Daily drug logs of the preoperative and postoperative period were evaluated to assess for changes in drug use patters. The primary outcome of interest was persistent postoperative opioid use, defined as at least 33% of the proportion of days covered by opioid prescriptions at 365-day follow-up. Patient demographic information and clinical risk factors for persistent postoperative opioid use at 365 days postoperatively were estimated using log-binomial regression.

RESULTS

A total of 17,530 patients met inclusion criteria; 6895 underwent fundoplication, 9235 underwent hiatal hernia repair, and 1400 underwent Heller myotomy. 9652 patients had at least one opioid prescription filled in the perioperative period. Sixty-five patients (0.4%) were found to have persistent postoperative opioid use at 365 days postoperatively. Lower Charlson comorbidity index scores and a history of mental illness or substance use disorder had a statistically but not clinically significant protective effect on the risk of persistent postoperative opioid use at 365 days postoperatively.

CONCLUSIONS

Only half of opioid naïve patients undergoing minimally invasive, benign foregut operations filled an opioid prescription postoperatively. The risk of progression to persistent postoperative opioid use was less than 1%. These findings support the current guidelines that limit the number of opioid pills prescribed following general surgery operations.

Identifying the risk of opioid misuse in a chronic pain population: the utility of the MMPI-2-RF personality psychopathology five (PSY-5-RF) and higher-order scales

Prescription-related opioid misuse, especially in chronic pain populations, is an ongoing problem and is related to increased mortality. The purpose of this study was to assess the utility of two restructured scales of the MMPI-2-RF: the Personality Psychopathology Five (PSY-5-RF) and the Higher-Order Scales to determine which of their subscales may be beneficial for identifying the risk of opioid misuse in a chronic pain population. A sample of 136 patients with chronic disabling occupational musculoskeletal disorders completed the MMPI-2-RF and the Current Opioid Misuse Measure (COMM) upon admission to a functional restoration program. The PSY-5-RF and H-O subscales were correlated with the baseline COMM scores. Correlation analyses, ROC curve analyses, and multiple binary logistic regression models were developed to determine which subscales were most associated with elevated COMM scores. The results of the regression analyses suggest that Scale elevations on two of the PSY-5-RF Scales and two Higher-Order Scales of the MMPI-2-RF demonstrated significant associations with elevated COMM scores, thus exhibiting the utility of these subscales in identifying the risk of opioid misuse among chronic pain patients. These findings are clinically meaningful in underscoring the importance of identifying specific personality traits as potential predictors of opioid misuse, and identifying those at risk through careful screening. Clinical implications based on each of the PSY-5-RF and H-O scales significantly associated with elevated COMM scores are discussed.

Postoperative Discharge Opioid Consumption, Leftover, and Disposal after Obstetric and Gynecologic Procedures: A Systematic Review

OBJECTIVE

To perform a systematic review on consumption, leftover, and disposal of prescribed opioids after surgery in obstetrics and gynecology (The International Prospective Register of Systematic Reviews ID 249856).

DATA SOURCES

Electronic database searches on PubMed, Embase, Cochrane Library, and MEDLINE and other search methods including all studies published between the years 2000 and 2021 were used.

METHODS OF STUDY SELECTION

We included all randomized trials, cohorts, case-control studies, and clinical trials. The search was limited to studies related to obstetrics and gynecology. Studies that pertained to opioid consumption, leftover, and disposal patterns were selected. We excluded review articles, meeting abstracts, case series and case reports, and abstracts without access to full texts. The search was limited to trials in humans and published in English language. Study population included women who were prescribed opioids after obstetric and/or gynecologic procedures. Information on opioid consumption, leftover, and disposal patterns were extracted and compared among different procedures. Potential risk of bias was evaluated using the Newcastle-Ottawa Scale for cohort studies and the National Heart, Lung, and Blood Institute Study Quality Assessment Tool of Controlled Interventional Studies for clinical trial.

TABULATION, INTEGRATION, AND RESULTS

Of 2343 articles, 10 were used in the analysis: 9 cohorts and 1 randomized clinical trial. We found that among patients who underwent obstetric and gynecologic procedures, a considerable number of opioids are unused. The total number of consumed opioids after discharge in patients who underwent cesarean delivery was 21.8 oral morphine equivalent (OME); vaginal hysterectomy, 55.7 OME; abdominal hysterectomy, 105.8 OME; and laparoscopic hysterectomy, 89.0 OME. The number of opioids leftover in the vaginal, abdominal, and laparoscopic hysterectomy groups was 67.6 OME, 115.5 OME, and 95.3 OME, respectively. On average, 77.5% of leftover opioids were not disposed/kept, whereas only 20% discarded their medication through a disposal program. Five studies were deemed to have fair quality, and the rest were rated as good quality.

CONCLUSION

Compared with those after cesarean delivery, patients undergoing gynecologic procedures consumed a large number of opioids, especially after abdominal hysterectomies. Abdominal hysterectomy was also associated with a high number of opioids leftover. Most patients did not use the entire prescribed opioids and were either keeping their unused opioids or unsure about what to do with them. We recommend perioperative opioid-specific counseling and education on opioid consumption, potential hazards of unused medication, and proper disposal for patients. Strategies to reduce opioids prescription by physicians should be considered.

Opioid dependence and treatment outcomes among patients with burn injury

BACKGROUND

Patients with burn injuries cause significant healthcare economic burden, often utilising extra-hospital resources, caregiving, and specialized care.

METHODS

We present a retrospective cohort analysis of the hospitalized patients in the USA with a primary diagnosis of burn injury. Opioid dependence was identified using ICD-10 CM codes. The 30-day all-cause readmission rate was the main outcome while secondary outcomes were inhospital mortality rate, resource utilization which included hospital length of stay, total hospitalization costs and charges and surgical procedures for burn injury treatment as well as the most important five principal diagnoses for admission and readmission.

RESULTS

Out of 22,348 patients included in the study, 597 had opioid dependence. Older patients (43 years, range: 38.6-47.2 years) as well as males (70.8%) were more likely to be opioid dependent. Opioid dependence was associated with higher 30-day readmission rates (aOR: 1.83, 95% confidence interval (CI): 1.30-2.57, p-value: <0.01), higher total hospitalization costs (aMD: $14,981, CI: $3820-$26,142, p-value: 0.01), total hospitalization charges (aMD: $47,078, CI: -$5093 to $89,063, p-value: 0.03), and a shorter mean length of stay (aMD: 5.13 days, CI: 2.60-7.66, p-value: <0.01). However, patients with and without opioid dependence had similar in-hospital mortality rates (aOR: 0.27, CI: 0.06-1.28, p-value: 0.10).

CONCLUSION

We are the first to our knowledge to report the association of treatment outcomes and opioid dependence in patients hospitalized at the national level with a burn injury. We show that there were higher 30-day all-cause readmission rates and in-hospital resource utilization among patients with opioid-dependence.

Association of pre-admission opioid abuse and/or dependence on major complications in traumatic brain injury (TBI) patients

SETTING

In the last few decades, an opioid related health crisis has been a challenging problem in many countries around the world, especially the United States. Better understanding of the association of pre-admission opioid abuse and/or dependence (POAD) on specific major complications in traumatic brain injury (TBI) patients can aid the medical team in improving patient care management and outcomes.

STUDY OBJECTIVE

Our goal is to assess and quantify the risk of POAD on in-hospital mortality and major complications in TBI patients.

DESIGN

We conducted a retrospective study and used the National Inpatient Sample (NIS) database from 2004 to 2015 to investigate the impact of POAD on in-hospital mortality and major complications in TBI patients. We utilized propensity score matching and conditional logistic regression models, adjusted with injury severity score (ISS) and comorbidities, to obtain the adjusted odds ratios (OR).

MAIN RESULTS

POAD TBI patients had lower risks of in-hospital mortality (OR 0.58; p < 0.001) and acute myocardial infarction (OR 0.53; p = 0.045), while a higher risk of respiratory (OR 1.59; p < 0.001) and neurologic complications (OR 2.54; p < 0.001), compared to non-POAD TBI patients. Additionally, POAD patients were significantly more likely to have sepsis (OR 2.16, p < 0.001), malnutrition (OR 1.56, p < 0.001), delirium (OR 2.81, p < 0.001), respiratory failure (OR 1.79, p < 0.001), and acute renal failure (OR 1.83, p < 0.001). POAD TBI patients had shorter length of hospital stay compared to non-POAD TBI patients (mean 8.0 vs 9.2 days, p < 0.001).

CONCLUSIONS

POAD TBI patients have a lower in-hospital mortality, shorter duration of hospitalization and a lower risk of acute myocardial infarction, while they are more likely to have respiratory failure, delirium, sepsis, malnutrition, and acute renal failure compared to TBI patients without POAD. Prospective study is warranted to further confirm these findings.

Trends and outcomes of opioid-related cardiac arrest in a contemporary US population

BACKGROUND

Opioid abuse is a worldwide public health issue, and deaths related to opioid abuse are increasing. We aimed to investigate trends, predictors, and outcomes of cardiac arrest in patients with opioid abuse.

METHODS

All hospitalizations for primary diagnosis of cardiac arrest between 2012 and 2018 identified in the Nationwide Inpatient Sample were categorized into those with or without a secondary diagnosis of opioid overdose. Multivariable logistic regression was used to analyze in-hospital outcomes of opioid-associated cardiac arrest after adjusting for patient and hospital characteristics.

RESULTS

Among 1,410,475 hospitalizations with cardiac arrest, opiate abuse as a secondary diagnosis was found in 3.1% (n=43,090) of hospitalizations, with an increasing trend during the study period. Hospitalizations for cardiac arrest with opioid abuse were seen less likely in patients with heart failure (21.2% vs. 40.6%; p<0.05), diabetes mellitus (19.5% vs. 35.4%; p<0.05), hypertension (43.4% vs. 64.9%; p<0.05) and renal failure (14.3% vs. 30.2%; p<0.05) and more frequently in those with history of alcohol abuse (16.9% vs. 7.1%; p<0.05), depression (18.8% vs. 9%; p<0.05), and smoking (37.0% vs. 21.8%; p<0.05) as compared with cardiac arrest without opioid use. In-hospital mortality in cardiac arrest patients with and without opioids was not different after multivariable adjustment (odds ratio OR 0.96, 0.91-1.00; p=0.07). OA-OHCA was associated with significantly higher risks of acute kidney injury, acute respiratory failure, and mechanical ventilation, p<0.05 for all.

CONCLUSION

Opioid abuse remains a significant cause of cardiac arrest. Despite similar in-hospital mortality and lower resource utilization, severe complications are more frequent in opioid abuse related cardiac arrests compared to those without opioid abuse.

Diagnostic and Predictive Capacity of the Spanish Versions of the Opioid Risk Tool and the Screener and Opioid Assessment for Patients with Pain-Revised: A Preliminary Investigation in a Sample of People with Noncancer Chronic Pain

INTRODUCTION

Accurate assessment of the risk of opioid abuse and misuse in people with noncancer chronic pain is crucial for their prevention. This study aimed to provide preliminary evidence of the diagnostic and predictive capacity of the Spanish versions of the Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R).

METHODS

We used the Current Opioid Misuse Measure (COMM) as criterion measure to assess the capacity of each tool to identify patients misusing opioids at the time of the assessment. Eighteen months later, we used the COMM and the Drug Abuse Screening Test-10 (DAST-10) to assess their predictive capacity. In total, 147 people with noncancer chronic pain participated in the diagnostic study, and 42 in the predictive study.

RESULTS

Receiver operating curve analysis showed that the SOAPP-R had an excellent capacity to identify participants who were misusing opioids at the time of assessment (area under the curve [AUC] = 0.827). The diagnostic capacity of the ORT was close to acceptable (AUC = 0.649-0.669), whereas its predictive capacity was poor (AUC = 0.522-0.554). The predictive capacity of the SOAPP-R was close to acceptable regarding misuse (AUC = 0.672) and poor regarding abuse (AUC = 0.423).

CONCLUSION

In the setting of Spanish-speaking communities, clinicians should be cautious when using these instruments to make decisions on opioid administration. Further research is needed on the diagnostic and predictive capacity of the Spanish versions of both instruments.

Does Maternal Incarceration Impact Infants with Neonatal Abstinence Syndrome?

OBJECTIVES

Opioid exposed infants born to incarcerated women represent a vulnerable and understudied subset of infants with neonatal abstinence syndrome (NAS). The impact of maternal incarceration on length of stay (LOS) for infants with NAS is unknown. We hypothesized that infants with NAS born to incarcerated women have longer hospitalizations compared to infants with NAS born to non-incarcerated women.

METHODS

This is a retrospective cohort study of infants with NAS born between 2011 and 2018 at the primary delivery site for Connecticut's only women's prison. Opioid exposed infants were assessed by Finnegan Scores for withdrawal and received morphine as a first line agent and phenobarbital as a second line agent. LOS was compared using Poisson regression.

RESULTS

Of 206 infants identified, 166 were included in the analysis, with 28 born to incarcerated women and 138 to non-incarcerated women. Incarcerated women were more likely to report prenatal alcohol use, 14.3% vs 2.2% p = 0.016 and benzodiazepine use 21.4% vs 7.3% p = 0.032. Infants of incarcerated women were less likely to be fed breast milk at discharge, 3.6% vs 37% p < 0.001. Adjusted mean LOS was longer among infants born to incarcerated women, 18.5 vs 16.6 days (p = 0.009).

CONCLUSIONS FOR PRACTICE

Infants with NAS born to incarcerated women in Connecticut had longer LOS, lower rates of being fed breast milk, and different prenatal substance exposures than infants with NAS born to non-incarcerated women. Supporting the maternal-infant dyad until infant discharge may mitigate the potential negative impact of maternal incarceration on the care of infants with NAS.

Opioid abuse and austerity: Evidence on health service use and mortality in England

Opioid abuse has become a public health concern among many developed countries, with policymakers searching for strategies to mitigate adverse effects on population health and the wider economy. The United Kingdom has seen dramatic increases in opioid-related mortality following the financial crises in 2008. We examine the impact of spending cuts resulting from government prescribed austerity measures on opioid-related hospitalisations and mortality, thereby expanding on existing evidence suggesting a countercyclical relationship with macroeconomic performance. We take advantage of the variation in spending cuts passed down from central government to local authorities since 2010, with reductions in budgets of up to fifty percent in some areas resulting in the rescaling of vital public services. Longitudinal panel data methods are used to analyse a comprehensive, linked dataset that combines information from spending records, official death registry data and large administrative health care data for 152 local authorities (i.e., unitary authorities and county councils) in England between April 2010 and March 2017. A total of 280,827 people experienced a hospital admission in the English National Health Service because of an opioid overdose and 14,700 people died from opioids across the study period. Local authorities that experienced largest spending cuts also saw largest increases in opioid abuse. Interactions between changes in unemployment and spending items for welfare programmes show evidence about the importance for governments to protect populations from social-risk effects at times of deteriorating macroeconomic performance. Our study carries important lessons for countries aiming to address high rates of opioid abuse, including the United States, Canada and Sweden.

Opioid prescribing practices in academic otolaryngology: A single institutional survey

OBJECTIVES

Opioids are highly addictive medications and otolaryngologists have a responsibility to practice opioid stewardship. We investigated postoperative opioid prescribing patterns among resident and attending physicians as an educational platform to underscore the importance of conscientious opioid prescribing.

METHODS

This quality improvement study was designed as a cross-sectional electronic survey. Residents and attending clinical faculty members at a single academic institution were queried from February through April 2020. An electronic survey was distributed to capture postoperative opioid prescribing patterns after common procedures. At the conclusion of the study, results were sent to all faculty and residents.

RESULTS

A total of 29 attending otolaryngologists and 22 residents completed the survey. Resident physicians prescribed on average fewer postoperative opioid pills than attendings. Among attendings, the largest number of opioids were prescribed following tonsillectomy (dose varied by patient age), neck dissection (12.6 pills), brow lift (13.3 pills), facelift (13.3 pills), and open reduction of facial trauma (10.7 pills). For residents, surgeries with the most postoperatively prescribed opioids were for tonsillectomy (varied by patient age), neck dissection (13.4 pills), open reduction of facial trauma (10.5 pills), parotidectomy (10.0 pills), and thyroid/parathyroidectomy (9.0 pills). The largest volume of postoperative opioids for both groups was prescribed following tonsillectomy. Attendings prescribed significantly more opioids after facelift and brow lift than did residents (p = 0.01 and p = 0.003, respectively).

CONCLUSION

There was good concordance between resident and attending prescribers. Improvement in opioid prescribing and pain management should be an essential component of otolaryngology residency education and attending continuing medical education.

LEVEL OF EVIDENCE

4.

Changes in opioid discharge prescriptions after primary total hip and total knee arthroplasty affect opioid refill rates and morphine milligram equivalents : an institutional experience of 20,000 patients

AIMS

Due to the opioid epidemic in the USA, our service progressively decreased the number of opioid tablets prescribed at discharge after primary hip (THA) and knee (TKA) arthroplasty. The goal of this study was to analyze the effect on total morphine milligram equivalents (MMEs) prescribed and post-discharge opioid repeat prescriptions.

METHODS

We retrospectively reviewed 19,428 patients undergoing a primary THA or TKA between 1 February 2016 and 31 December 2019. Two reductions in the number of opioid tablets prescribed at discharge were implemented over this time; as such, we analyzed three periods (P1, P2, and P3) with different routine discharge MME (750, 520, and 320 MMEs, respectively). We investigated 90-day refill rates, refill MMEs, and whether discharge MMEs were associated with represcribing in a multivariate model.

RESULTS

A discharge prescription of < 400 MMEs was not a risk factor for opioid represcribing in the entire population (p = 0.772) or in opioid-naïve patients alone (p = 0.272). Procedure type was the most significant risk factor for narcotic represcribing, with unilateral TKA (hazard ratio (HR) = 5.62), bilateral TKA (HR = 6.32), and bilateral unicompartmental knee arthroplasty (UKA) (HR = 5.29) (all p < 0.001) being the highest risk for refills. For these three procedures, there was approximately a 5% to 6% increase in refills from P1 to P3 (p < 0.001); however, there was no significant increase in refill rates after any hip arthroplasty procedures. Total MMEs prescribed were significantly reduced from P1 to P3 (p < 0.001), leading to the equivalent of nearly 500,000 fewer oxycodone 5 mg tablets prescribed.

CONCLUSION

Decreasing opioids prescribed at discharge led to a statistically significant reduction in total MMEs prescribed. While the represcribing rate did not increase for any hip arthroplasty procedure, the overall refill rates increased by about 5% for most knee arthroplasty procedures. As such, we are now probably prescribing an appropriate amount of opioids at discharge for knee arthroplasty procedure, but further reductions may be possible for hip arthroplasty procedures. Cite this article: Bone Joint J 2021;103-B(7 Supple B):103-110.

Comparative outcomes for Black children served by the Sobriety Treatment and Recovery Teams program for families with parental substance abuse and child maltreatment

INTRODUCTION

An urgent need exists for child welfare and substance use disorder (SUD) interventions that safely preserve Black families, engage parents in treatment services, and improve child and parent outcomes. The Title IV-E Prevention Services Clearinghouse rated The Sobriety Treatment and Recovery Teams (START) as a promising practice for families with parental substance use and child maltreatment. This study is the first to test the effects of START on Black families.

METHODS

This study compared child welfare and parent outcomes for 894 children and their 567 primary parents in three groups: Black children served by START, Black children served in treatment as usual (TAU), and White children served in START. This was a quasi-experimental study using a propensity score matched dataset of START-served children to TAU children. Comparisons included placement in state custody and repeat child abuse or neglect (CA/N) during the intervention period, and at 12 months post-intervention. Generalized linear models accounted for the effects of clustering and unbalanced covariates on outcomes.

RESULTS

In this study, 51.8% of children were neonates or infants at the CPS report. At 12-months post-intervention, 80.6% of Black children served by START, but only 56.0% of Black children in TAU, remained free of both placement in state custody and CA/N (p < .001, OR = 3.27, 95% CI [2.14, 4.98]); these effects held after controlling for family clusters. Black and White families in START received equal SUD treatment and community-based services. For START-served families, parental use of opioids (p = .005, OR = 3.52, 95% CI [1.46, 8.48]) and mental health issues (p = .002, OR = 1.90, 95% CI [1.27, 2.86]), rather than race, predicted child placement in state custody. Parent mental health issues or opioid use doubled or quadrupled, respectively, the odds of failing to achieve early recovery by case closure.

CONCLUSIONS

START is a potent intervention, co-implemented with SUD treatment providers, that kept Black children safely with their families through the intervention and 12-months post-intervention periods. Scaling up effective programs, like START, that align with the goals of the Family First Prevention Services Act might reduce racial disparities and improve child welfare and SUD treatment outcomes.

Direct Costs of Opioid Abuse in an Insured Population in the United States

OBJECTIVE

To (a) describe the demographics of opioid abusers; (b) compare the prevalence rates of selected comorbidities and the medical and drug utilization patterns of opioid abusers with patients from a control group, for the period from 1998 to 2002; and (c) calculate the mean annual per-patient total health care costs (e.g., inpatient, outpatient, emergency room, drug, other) from the perspective of a private payer.

METHODS

An administrative database of medical and pharmacy claims from 1998 to 2002 of 16 self-insured employer health plans with approximately 2 million lives was used to identify "opioid abusers"-patients with claims associated with ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) codes for opioid abuse (304.0, 304.7, 305.5, and 965.0 [excluding 965.01]). A control group of nonabusers was selected using a matched sample (by age, gender, employment status, and census region) in a 3:1 ratio. Per-patient annual health care costs (mean total medical and drug costs) were measured in 2003 U.S. dollars. Multivariate regression techniques were also used to control for comorbidities and to compare costs with a benchmark of depressed patients.

RESULTS

740 patients were identified as opioid abusers, a prevalence of 8 in 10,000 persons aged 12 to 64 years continuously enrolled in health care plans for whom 12 months of data were available for calculating costs. Opioid abusers, compared with nonabusers, had significantly higher prevalence rates for a number of specific comorbidities, including nonopioid poisoning, hepatitis (A, B, or C), psychiatric illnesses, and pancreatitis, which were approximately 78, 36, 9, and 21 (P<0.01) times higher, respectively, compared with nonabusers. Opioid abusers also had higher levels of medical and prescription drug utilization. Almost 60% of opioid abusers had prescription drug claims for opioids compared with approximately 20% for nonabusers. Prevalence rates for hospital inpatient visits for opioid abusers were more than 12 times higher compared with nonabusers (P<0.01). Mean annual direct health care costs for opioid abusers were more than 8 times higher than for nonabusers ($15,884 versus $1,830, respectively, P < 0.01). Hospital inpatient and physician-outpatient costs accounted for 46% ($7,239) and 31% ($5,000) of opioid abusers' health care costs, compared with 17% ($310) and 50% ($906), respectively, for nonabusers. Mean drug costs for opioid abusers were more than 5 times higher than costs for nonabusers ($2,034 vs. $386, respectively, P<0.01), driven by higher drug utilization (including opioids) for opioid abusers. Even when controlling for comorbidities using a multivariate regression model of a matched control of depressed patients, the average health care costs of opioid abusers were 1.8 times higher than the average health care costs of depressed patients.

CONCLUSION

The high costs of opioid abuse were driven primarily by high prevalence rates of costly comorbidites and high utilization rates of medical services and prescription drugs.

DISCLOSURES

Funding for this research was provided by an unrestricted grant from Janssen Medical Affairs, L.L.C. and was obtained by authors Susan Vallow and Jeff Schein, who are employed by Janssen Medical Affairs, L.L.C. Nathaniel Katz is a consultant to Janssen and numerous other pharmaceutical companies that manufacture branded opioid products and nonopioid analgesics; authors Alan G. White, Howard G. Birnbaum, Milena N. Mareva, and Maham Daher disclose no potential bias or conflict of interest relating to this article. White served as principal author of the study. Study concept and design were contributed primarily by White, Vallow, Schein, and Katz. Analysis and interpretation of data were contributed by all authors. Drafting of the manuscript was primarily the work of White, and its critical revision was the work of White and Vallow. Statistical expertise was contributed by White, Birnbaum, and Daher, and administrative, technical, and/or material support was provided by Analysis Group, Inc., Boston, MA.

"Doctor and pharmacy shopping": A fading signal for prescription opioid use monitoring?

BACKGROUND

The term "doctor and pharmacy shopping" colloquially describes patients with high multiple provider episodes (MPEs)-a threshold count of distinct prescribers and/or pharmacies involved in prescription fulfillment. Opioid-related MPEs are implicated in the global opioid crisis and heavily monitored by government databases such as U.S. state prescription drug monitoring programs (PDMPs). We applied a widely-used MPE definition to examine U.S. trends from a large, commercially-insured population from 2010 to 2017. Further, we examined the proportion of enrollees identified as "doctor shoppers" with evidence of a cancer diagnosis to examine the risk of false positives.

METHODS

Using a large, commercially-insured population, we identified patients with opioid-related MPEs: opioid prescriptions (Schedule II-V, no buprenorphine) filled from ≥5 prescribers AND ≥ 5 pharmacies within the past 90 days ("5x5x90d"). Quarterly rates per 100,000 enrollees (two specifications) were calculated between 2010 and 2017. We examined the trend in a recently published all-payer, 7 state cohort from the U.S. Centers for Disease Control and Prevention for comparison. Cancer-related ICD-9/10-CM codes were used.

RESULTS

Quarterly MPE rates declined by approximately 73 % from 18.2-4.9 per 100,000 enrollee population with controlled substance prescriptions. In 2017, nearly one fifth of these commercially-insured enrollees identified by the 5x5x90d algorithm were diagnosed with cancer. Approximately 8% of this sample included patients with ≥ 1 buprenorphine prescriptions.

CONCLUSIONS

Opioid "shopping" flags are a long-standing but rapidly fading PDMP signal. To avoid unintended consequences, such as identifying legitimate medical encounters requiring high healthcare utilization or opioid treatment, while maintaining vigilance, more nuanced and sophisticated approaches are needed.

Impact of motivational interviewing training on emergency department nurses' skills: A one-group pretest-posttest pilot study

BACKGROUND

Overdose from opioid abuse is an increasing cause of mortality worldwide. Emergency department nurses experience barriers when caring for patients with illicit opioid use. Motivational interviewing (MI) may help address these barriers.

METHODS

A one-group pretest-posttest design was used to investigate the impact of an eight-hour MI training workshop for 39 emergency department nurses at a community hospital. Audio-recorded interviews of nurses with standardized patients were assessed before, immediately after, and three to five months after training. Proficiency was assessed using the Motivational Interviewing Treatment Integrity 4.2.1.

RESULTS

Paired t-test analysis found statistically significant technical score increases from 2.20 (SD = 0.64) to 2.51 (SD = 0.52, p = 0.02) but not in relational scores, 2.04 (SD = 0.59) to 2.46 (SD = 0.53, p = 0.06), during the immediate pretest-posttest period. At follow-up, proficiency in MI was unattained and both technical (2.35, SD = 0.61, p = 0.49) and relational scores regressed (2.08, SD 0.74, p = 0.19).

CONCLUSIONS

Although short-term improvements in technical scores were observed, proficiency in MI was not attained and skills regressed over time. This suggests that a one-day training session may be inadequate. On-going coaching and supervision may be beneficial to maintain MI skills.

Conditioned Place Preference (CPP) in Rats: From Conditioning to Reinstatement Test

Opioid addiction in humans is a chronically relapsing disorder characterized by discontinuous periods of drug use and abstinence resulting in dependence. With time, the probability of falling into renewed drug consumption becomes particularly high and constitutes a considerable problem in the management of opioid addicts. Opioid addiction represents an important health concern and animal models have been crucial in understanding the neurobiology and pathophysiology of this complex disease. Although animal models of addiction do not fully reproduce the human condition, they do permit investigation of specific elements of the process as well as identification of potential therapeutic targets. In this chapter, we provide a step-by-step description of the morphine-conditioned place preference (CPP) model that represents a useful preclinical animal model extensively used to study the rewarding/aversive effect of drugs.

The Association of Chronic Opioid Use with Resource Utilization and Outcomes after Emergency General Surgery

INTRODUCTION

Chronic opioid use is prevalent among patients undergoing emergent surgery. We sought to understand it on the outcomes of the most common emergency surgery procedures, Appendectomy and Cholecystectomy.

METHODS

We used the National Inpatient Sample to identify chronic opioid use in emergency appendectomies (n = 953) and cholecystectomies (n = 2826) from 2005 to 2014. Primary outcome was length of stay (LOS), and secondary outcomes included total charges and mortality. LOS was analyzed with multivariate Poisson regression, total charges with multivariate linear regression.

RESULTS

For Appendectomy, the opioid abuse group was younger, had similar gender and racial demographics, had more Medicaid and private insurance and less self-pay, and had no clinically significant differences in comorbidities. Those with chronic opioid use had a 24% increased LOS (20-29%, p < .001) and $5532(±$881, p < .001) higher hospital charges. Mortality was very rare and not different (0.2% vs 0.6%, aOR 0.54 [0.11-2.58], p = .44). For Cholecystectomy, the opioid abuse group was similar in age and gender, had slightly more white individuals, had a slightly different payor mix including higher rate of private insurance, and had no clinically significant differences in comorbidities. Patients with preoperative chronic opioid abuse showed a 14% increased LOS (12-16%, p < .001) and $5352 (± $1065, p < .001) higher hospital charges, but no significant increase in mortality (0.7% vs 0.6%, aOR 1.58 [0.77-3.25], p = .22).

CONCLUSION

Patients with chronic opioid abuse did not have increased mortality following EGS but had increased resource utilization and LOS. These findings may help explore the impact of opioid abuse on hospital and societal cost.

Utilizing a multi-class classification approach to detect therapeutic and recreational misuse of opioids on Twitter

BACKGROUND

Opioid misuse (OM) is a major health problem in the United States, and can lead to addiction and fatal overdose. We sought to employ natural language processing (NLP) and machine learning to categorize Twitter chatter based on the motive of OM.

MATERIALS AND METHODS

We collected data from Twitter using opioid-related keywords, and manually annotated 6988 tweets into three classes-No-OM, Pain-related-OM, and Recreational-OM-with the No-OM class representing tweets indicating no use/misuse, and the Pain-related misuse and Recreational-misuse classes representing misuse for pain or recreation/addiction. We trained and evaluated multi-class classifiers, and performed term-level k-means clustering to assess whether there were terms closely associated with the three classes.

RESULTS

On a held-out test set of 1677 tweets, a transformer-based classifier (XLNet) achieved the best performance with F₁-score of 0.71 for the Pain-misuse class, and 0.79 for the Recreational-misuse class. Macro- and micro-averaged F₁-scores over all classes were 0.82 and 0.92, respectively. Content-analysis using clustering revealed distinct clusters of terms associated with each class.

DISCUSSION

While some past studies have attempted to automatically detect opioid misuse, none have further characterized the motive for misuse. Our multi-class classification approach using XLNet showed promising performance, including in detecting the subtle differences between pain-related and recreation-related misuse. The distinct clustering of class-specific keywords may help conduct targeted data collection, overcoming under-representation of minority classes.

CONCLUSION

Machine learning can help identify pain-related and recreational-related OM contents on Twitter to potentially enable the study of the characteristics of individuals exhibiting such behavior.

Opioid abuse surveillance in patients with endocarditis

BACKGROUND

Opioid abuse is a significant cause of morbidity and mortality in the United States, and injection drug use (IDU) is a common form of opioid abuse. IDU is a major risk factor for infections including infective endocarditis (IE).

OBJECTIVES

To determine the prevalence of opioid abuse among patients with IE in both patient problem lists and diagnostic codes and describe underlying patient characteristics.

METHODS

A retrospective chart review from 1-1-2010 to 11-19-2018 of a large academic medical center's patients with documented IE was performed. Demographic, comorbidity, opioid prescription data and records of drug abuse in both the patient's problem list and ICD9/10 codes were recorded.

RESULTS

Of the 796 patients with documented IE, 105 patients (13.2%) had opioid abuse or related IDU in their problem list, but only 22 received an ICD-9/10 code associated with drug abuse. IE patients with opioid abuse were generally younger (43.6 vs 61.7 years [P < 0.001]), had fewer chronic comorbidities, and were prescribed opioids more often (86.7% vs 53.8% [P < 0.001]).

CONCLUSIONS

Opioid abuse and IDU are commonly recorded in the problem list of patients with IE, but opioid abuse is frequently not listed as a diagnosis in administrative billing codes.

HIV and opiates dysregulate K+- Cl- cotransporter 2 (KCC2) to cause GABAergic dysfunction in primary human neurons and Tat-transgenic mice

Approximately half of people infected with HIV (PWH) exhibit HIV-associated neuropathology (neuroHIV), even when receiving combined antiretroviral therapy. Opiate use is widespread in PWH and exacerbates neuroHIV. While neurons themselves are not infected, they incur sublethal damage and GABAergic disruption is selectively vulnerable to viral and inflammatory factors released by infected/affected glia. Here, we demonstrate diminished K+-Cl- cotransporter 2 (KCC2) levels in primary human neurons after exposure to HIV-1 or HIV-1 proteins ± morphine. Resulting disruption of GABAAR-mediated hyperpolarization/inhibition was shown using genetically-encoded voltage (Archon1) and calcium (GCaMP6f) indicators. The HIV proteins Tat (acting through NMDA receptors) and R5-gp120 (acting via CCR5) but not X4-tropic gp120 (acting via CXCR4), and morphine (acting through μ-opioid receptors) all induced KCC2 loss. We demonstrate that modifying KCC2 levels or function, or antagonizing NMDAR, CCR5 or MOR rescues KCC2 and GABAAR-mediated hyperpolarization/inhibition in HIV, Tat, or gp120 ± morphine-exposed neurons. Using an inducible, Tat-transgenic mouse neuroHIV model, we found that chronic exposure to Tat also reduces KCC2. Our results identify KCC2 as a novel therapeutic target for ameliorating the pathobiology of neuroHIV, including PWH exposed to opiates.

Eye-Related Emergency Department Visits and The Opioid Epidemic: a 10-Year Analysis

PURPOSE

To describe the epidemiology of Emergency Department (ED) visits related to opioid abuse with primary ophthalmic diagnoses in the United States (US).

METHODS

This retrospective cross-sectional study used National ED Sample (NEDS) (2006-2015), a representative sample of all US EDs, to analyze and compare the epidemiology of primary ophthalmic diagnoses in opioid abusers and a control group of non-opioid users. National incidence and descriptive statistics were calculated for demographics and prevalent diagnoses. Multivariable logistic regression was used to compare outcomes between primary ophthalmic diagnoses in opioid and non-opioid abusers.

RESULTS

An estimated 10,617 visits had a primary ophthalmic diagnosis and an accompanying opioid abuse diagnosis, and the incidence increased from 0.2 in 2006 to 0.6 per 100,000 US population in 2015. Opioid abuse group had more adults (6,747:63.5%) and middle-aged (3,361:31.7%) patients, while in controls adults (7,905,003:40.4%) and children (4,068,534:20.8%) were affected more. Leading etiologies were similar: traumatic and infectious etiologies were most common; however, opioid abuse patients had more severe ophthalmic diagnoses such as orbital fractures (8.4%), orbital cellulitis (7.4%), globe injury (3.4%) and endophthalmitis (3.2%) compared to controls. Patients in the opioid abuse group were also more likely to be admitted (adjusted Odds Ratio [aOR], 28.38 [95% CI, 24.50-32.87]).

CONCLUSIONS

In the era of opioid crisis, an increase in ED visits with ophthalmic complaints is seen, with increasing direct and indirect costs on the healthcare system. More research is needed to establish causality and devise strategies to lower this burden.

Medication assisted treatment (MAT) in criminal justice settings as a double-edged sword: balancing novel addiction treatments and voluntary participation

Medication-Assisted Treatment (MAT) provides an opportunity to address opioid addiction among justice-involved individuals, an often difficult to reach population. This potential has been increasingly recognized by agencies, policymakers and pharmaceutical companies. The result has been a marked increase in the number of drug courts, prisons and agencies in which MAT, notably with long-acting injectable medications, is offered. While this is a positive development, ensuring that vulnerable individuals are in a position voluntarily participation within the complex criminal justice environment is necessary. The unequal authority and agency inherent in the nature of these environments should be recognized. Therefore, rigorous protections, mirroring the goals of the consent processes required for medical or sociobehavorial research, should be employed when MAT is offered to protect individual autonomy.

Prescription opioid misuse among adolescents and emerging adults in the United States: A scoping review

The U.S. opioid epidemic is a critical public health problem. As substance use and misuse typically begin in adolescence and emerging adulthood, there is a critical need for prevention efforts for this key developmental period to disrupt opioid misuse trajectories, reducing morbidity and mortality [e.g., overdose, development of opioid use disorders (OUD)]. This article describes the current state of research focusing on prescription opioid misuse (POM) among adolescents and emerging adults (A/EAs) in the U.S. Given the rapidly changing nature of the opioid epidemic, we applied PRISMA Scoping Review (PRISMA-ScR) guidelines to identify empirical articles published in the past 5 years (January 2013-September 2018) from nine databases examining POM among A/EAs (ages 10-25) in the U.S. Seventy-six articles met our inclusion criteria focusing on POM in the following areas: cross-sectional surveys (n = 60), longitudinal cohort studies (n = 5), objective, non-self-reported data sources (n = 9), and interventions (n = 2). Final charted data elements were organized by methodology and sample, with results tables describing design, sample, interventions (where applicable), outcomes, and limitations. Most studies focused on the epidemiology of POM and risk/protective factors, including demographic (e.g., sex, race), individual (e.g., substance use, mental health), and social (e.g., peer substance use) factors. Despite annual national surveys conducted, longitudinal studies examining markers of initiation and escalation of prescription opioid misuse (e.g., repeated overdoses, time to misuse) are lacking. Importantly, few evidence-based prevention or early intervention programs were identified. Future research should examine longitudinal trajectories of POM, as well as adaptation and implementation of promising prevention approaches.

Gender differences in prescription opioid use and misuse: Implications for men's health and the opioid epidemic

The majority of research on gender and the opioid epidemic focuses on women as patients, caregivers, or expectant mothers. However, little research approaches men as gendered subjects, despite their dramatically increased risk of opioid overdose. Accordingly, we examined gender differences in prescription opioid use and misuse with specific attention to implications for men using data from the 2017 National Survey on Drug Use and Health. We used design-adjusted, weighted Wald tests and multivariate logistic regression to compare gender differences in rates of prescription opioid use and misuse, prescription opioid sources, primary motivation for misuse, and prescription opioid dependence. We found that although men were significantly less likely than women to report opioid use, they were significantly more likely to report opioid misuse and to misuse prescription opioids primarily to feel good or get high. Among past-year opioid users, men were significantly more likely than women to meet DSM-IV criteria for opioid dependence. Results are consistent with past work on the intersection of masculinity norms and health behaviors. Although gender-specific interventions are typically synonymous with interventions tailored to women, our results suggest that such interventions could alleviate the burden of the opioid epidemic for men as well. Further research studying possible mechanisms that explain men's increased vulnerability to the opioid epidemic is urgently needed to address this growing public health crisis.

Behavioral Pharmacology of Drugs Acting at Mu Opioid Receptors

Despite the therapeutic utility of opioids for relieving pain, other behavioral effects, including their potential for abuse and overdose, can be quite detrimental to individuals as well as society and have contributed to the ongoing opioid crisis. The dramatic escalation in overdose deaths over the last 15 years was initially driven by abuse of prescription opioids, although abuse of heroin, fentanyl, and fentanyl analogs has been increasing, largely due to increased availability and lower cost compared with prescription opioids. All of these opioids share pharmacological properties, acting as agonists at mu opioid receptors, and produce similar behavioral effects, including abuse-related, pain-relieving, dependence-producing, and respiratory-depressant effects. Despite their similarities, opioids are not pharmacologically identical. In fact, drugs that act at mu opioid receptors, including abused opioids, can vary on a number of dimensions, including pharmacological efficacy, drug-receptor interactions, receptor selectivity, and pharmacokinetics. Overall, these differences impact behavioral effects of drugs acting at mu opioid receptors, and this chapter describes variations in those behavioral effects and how these differences continue to provide new strategies that can be developed to address the ongoing opioid epidemic.

Opioid use disorder in admissions for acute exacerbations of chronic pancreatitis and 30-day readmission risk: A nationwide matched analysis

BACKGROUND

The opioid epidemic in the United States has been on the rise. Acute exacerbations of chronic pancreatitis (AECP) patients are at higher risk for Opioid Use Disorder (OUD). Evidence on OUD's impact on healthcare utilization, especially hospital re-admissions is scarce. We measured the impact of OUD on 30-day readmissions, in patients admitted with AECP from 2010 to 2014.

METHODS

This is a retrospective cohort study which included patients with concurrently documented CP and acute pancreatitis as first two diagnoses, from the National Readmissions Database (NRD). Pancreatic cancer patients and those who left against medical advice were excluded. We compared the 30-day readmission risk between OUD-vs.-non-OUD, while adjusting for other confounders, using multivariable exact-matched [(EM); 18 confounders; n = 28,389] and non-EM regression/time-to-event analyses.

RESULTS

189,585 patients were identified. 6589 (3.5%) had OUD. Mean age was 48.7 years and 57.5% were men. Length-of-stay (4.4 vs 3.9 days) and mean index hospitalization costs ($10,251 vs. $9174) were significantly higher in OUD-compared to non-OUD-patients (p < 0.001). The overall mean 30-day readmission rate was 27.3% (n = 51,806; 35.3% in OUD vs. 27.0% in non-OUD; p < 0.001). OUD patients were 25% more likely to be re-admitted during a 30-day period (EM-HR: 1.25; 95%CI: 1.16-1.36; p < 0.001), Majority of readmissions were pancreas-related (60%), especially AP. OUD cases' aggregate readmissions costs were $23.3 ± 1.5 million USD (n = 2289).

CONCLUSION

OUD contributes significantly to increased readmission risk in patients with AECP, with significant downstream healthcare costs. Measures against OUD in these patients, such as alternative pain-control therapies, may potentially alleviate such increase in health-care resource utilization.

Chronic pain, posttraumatic stress disorder, and opioid intake: A systematic review

BACKGROUND

The literature suggests that there is a high degree of co-occurrence between chronic pain and posttraumatic stress disorder (PTSD). An association has been found between PTSD and substance abuse. PTSD is a severe disorder that should be taken into account when opioids are prescribed. It has been found that the prevalence of opioid use disorder (OUD) in chronic pain patients is higher among those with PTSD than those without this disorder.

AIM

To perform a systematic review on the association between PTSD, chronic non-cancer pain (CNCP), and opioid intake (i.e., prescription, misuse, and abuse).

METHODS

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Patient, Intervention, Comparator, and Outcomes (PICOS) criteria were formulated a priori in the protocol of the systematic review. A search was conducted of the PROSPERO database. In March 2019, searches were also conducted of 5 other databases: PubMed, MEDLINE, PsycINFO, Web of Science, and PILOTS. The Scottish Intercollegiate Guidelines Network checklist for cohort studies was used to assess the selected studies for their methodological quality and risk of bias. Each study was evaluated according to its internal validity, participant sampling, confounding variables, and the statistical analysis.

RESULTS

A total of 151 potentially eligible studies were identified of which 17 were retained for analysis. Only 10 met the selection criteria. All the studies were published between 2008 and 2018 and were conducted in the United States. The eligible studies included a total of 1622785 unique participants. Of these, 196516 had comorbid CNCP and PTSD and were consuming opiates. The participants had a cross-study mean age of 35.2 years. The majority of participants were men (81.6%). The most common chronic pain condition was musculoskeletal pain: back pain (47.14% across studies; range: 16%-60.6%), arthritis and joint pain (31.1%; range: 18%-67.5%), and neck pain (28.7%; range: 3.6%-63%). In total, 42.4% of the participants across studies had a diagnosis of PTSD (range: 4.7%-95%). In relation to opioid intake, we identified 2 different outcomes: opioid prescription and OUD. All the studies reported evidence of a greater prevalence of PTSD in CNCP patients who were receiving prescribed opioids and that PTSD was associated with OUD in CNCP patients.

CONCLUSION

Opioid analgesic prescription as the treatment of choice for CNCP patients should include screening for baseline PTSD to ensure that these drugs are safely consumed.

Association between homelessness and opioid overdose and opioid-related hospital admissions/emergency department visits

BACKGROUND

Although homelessness and opioid overdose are major public health issues in the U.S., evidence is limited as to whether homelessness is associated with an increased risk of opioid overdose.

OBJECTIVE

To compare opioid-related outcomes between homeless versus housed individuals in low-income communities.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis of individuals who had at least one ED visit or hospitalization in four states (Florida, Maryland, Massachusetts, and New York) in 2014.

MEASUREMENTS

Risk of opioid overdose and opioid-related ED visits/hospital admissions were compared between homeless versus low-income housed individuals, adjusting for patient characteristics and hospital-specific fixed effects (effectively comparing homeless versus low-income housed individuals treated at the same hospital). We also examined whether risk of opioid-related outcomes varied by patients' sex and race/ethnicity.

RESULTS

A total of 96,099 homeless and 2,869,230 low-income housed individuals were analyzed. Homeless individuals had significantly higher risk of opioid overdose (adjusted risk, 1.8% for homeless vs. 0.3% for low-income housed individuals; adjusted risk difference [aRD], +1.5%; 95%CI, +1.0% to +2.0%; p < 0.001) and opioid-related ED visit/hospital admission (10.4% vs. 1.5%; aRD, +8.9%; 95%CI, +7.2% to +10.6%; p < 0.001) compared to low-income housed individuals. Non-Hispanic White females had the highest risk among the homeless population, whereas non-Hispanic White males had the highest risk among the low-income housed population.

LIMITATIONS

Individuals with no ED visit or hospitalization in 2014 were not included.

CONCLUSION

Homeless individuals had disproportionately higher adjusted risk of opioid-related outcomes compared to low-income housed individuals treated at the same hospital. Among homeless individuals, non-Hispanic White females incurred the highest risk. These findings highlight the importance of recognizing the homeless population-especially the non-Hispanic White female homeless population-as a high-risk population for opioid overdose.

Opioid use disorder and chronic pain: challenges for palliative care practice

Along with a well-documented increase in opioid use disorder (OUD) and a rapidly escalating rate of fatal overdose in North America, inadequate management of chronic pain remains a pervasive problem. The increasing number of individuals living with OUD also experience multiple cancer risk factors, which are related to their substance use, while people with cancer diagnoses have similar risks of current or past addiction as the general population. Recent pain guidelines focus on chronic non-cancer pain and do not include recommendations for cancer pain management. Managing cancer pain at the end of life is more challenging in people with current or past substance use disorder (SUD), especially OUD. Addressing these challenges requires confronting stigmas and stereotypes, building knowledge among palliative care providers and assessing the risks and benefits of opioids for pain management on an individual basis in order to continue to provide the holistic care.

Association between long-term NSAID use and opioid abuse among patients with breast cancer

BACKGROUND

Improving survival rates among patients with breast cancer has been associated with an increase in the prevalence of co-morbidities like cancer-related pain. Opioids are an important component in the management of pain among these patients. However, the progression from judicious use to abuse defeats the aim of pain control. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as the first step in cancer-related pain management. Due to their anti-inflammatory, anti-neoplastic and neuroprotective properties, NSAIDs have been shown to reduce the risk of progression of certain cancers including breast cancers. In this study, we assessed whether an association exists between long-term NSAID use and opioid abuse among breast cancer survivors. We also explored the relationship between long-term NSAID use and inpatient mortality and length of stay (LOS).

METHODS

Using ICD-9-CM codes, we identified and selected women aged 18 years and older with breast cancer from the National Inpatient Sample. Our primary predictor was a history of long-term NSAID use. Multivariable regression models were employed in assessing the association between long-term NSAID use and opioid abuse, inpatient mortality and LOS.

RESULTS

Among 170,644 women with breast cancer, 7,838 (4.6%) reported a history of long-term NSAID use. Patients with a history of long-term NSAID use had lower odds of opioid abuse (adjusted odds ratio (aOR) 0.53; 95% CI [0.32-0.88]), lower in-hospital mortality (aOR 0.52; 95% CI [0.45-0.60]) and shorter LOS (7.12 vs. 8.11 days).

DISCUSSION

Further studies are needed to understand the underlying mechanism of the association between long-term NSAID use and opioid abuse.

Buprenorphine in the United States: Motives for abuse, misuse, and diversion

Opioid use disorder (OUD) and its consequences are a major public health concern. The partial agonist buprenorphine is a safe and effective treatment for OUD, but concerns about abuse, misuse, and diversion of buprenorphine have been raised. This narrative review examined the rates and motives for use of illicit buprenorphine in the United States. Findings from the 17 included studies suggest the majority of study participants using illicit buprenorphine do so for reasons related to misuse (to manage opioid withdrawal symptoms or achieve or maintain abstinence from other opioids). A smaller percentage of study respondents reported using buprenorphine for reasons related to abuse (to get high). There appears to be a gap between need for buprenorphine and access to adequate treatment. Attenuation of policy-related barriers and adoption of appropriate buprenorphine use by the treatment community are critical tools in the continued effort to reduce the burdens associated with OUD.

Outpatient opioid use of burn patients: A retrospective review

INTRODUCTION

Opioid overuse is a growing patient safety issue but continue to be integral to burn pain management. This study aims to characterize opioid use in discharged patients and factors for predictive of long term use.

METHODS

Participants with burns admitted to a single center from 2006 to 2015 were included. Total outpatient morphine equivalent dose (MED) was recorded at discharge and each clinic visit. Burn size, percent grafted, age, sex, and preadmission drug use were collected. For each time point, multivariate logistic regression was performed to examine the relationship of discharge MED and long-term opioid use, adjusting for age, sex, burn size, and percent grafted. MED was divided into low (0-150 mg per day), medium (151-300 mg per day), and high (greater than 301 mg) groups on day of discharge.

RESULTS

At discharge, 366 (90%) patients received opioids. At day 14, both the medium MED (OR 2.72; CI 1.18-6.23) and high MED (OR 2.74; CI 1.02-7.37) groups had an increased risk for continued opioid use. On day 60, only the high MED group (OR 6.06; CI 1.60-22.97) had an increased risk. History of drug use was significant at 60 days (OR 7.67; 1.67-35.26) and alcohol use was significant at 14 days (OR 3.14; CI 1.25-7.93) and 30 days (OR 5.92; CI 1.81-19.36).

CONCLUSIONS

Whereas opioids are widely prescribed upon discharge, most patients no longer use them 30 days later. Higher opiate utilization at discharge increases risk of long term use, as does pre-injury drug and alcohol use, but only temporarily.

[Palliative care of patients receiving opioid substitution therapy]

Patients with opioid use disorder survive longer and reach higher ages due to harm reduction and maintenance programs. Therefor and because of concomitant comorbidities there is an increased incidence of life-limiting diseases. Thus, increasing numbers of patients with opioid use disorder or in maintenance programs will require palliative care. However, both inpatient and outpatient service providers are uncertain about providing palliative care for these patients. Home-care teams and inpatient hospices have been known to refuse admission for patients with opioid use disorder. Providing medical care to patients receiving substitution therapy can be challenging because maintenance programs require strict compliance with their rules and regulations; however, an individualized approach with knowledge of basic legal requirements enables good palliative care. In this manner, it is possible to ensure healthcare for these aging patients.

Safe Opioid Use, Storage, and Disposal Strategies in Cancer Pain Management

Opioids are required by a majority of patients with advanced cancer. Oncologists and palliative care clinicians are faced with the challenge of safely prescribing opioids in the current environment of an opioid crisis. Many patients with cancer use opioids unsafely, store them in unsecure locations, and do not dispose of unused opioids, leading to increased availability of these opioids for others to misuse. More than 50% of people who misuse opioids obtain the drugs from a friend or relative with or without their consent. Patient and provider education has been shown to improve safe opioid use, promote secure storage, and also increase disposal of unused opioids safely in drug take-back programs that are now widely available. This article highlights the importance of patient education and cautious opioid prescribing in patients with cancer. IMPLICATIONS FOR PRACTICE: The current opioid crisis makes it challenging to effectively manage cancer pain. Providers play a prominent role in minimizing opioid misuse. Cautious prescribing with limits enforced on the quantity of opioids prescribed, close follow-up, and consistent and frequent provision of opioid education are a must. Evidence points to the impact of patient education in promoting safety around opioid use. Most people who misuse prescription opioids obtain them from family or friends. Storing opioids in the open or not disposing of unused opioids increases the availability of these opioids for misuse by others. The importance of not sharing, always locking up, and disposing of unused and expired opioids must be highlighted as part of the opioid education that must be delivered every time that opioids are prescribed. Information about local drug take-back programs may also help increase disposal of unused opioids.

Neonatal Abstinence Syndrome: An Uncontrollable Epidemic

There is an uncontrollable epidemic of drug abuse, with the misuse of opioids the most alarming. Along with the increase in opioid abuse, there exists a concomitant upsurge in the number of neonates experiencing neonatal abstinence syndrome (NAS) due to the effects of the mother's withdrawal from the drug. Neonates experiencing NAS exhibit various nervous system, gastrointestinal, and respiratory untoward symptoms. Diagnosis is determined by taking an accurate maternal history and assessment of clinical signs and symptoms. Clinical management strategies include pharmacologic and nonpharmacologic therapies. Nursing care is evidence based, includes nonpharmacologic therapies, and focuses on prevention and support.

State variation in opioid treatment policies and opioid-related hospital readmissions

BACKGROUND

State policy approaches designed to provide opioid treatment options have received significant attention in addressing the opioid epidemic in the United States. In particular, expanded availability of naloxone to reverse overdose, Good Samaritan laws intended to protect individuals who attempt to provide or obtain emergency services for someone experiencing an opioid overdose, and expanded coverage of medication-assisted treatment (MAT) for individuals with opioid abuse or dependence may help curtail hospital readmissions from opioids. The objective of this retrospective cohort study was to evaluate the association between the presence of state opioid treatment policies-naloxone standing orders, Good Samaritan laws, and Medicaid medication-assisted treatment (MAT) coverage-and opioid-related hospital readmissions.

METHODS

We used 2013-2015 hospital inpatient discharge data from 13 states from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. We examined the relationship between state opioid treatment policies and 90-day opioid-related readmissions after a stay involving an opioid diagnosis.

RESULTS

Our sample included 383,334 opioid-related index hospitalizations. Patients treated in states with naloxone standing-order policies at the time of the index stay had higher adjusted odds of an opioid-related readmission than did those treated in states without such policies; however, this relationship was not present in states with Good Samaritan laws. Medicaid methadone coverage was associated with higher odds of readmission among all insurance groups except Medicaid. Medicaid MAT coverage generosity was associated with higher odds of readmission among the Medicaid group but lower odds of readmission among the Medicare and privately insured groups. More comprehensive Medicaid coverage of substance use disorder treatment and a greater number of opioid treatment programs were associated with lower odds of readmission.

CONCLUSIONS

Differences in index hospitalization rates suggest that states with opioid treatment policies had a higher level of need for opioid-related intervention, which also may account for higher rates of readmission. More research is needed to understand how these policies can be most effective in influencing acute care use.

Reprint of Trends and key correlates of prescription opioid injection misuse in the United States

BACKGROUND

Despite concerns over increasing harms associated with prescription opioid injection misuse, there is a paucity of research on the magnitude, characteristics, injection practices, and syringe sources for people who inject prescription opioids; limiting the implementation of targeted policy and programmatic initiatives.

MATERIALS AND METHODS

Data from the 2003 through 2014 National Surveys on Drug Use and Health were used to estimate prescription opioid injection trends and examine risky injection practices and syringe sources for people who inject prescription opioids. Multivariable logistic regression was used to identify characteristics associated with prescription opioid injection.

RESULTS

Among people 12years or older, the rate of prescription opioid injection misuse increased from 1.6 per 1000 in 2003-2005 to 2.7 per 1000 in 2012-2014 (p value for trend <0.05). Groups with increased odds of prescription opioid injection included: males, non-Hispanic whites, having an annual household income <$50,000, the uninsured, people with Medicaid, and people with past-year use disorders for cocaine, heroin, or prescription opioids. Risky injection practices such as reusing a needle and sharing needles were common among people with a history of prescription opioid injection misuse.

CONCLUSION

This study found significant increases in prescription opioid injection misuse trends in the U.S. These findings underscore the need to bring to scale evidence-based interventions to increase the provision of medication-assisted treatment for opioid use disorders and expand access to comprehensive risk-reduction services for people who inject drugs.

Abuse liability of mitragynine assessed with a self-administration procedure in rats

RATIONALE

Substantial use of the plant kratom for psychoactive effects has driven interest in its abuse liability. Several place conditioning studies suggest abuse liability of the active ingredient mitragynine, though studies of its self-administration have not been published.

METHODS

Binding of mitragynine to rat brain mu, kappa, and delta opioid receptors was compared to that for heroin and morphine. Self-administration of mitragynine, heroin, methamphetamine, or saline was assessed during single-session substitutions in rats trained to self-administer methamphetamine (0.022 mg/kg/injection, i.v.) during 1-h daily sessions.

RESULTS

Mitragynine had > 2- or ~ 16-fold greater affinity for the mu opioid receptor than, respectively, for kappa or delta opioid receptors. Its affinity for the mu receptor was ~ 200-fold less than that for morphine. In rats trained to self-administer methamphetamine, saline substitutions significantly decreased the number of responses, whereas different doses of methamphetamine (0.002-0.068 mg/kg/injection) or heroin (0.001-0.03 mg/kg/injection) maintained self-administration with maximal responding at 0.022 or 0.01 mg/kg/injection, respectively. In contrast, no dose of mitragynine maintained response rates greater than those obtained with saline. Presession mitragynine treatment (0.1 to 3.0 mg/kg) decreased response rates maintained by heroin but had little effect on responding maintained by methamphetamine across the same range of doses.

CONCLUSIONS

These results suggest a limited abuse liability of mitragynine and potential for mitragynine treatment to specifically reduce opioid abuse. With the current prevalence of opioid abuse and misuse, it appears currently that mitragynine is deserving of more extensive exploration for its development or that of an analog as a medical treatment for opioid abuse.

A double-blind, randomized controlled trial of gabapentin vs. placebo for acute pain management in critically ill patients with rib fractures

INTRODUCTION

Achieving adequate pain control for rib fractures remains challenging; prescription of alternatives to narcotics is imperative to curtail the current opioid epidemic. Although gabapentin has shown promise following elective thoracic procedures, its efficacy in patients with rib fractures remains unstudied. We hypothesized that gabapentin, as compared to placebo, would both improve acute pain control and decrease narcotic use among critically ill patients with rib fractures.

MATERIALS AND METHODS

Adult patients admitted to the trauma surgery service from November 2016 - November 2017 at an urban, Level I trauma center with one or more rib fractures were randomized to either gabapentin 300 mg thrice daily or placebo for one month following their injury. Daily numeric pain scores, opioid consumption, oxygen requirement, respiratory rate, and incentive spirometry recordings during the index admission, as well as and one-month quality of life survey data were abstracted.

RESULTS

Forty patients were randomized. The groups were well matched with respect to age, gender, prior narcotic use, tobacco use, and prior respiratory disease. Although the median RibScore did not differ between groups, the gabapentin group had a higher median number of ribs fractured as compared to the placebo group (7 vs. 5, respectively). Degree of pulmonary contusion and injury severity score were similar between groups. Use of loco-regional anesthetic modalities did not differ between groups. Daily numeric pain scores, opioid consumption, oxygen requirement, respiratory rate, and incentive spirometry recordings were similar between both groups. No benefit was observed when adding gabapentin to a multi-modal analgesic regimen for rib fractures. There were no instances of pneumonia, respiratory failure, or mortality in either group. Hospital and intensive care unit length of stay were similar between groups. Both overall and chest-specific quality of life was equivalent between groups at one month follow-up.

CONCLUSIONS

In this group of critically ill patients with rib fractures, gabapentin did not improve acute outcomes for up to one month of treatment.

Determining Abuse Deterrence Performance of Poly (ethylene oxide) Using a Factorial Design

Purpose: The purpose of this study was to determine the effects of thermal processing and antioxidant formulation variables on the abuse deterrence performance of a high molecular weight poly(ethylene oxide) (PEO) polymer.

Methods: A 2⁴ factorial design with one categorical factor (antioxidant type) and three continuous factors (curing time, curing temperature, % antioxidant) was used. Abuse deterrence performance was evaluated using solution viscosity, surface melting temperature, and mechanical strength. Thermal degradation of PEO powders before compaction was also studied using DSC, FTIR spectroscopy, and viscosity analysis.

Results: Our results showed that curing temperature and type of antioxidant can significantly affect the deterrence performance of PEO. The main effect plot for viscosity shows the most prominent factors affecting viscosity are curing temperature and type of antioxidant. However, curvature in the linear model obtained was not sufficient to completely describe the behavior. For surface melting temperature, butylated hydroxytoluene was associated with higher surface melting temperatures compared to ascorbic acid. Additionally, higher percent of antioxidant resulted in higher melting temperature. Particle size distribution to indicate mechanical strength showed no significant effects of tested factors. This suggests that comminution method has more prominent effect on tablet fragment size than the formulation and processing factors studied.

Conclusion: While heat confers the mechanical strength to the polymer, it can diminish its physical stability and solution state viscosity. The experimental studies showed that prolonged exposure to high temperatures, even in the presence of antioxidants, can severely hamper polymer deterrence performance in both solid and solution states.