The risk of repeated suicidal presentations following residential treatment for substance use disorders: A recurrent event analysis using linked administrative data.

BACKGROUND: Individuals seeking alcohol and other drug (AOD) treatment consistently experience higher rates of suicidal behaviours and death by suicide when compared to the general population. By linking residential AOD treatment data to administrative healthcare and death datasets, we aimed to examine suicide-related behaviours and identify risk and protective factors for these events following discharge from residential treatment. METHODS: Participants included 1056 individuals aged 18-69 (M = 32.06, SD = 9.55, male = 696,65.9 %) admitted to three residential treatment facilities in Queensland, Australia from January 1, 2014 to December 31, 2016. Treatment data was linked to administrative hospital, emergency department (ED), mental health service, and Registry of Deaths data 2-years post-discharge. ICD-10 codes were used to identify and analyse suicide-related events. RESULTS: Within 2-years post-discharge, 175 (16.6 %) individuals had a suicide-related event (n = 298 episodes). The highest proportion of episodes (11.1 %) occurred within 1-month of discharge. Higher risk of a recurrent suicide-related event was associated with receiving a Disability Support Pension (aHR = 1.69 (95%CI:1.10,2.59), two or more previous episodes of residential AOD treatment (aHR = 1.49 (95%CI:1.30,2.15). Completing residential treatment was associated with a lower risk of suicide-related events (aHR = 0.54 (95%CI:0.35,0.83). LIMITATIONS: The amalgamation of suicidal ideation, attempts, and death into a single outcome oversimplifies their complex nature and interplay. The exclusive focus on one service provider limits generalisability, and data constraints and missingness preclude many analyses. CONCLUSIONS: Understanding suicidal behaviours and critical risk periods following discharge from residential treatment is crucial for improving continuing care, developing effective suicide prevention, and implementing targeted interventions among this high-risk population.

'We didn't cause the opioid epidemic': The experiences of Australians prescribed opioids for chronic non-cancer pain at a time of increasing restrictions.

INTRODUCTION: Many countries have implemented strategies to reduce opioid-related harms, including policies and prescribing restrictions. This study aimed to explore the lived experiences of Australians prescribed opioids for chronic non-cancer pain (CNCP) in the context of increasing restrictions for accessing opioids. METHODS: Semi-structured interviews were conducted with 14 Australians (aged 24-65-years; 10 female/4 male) self-reporting regular use of prescribed opioids for CNCP. Participants were asked to describe their experiences using prescribed opioids, and perceived and actual changes in pain management including access to treatments. Using thematic analysis, four dominant themes were identified. RESULTS: In 'On them for a reason': Opioids as a last resort, participants described the role of opioids as an important tool for pain management following unsuccessful treatment using other strategies. In 'You're problematic': Deepening stigma, participants described how increased attention and restrictions led to increasing stigma of opioid use and CNCP. In 'We didn't cause the opioid epidemic': Perceiving and redirecting blame, participants described feeling unfairly blamed for public health problems and an 'opioid epidemic' they described as 'imported' from America, drawing distinctions between legitimate and illegitimate opioid use. Finally, in 'Where do we go from here?': Fearing the future, participants described anticipating further restrictions and associating these with increased pain and disability. DISCUSSION AND CONCLUSIONS: The experience of being prescribed opioids for CNCP in Australia in the context of increasing restrictions was characterised by stigma, blame and fear. There is a need to ensure people prescribed opioids for pain are considered when designing measures to reduce opioid-related harms.

Prevalence of comorbid substance use disorders among people with opioid use disorder: A systematic review & meta-analysis.

BACKGROUND: Comorbid substance use disorders (SUDs) among people with opioid use disorder (OUD) contribute to poor clinical outcomes, including overdose and mortality. We present the first systematic review and meta-analysis to estimate the prevalence of specific non-opioid SUDs among people with OUD. METHODS: We searched Embase, PsycINFO, and MEDLINE from 1990 to 2022 for studies that used Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria to assess the prevalence of non-opioid SUDs among individuals with OUD. We used random-effects meta-analyses with 95% Confidence Intervals (CIs) to pool current and lifetime prevalence estimates separately. Meta-regressions and stratified meta-analyses were used to examine differences in prevalence estimates by sample characteristics and methodological factors. RESULTS: Of the 36,971 publications identified, we included data from 194 studies and 77,212 participants with OUD. The prevalence of any comorbid SUD among people with OUD was 59.5% (95%CI 49.1-69.5%) for current non-opioid SUDs, with 72.0% (95%CI 52.5-87.9%) experiencing a comorbid SUD in their lifetime. Of the studies that examined current comorbid SUDs, cocaine use disorder (30.5%, 95%CI 23.0-38.7%) was most common, followed by alcohol (27.1%, 95%CI 24.4- 30.0%), cannabis (22.7%, 95%CI 19.0-26.6%), sedative (16.1%, 95%CI 13.1-19.3%), and methamphetamine (11.4%, 95%CI 6.8-17.1%) use disorders. Substantial heterogeneity (I2>90%) across estimates was observed. Substantial heterogeneity (I2>90%) was observed across estimates, with significant variations in prevalence identified across geographic locations, recruitment settings, and other study-level factors. CONCLUSION: Findings from this study emphasize the importance of comorbid SUD treatment access for people with OUD. Our estimates can inform the provision of treatment and harm reduction strategies for people with OUD and specific subpopulations.

Clinical Observation, Management and Function Of low back pain Relief Therapies (COMFORT): A cluster randomised controlled trial protocol.

INTRODUCTION: Low back pain (LBP) is commonly treated with opioid analgesics despite evidence that these medicines provide minimal or no benefit for LBP and have an established profile of harms. International guidelines discourage or urge caution with the use of opioids for back pain; however, doctors and patients lack practical strategies to help them implement the guidelines. This trial will evaluate a multifaceted intervention to support general practitioners (GPs) and their patients with LBP implement the recommendations in the latest opioid prescribing guidelines. METHODS AND ANALYSIS: This is a cluster randomised controlled trial that will evaluate the effect of educational outreach visits to GPs promoting opioid stewardship alongside non-pharmacological interventions including heat wrap and patient education about the possible harms and benefits of opioids, on GP prescribing of opioids medicines dispensed. At least 40 general practices will be randomised in a 1:1 ratio to either the intervention or control (no outreach visits; GP provides usual care). A total of 410 patient-participants (205 in each arm) who have been prescribed an opioid for LBP will be enrolled via participating general practices. Follow-up of patient-participants will occur over a 1-year period. The primary outcome will be the cumulative dose of opioid dispensed that was prescribed by study GPs over 1 year from the enrolment visit (in morphine milligram equivalent dose). Secondary outcomes include prescription of opioid medicines, benzodiazepines, gabapentinoids, non-steroidal anti-inflammatory drugs by study GPs or any GP, health services utilisation and patient-reported outcomes such as pain, quality of life and adverse events. Analysis will be by intention to treat, with a health economics analysis also planned. ETHICS AND DISSEMINATION: The trial received ethics approval from The University of Sydney Human Research Ethics Committee (2022/511). The results will be disseminated via publications in journals, media and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12622001505796.

Picky eating in children: Current clinical trends, practices, and observations within the Australian health-care context.

BACKGROUND/AIM: Childhood picky eating occurs when there is limited intake or variety of food and/or unwillingness to try new foods. Within research settings, standardised assessments are used to describe picky eating behaviours in children. However, little is known about assessment practices of occupational therapists. Similarly, occupational therapy interventions for picky eating in the literature focus on; providing strategies for parents, and working with the child on self-feeding skills. Despite this, interventions and strategies utilised by occupational therapists in clinical practice within an Australian health-care context are unknown. This study examines Australian health professionals' observations of picky eating behaviours, the use of childhood picky eating assessments and interventions, and differences between occupational therapists and other professionals. METHODS: Health professionals (n = 179) were recruited through professional organisations, such as Occupational Therapy Australia. Participants completed an online survey between March and May 2021. Independent variables were reported using descriptive statistics, with logistic regression used to consider differences between occupational therapists and other health professionals. Conventional content analysis was used to analyse responses to open-ended questions. RESULTS: The final sample included 109 eligible participants, with an average of 8.5 years working with picky eaters. Results indicated picky eating behaviours aligned with those reported in the literature. Participants relied on clinical observations and workplace designed assessments. The most common interventions were education, coaching, and the sequential oral sensory approach to feeding. Occupational therapy participants were significantly more likely than other health professional participants to report always using coaching and education. CONCLUSION: Although few health professionals used standardised or validated assessments, the use of education and coaching by occupational therapists aligned with the literature. Results highlight the need for more rigorous investigation to determine the sensitivity of current assessments to differentiate between clinical and typical picky eating, and the effectiveness of interventions for childhood picky eating.

The effects of childhood trauma and mental disorders on treatment engagement, contact with the criminal justice system, and mortality among people with opioid dependence.

BACKGROUND: Childhood trauma and mental disorders increase the risk of opioid dependence. We aimed to examine whether childhood trauma and mental disorders are associated with opioid agonist treatment (OAT) engagement, contact with the criminal justice system, and mortality among people with opioid dependence. METHODS: This observational study linked survey data from 1482 people receiving OAT in Sydney, Australia (2004-2008) to administrative data on OAT, crime, and mortality through 2017. We used survey data to assess childhood trauma, depression, panic disorder, post-traumatic stress disorder (PTSD), borderline personality disorder, anti-social personality disorder (ASPD), and comorbid substance dependence. We used discrete-time analysis to examine time from opioid dependence onset to OAT entry and mortality. Poisson regressions were used to analyze time receiving OAT and number of charges. RESULTS: Participants with extensive childhood trauma histories and ASPD were less likely to enter OAT and those with depression were more likely to enter OAT in any given year after opioid dependence onset. Panic disorder, PTSD, and borderline personality disorder were associated with less time in OAT. Extensive histories of childhood trauma, PTSD, ASPD, and comorbid substance dependence increased risk of charges for any offence. There were no significant associations between the exposure variables and mortality. CONCLUSIONS: Our findings suggest that childhood trauma and mental disorders increase the risk of adverse treatment and social outcomes among people with opioid dependence. Interventions that aim to reduce harm among people with opioid dependence may consider the effect of childhood trauma and mental disorders on OAT engagement and crime.

"Frustrated with the whole system": a qualitative framework analysis of the issues faced by people accessing health services for chronic pain.

BACKGROUND: Chronic non-cancer pain (CNCP) is complex and often requires multimodal management comprising of both pharmacological and non-pharmacological treatments. To inform delivery of CNCP management, it is important to understand how current health services providing non-pharmacological treatments are accessed by exploring the experiences of people attempting to access services. In doing so, this study sought to explore the underlying drivers of service access barriers. METHODS: This study explored the experiences of Australians accessing services for CNCP using semi-structured telephone interviews undertaken between 01 October 2020 and 31 March 2021. Thematic analysis was guided by Levesque et al.'s 2013 conceptual framework of access to health care, with emerging themes mapped to five dimensions of accessibility and corresponding abilities of consumers: Approachability/Ability to perceive; Acceptability/Ability to seek; Availability and Accommodation/Ability to reach; Affordability/Ability to pay; and Appropriateness/Ability to engage. RESULTS: The 26 participants (aged 24-78 years, 22 female) reported accessing a range of services including general practitioners (GP), allied health services, and specialised pain clinics, for a variety of conditions. Three themes were mapped to accessibility dimensions (in brackets): 'GP as guide or gatekeeper' (Approachability); 'Outside of my control' (Availability and Accommodation; Affordability); and 'Services aren't always good enough' (Appropriateness). A fourth identified theme illustrated how participants responded to encountering these barriers: 'Leading my own pain management'. Participant experiences suggest problems with the translation of contemporary pain management principles into practice, including continued application of biomedical health models as opposed to the biopsychosocial model, and demonstrate systemic issues with service delivery, including a lack of benchmarking of specialised services. CONCLUSIONS: The identified themes highlight several evidence-to-practice gaps in the delivery of health services for people with CNCP in Australia. To address these gaps, there is a need for improved clinician training, increased investment in specialised pain services, and development of clear primary care pathways for CNCP management for evidence-based multimodal pain management to be accessible and equitable.

Intimate Partner Violence in the Sub-Saharan African Immigrant Community in Chicago: A Changing Landscape.

The challenges of conducting research on intimate partner violence (IPV) in immigrant communities means little is known about the occurrence of various forms of IPV, making it difficult to address in these populations. This research draws on data gathered in Chicago's large and varied African immigrant communities. This research used a mixed methods approach: collection of quantitative survey data on occurrence, followed by qualitative interviews to explain the results. Missing quantitative data and contradicting qualitative responses made it difficult to draw definite conclusions on physical IPV; however, verbal abuse and controlling behaviours appear to be relatively widespread and normalised, and not always viewed as violence. Particularly with the probability of future pandemics and natural disasters, which are known to increase prevalence, it is important to raise awareness of less visible controlling behaviours and verbal abuse as forms of violence, and to implement appropriate prevention programs to minimise a concomitant rise in IPV within African immigrant communities.

Presentations to the emergency department with self-harm or suicidal behaviours: A role for digital mental health services?

Emergency Department (ED) is an important site for assessing people presenting with self-harm or suicidal behaviors. Digital mental health services (DMHS) offer evidence-based interventions for mental health issues, but are often under-utilised, and information about them is rarely provided in ED. This feasibility study explored whether offering information about a DMHS to individuals presenting to ED with self-harm/suicidal behaviors resulted in self-enrolment in DMHS interventions for anxiety, depression and/or chronic pain. METHODS: all individuals aged 18+ presenting with self-harm/suicidal behaviors to a metropolitan ED were screened for symptoms of anxiety, depression and/or chronic pain. Those with these symptoms were invited to participate in a study investigating enrolment with a DMHS. Study participants were provided with information about DMHS and followed up at one month. RESULTS: 260 individuals presented with self-harm/suicidal behaviors over the 6-month study period. Many reported low mood (73.5%, n = 191) anxiety (67.2%, n = 174) and/or chronic pain (18.5%, n = 48). Half of those eligible for DMHS agreed at point of ED discharge to be contacted about participation in the DMHS study (51.4%, n = 108). One-third of these participated in the study (35.2%, n = 38). Rates of past-month high-risk SB (65.8%, n = 25), depression (92.1%, n = 35), anxiety (78.9%, n = 30) and chronic pain (57.9%, n = 22) were very high. Of these, 39.5% (n = 15) self-enrolled with the DMHS; almost all (80.0%, n = 13) engaged with an online intervention. CONCLUSIONS: A subset of people presenting to emergency department with suicidal behaviors will engage with DMHS. Better understanding is needed of factors contributing to uptake of DMHS in this group.

Prevalence of mental disorders among people with opioid use disorder: A systematic review and meta-analysis.

BACKGROUND: Opioid use disorder (OUD) and mental disorders are major public health issues and comorbidity is common. Among people with OUD, comorbid mental disorders are associated with poorer health outcomes. To our knowledge, this is the first systematic review and meta-analysis to estimate prevalence of specific mental disorders among people with OUD. METHODS: We searched Embase, MEDLINE, and PsycInfo from 1990 to 2021 for observational studies of depression, anxiety, post-traumatic stress disorder (PTSD), bipolar, personality, and other pre-specified mental disorders among people with OUD. We pooled current and lifetime estimates of each disorder using random-effects meta-analyses with 95% Confidence Intervals (CIs). Meta-regressions and stratified analyses were used to assess heterogeneity of prevalence estimates by methodological factors and sample characteristics. FINDINGS: Of the 36,971 publications identified, we included data from 345 studies and 104,135 people with OUD in at least one pooled estimate. Among people with OUD, the prevalence of current depression was 36.1% (95%CI 32.4-39.7%), anxiety was 29.1% (95%CI 24.0-33.3%), attention-deficit/hyperactivity disorder was 20.9% (95%CI 15.7-26.2%), PTSD was 18.1% (95%CI 15.4-20.9%), and bipolar disorder was 8.7% (95%CI 6.7-10.7%). Lifetime prevalence of anti-social personality disorder was 33.6% (95%CI 29.1-38.0%) and borderline personality disorder was 18.2% (95% CI 13.4-23.1%). Sample characteristics and methodological factors, including sex, were associated with variance of multiple prevalence estimates. INTERPRETATION: Our findings emphasise the need for access to mental disorder treatment among people with OUD. Specific mental disorder estimates may inform clinical guidelines, treatment services, and future research for people with OUD, including subpopulations with distinct treatment needs.

Self-reported challenges obtaining ongoing prescription opioids among Australians with chronic non-cancer pain.

BACKGROUND: Policies to address opioid-related harms include strategies to reduce opioid prescribing for new and ongoing pain management. Concerns have been raised that people with chronic non-cancer pain (CNCP) may be adversely affected by prescribing restrictions, and by involuntary tapering and cessation of opioids. We describe self-reported challenges obtaining prescription opioids among people prescribed opioids long-term for CNCP and explore associations with participant and treatment characteristics. METHODS: This cross-sectional study analysed data from a longitudinal cohort study of Australians prescribed restricted opioids for CNCP. In 2018, 861 participants who took part in Year 5 follow-up and who also reported past 12-month opioid use were asked about challenges obtaining opioid prescriptions, including prescriber access-related difficulties obtaining prescriptions or having opioids tapered or ceased involuntarily. Associations between challenges and demographics, treatment characteristics including daily opioid dose as oral morphine equivalent milligrams (OME mg/day), substance use disorder (SUD), and opioid dependence were assessed. RESULTS: Overall, 285 (31%) participants reported at least one challenge, predominantly prescriber access-related difficulties (n=177/285; 62%). Prescriber access-related difficulties were associated with younger age (adjustedOR 0.94 per year increase, 95%CI 0.93-0.96), and past 12-month pharmaceutical opioid dependence (adjustedOR 2.25, 95%CI 1.33-3.80). Involuntary opioid tapering or cessation was reported by 73 participants (26% of those reporting challenges) and was associated with lifetime SUD diagnosis (adjustedOR 2.15, 95%CI 1.15-3.90), and opioid doses of ≥200 OME mg/day (adjustedOR 2.41, 95%CI 1.18-4.88). CONCLUSION: One-third of participants with CNCP reported experiencing challenges obtaining prescriptions for opioids or having their opioid medicines involuntarily reduced. Given increasing restrictions to opioid access, it is important that strategies to reduce opioid-related harms are balanced against the current treatment needs of people prescribed opioids long-term for CNCP.

Opioid-sparing effect of cannabinoids for analgesia: an updated systematic review and meta-analysis of preclinical and clinical studies.

Cannabinoid co-administration may enable reduced opioid doses for analgesia. This updated systematic review on the opioid-sparing effects of cannabinoids considered preclinical and clinical studies where the outcome was analgesia or opioid dose requirements. We searched Scopus, Cochrane Central Registry of Controlled Trials, Medline, and Embase (2016 onwards). Ninety-two studies met the search criteria including 15 ongoing trials. Meta-analysis of seven preclinical studies found the median effective dose (ED50) of morphine administered with delta-9-tetrahydrocannabinol was 3.5 times lower (95% CI 2.04, 6.03) than the ED50 of morphine alone. Six preclinical studies found no evidence of increased opioid abuse liability with cannabinoid administration. Of five healthy-volunteer experimental pain studies, two found increased pain, two found decreased pain and one found reduced pain bothersomeness with cannabinoid administration; three demonstrated that cannabinoid co-administration may increase opioid abuse liability. Three randomized controlled trials (RCTs) found no evidence of opioid-sparing effects of cannabinoids in acute pain. Meta-analysis of four RCTs in patients with cancer pain found no effect of cannabinoid administration on opioid dose (mean difference -3.8 mg, 95% CI -10.97, 3.37) or percentage change in pain scores (mean difference 1.84, 95% CI -2.05, 5.72); five studies found more adverse events with cannabinoids compared with placebo (risk ratio 1.13, 95% CI 1.03, 1.24). Of five controlled chronic non-cancer pain trials; one low-quality study with no control arm, and one single-dose study reported reduced pain scores with cannabinoids. Three RCTs found no treatment effect of dronabinol. Meta-analyses of observational studies found 39% reported opioid cessation (95% CI 0.15, 0.64, I2 95.5%, eight studies), and 85% reported reduction (95% CI 0.64, 0.99, I2 92.8%, seven studies). In summary, preclinical and observational studies demonstrate the potential opioid-sparing effects of cannabinoids in the context of analgesia, in contrast to higher-quality RCTs that did not provide evidence of opioid-sparing effects.

Use of pharmacological and nonpharmacological treatments for chronic noncancer pain among people using opioids: a longitudinal cohort study.

ABSTRACT: Although multimodal management of chronic noncancer pain (CNCP) is recommended, long-term treatment utilization patterns among people using opioids are not well known. The Pain and Opioids IN Treatment study recruited Australian adults receiving opioids for CNCP for more than 6 weeks from community pharmacies. Pharmacological (opioid and nonopioid analgesics and psychotropic medicines) and nonpharmacological (physical, mental health, and specialized) treatments used in the previous 12 months and 30 days were collected annually over 4 years (2015-2018). Associations were explored between 30-day treatment use and sociodemographic characteristics and pain measures. Overall, 1334 participants completed at least one annual follow-up. The median pain severity (5.0, interquartile range [IQR] 3.8 to 6.3) and pain interference scores (5.7, IQR 3.9-7.3) indicated moderate pain throughout the study period, despite most participants reporting the use of nonopioid pharmacological (12 month: 97.6% and 30 day: 96.8%) and nonpharmacological treatments (12 month: 91.8% and 30 day: 66.1%). Some treatment use was inconsistent with guidelines: ongoing nonsteroidal anti-inflammatory drugs and sedative-hypnotic use were common, whereas fewer people engaged with pain management programs (12 month: 22.3%). Private health insurance was associated with using physical (adjusted odds ratio 1.61, 99.5% confidence intervals 1.15-2.24) and specialized nonpharmacological treatments (adjusted odds ratio 1.47, 99.5% confidence intervals 1.14-1.91). This study demonstrates that many Australians taking opioids long-term for CNCP also use nonopioid pharmacological and nonpharmacological treatments. The use of pharmacological treatments including nonsteroidal anti-inflammatory drugs, psychotropic medicines, and gabapentinoids, outside guidelines, warrants review. Furthermore, despite Australia's universal healthcare scheme subsidising some nonpharmacological treatments, overall use of these treatments was associated with having private health insurance, highlighting a need for more equitable service provision.

Barbiturate-related hospitalisations, drug treatment episodes, and deaths in Australia, 2000-2018.

OBJECTIVES: To determine the characteristics and population rates of barbiturate-related hospitalisations, treatment episodes, and deaths in Australia, 2000-2018. DESIGN, SETTING: Analysis of national data on barbiturate-related hospitalisations (National Hospital Morbidity Database, 1999-2000 to 2017-18), drug treatment episodes (Alcohol and Other Drug Treatment Services National Minimum Data Set, 2002-03 to 2017-18), and deaths (National Coronial Information System, 2000-01 to 2016-17). MAIN OUTCOME MEASURES: Population rates directly age-standardised to the 2001 Australian standard population; average annual percentage change (AAPC) in rates estimated by Joinpoint regression. RESULTS: We identified 1250 barbiturate-related hospitalisations (791 cases of deliberate self-harm [63%]), 993 drug treatment episodes (195 cases with barbiturates as the principal drug of concern [20%]), and 511 deaths during the respective analysis periods. The barbiturate-related hospitalisation rate declined from 0.56 in 1999-2000 to 0.14 per 100 000 population in 2017-18 (AAPC, -6.0%; 95% CI, -7.2% to -4.8%); the declines in hospitalisations related to accidental poisoning (AAPC, -5.8%; 95% CI, -9.1% to -2.4%) and intentional self-harm (AAPC, -5.6%; 95% CI, -6.9% to -4.2%) were each statistically significant. Despite a drop from 0.67 in 2002-03 to 0.23 per 100 000 in 2003-04, the drug treatment episode rate did not decline significantly (AAPC, -6.7%; 95% CI, -16% to +4.0%). The population rate of barbiturate-related deaths increased from 0.07 in 2000-01 to 0.19 per 100 000 population in 2016-17 (AAPC, +9.3%; 95% CI, +6.2-12%); the rate of intentional self-harm deaths increased (AAPC, +11%; 95% CI, +7.4-15%), but not that of accidental deaths (AAPC, -0.3%; 95% CI, -4.1% to +3.8%). CONCLUSIONS: While prescribing and community use of barbiturates has declined, the population rate of intentional self-harm using barbiturates has increased. The major harm associated with these drugs is now suicide.

Exposure to childhood trauma increases risk of opioid use disorder among people prescribed opioids for chronic non-cancer pain.

BACKGROUND: Little is known about childhood trauma exposure and Opioid Use Disorder (OUD) among people prescribed opioids for chronic non-cancer pain (CNCP). We aimed to (1) describe childhood trauma exposure among this population, and (2) examine if childhood trauma exposure was an independent risk factor for OUD among people prescribed opioids for CNCP. METHODS: This study used baseline data from 1514 people prescribed opioids for CNCP in Australia. We used latent class analysis to characterise participants by five indicators of childhood trauma exposure and logistic regression to characterise class membership. We used discrete-time survival analysis to determine whether there was an independent association between childhood trauma exposure and risk of OUD according to adjusted odds ratios (AOR). RESULTS: We identified three classes of childhood trauma exposure: (1) 'low exposure' (n = 765; 54.0%), (2) 'emotional & sexual abuse' (n = 324; 22.9%), and (3) 'high all' (n = 329; 23.2%). 'Emotional & sexual abuse' or 'high all' childhood trauma exposure class membership was associated with higher rates of pain difficulties, mental disorders, and substance use disorders, compared to 'low exposure' class membership. After we adjusted for previously identified OUD risk factors, participants in the 'emotional & sexual abuse' (AOR 1.51; 95%CI 1.09-2.12; p = 0.016) and 'high all' (AOR 1.77; 95%CI 1.28-2.45; p = 0.001) childhood trauma exposure classes were at increased risk of OUD. CONCLUSIONS: Among people prescribed opioids for CNCP, childhood trauma exposure was a common, independent risk factor for OUD. Availability of trauma-informed services for those prescribed opioids for CNCP may reduce risk of transition to OUD.

Association of Opioid Agonist Treatment With All-Cause Mortality and Specific Causes of Death Among People With Opioid Dependence: A Systematic Review and Meta-analysis.

Importance: Mortality among people with opioid dependence is higher than that of the general population. Opioid agonist treatment (OAT) is an effective treatment for opioid dependence; however, there has not yet been a systematic review on the relationship between OAT and specific causes of mortality. Objective: To estimate the association of time receiving OAT with mortality. Data Sources: The Embase, MEDLINE, and PsycINFO databases were searched through February 18, 2020, including clinical trial registries and previous Cochrane reviews. Study Selection: All observational studies that collected data on all-cause or cause-specific mortality among people with opioid dependence while receiving and not receiving OAT were included. Randomized clinical trials (RCTs) were also included. Data Extraction and Synthesis: This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data on study, participant, and treatment characteristics were extracted; person-years, all-cause mortality, and cause-specific mortality were calculated. Crude mortality rates and rate ratios (RRs) were pooled using random-effects meta-analyses. Main Outcomes and Measures: Overall all-cause and cause-specific mortality both by setting and by participant characteristics. Methadone and buprenorphine OAT were evaluated specifically. Results: Fifteen RCTs including 3852 participants and 36 primary cohort studies including 749 634 participants were analyzed. Among the cohort studies, the rate of all-cause mortality during OAT was more than half of the rate seen during time out of OAT (RR, 0.47; 95% CI, 0.42-0.53). This association was consistent regardless of patient sex, age, geographic location, HIV status, and hepatitis C virus status and whether drugs were taken through injection. Associations were not different for methadone (RR, 0.47; 95% CI, 0.41-0.54) vs buprenorphine (RR, 0.34; 95% CI, 0.26-0.45). There was lower risk of suicide (RR, 0.48; 95% CI, 0.37-0.61), cancer (RR, 0.72; 95% CI, 0.52-0.98), drug-related (RR, 0.41; 95% CI, 0.33-0.52), alcohol-related (RR, 0.59; 95% CI, 0.49-0.72), and cardiovascular-related (RR, 0.69; 95% CI, 0.60-0.79) mortality during OAT. In the first 4 weeks of methadone treatment, rates of all-cause mortality and drug-related poisoning were almost double the rates during the remainder of OAT (RR, 2.01; 95% CI, 1.55-5.09) but not for buprenorphine (RR, 0.58; 95% CI, 0.18-1.85). All-cause mortality was 6 times higher in the 4 weeks after OAT cessation (RR, 6.01; 95% CI, 4.32-8.36), remaining double the rate for the remainder of time not receiving OAT (RR, 1.81; 95% CI, 1.50-2.18). Opioid agonist treatment was associated with a lower risk of mortality during incarceration (RR, 0.06; 95% CI, 0.01-0.46) and after release from incarceration (RR, 0.09; 95% CI, 0.02-0.56). Conclusions and Relevance: This systematic review and meta-analysis found that OAT was associated with lower rates of mortality. However, access to OAT remains limited, and coverage of OAT remains low. Work to improve access globally may have important population-level benefits.

Pharmaceutical Opioid Use Patterns and Indicators of Extramedical Use and Harm in Adults With Chronic Noncancer Pain, 2012-2018.

Importance: Despite concern about harms related to long-term prescribed opioid use among individuals with chronic noncancer pain (CNCP), no study has examined whether the same patients engage in a risky pattern of use consistently for the long term. Objective: To examine the prevalence, incidence, persistence, and cessation of a range of opioid behaviors, indicators of extramedical use, and harm among individuals who are prescribed opioids. Design, Setting, and Participants: This 5-year prospective cohort study in communities across Australia included 1514 adults who were prescribed opioids for CNCP. Data collection took place from August 2012 to December 2018, and data analysis took place from February to November 2020. Exposure: Prescription opioid use. Main Outcomes and Measures: High-dose opioid use (≥200 oral morphine equivalent [OME] mg/d); requesting an increase in opioid dose; requesting an early prescription renewal; tampering with opioid medication; diversion of medication to others; and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision opioid dependence. Cessation of opioid use was also assessed. Results: Of the 1514 participants, 672 (44.39%) were men, the mean (SD) age was 58 (19) years, and 737 (48.68%) were unemployed. At each annual interview, approximately 1 in 8 people (10.98% [95% CI, 10.33%-11.63%] to 14.73% [95% CI, 13.98%-15.48%] at any given interview) were taking more than 200 OME mg/d; comparatively more had requested an increased dosage in the previous 3 months (8.46% [95% CI, 7.89%-9.03%] to 23.77% [95% CI, 22.82%-24.73%]); and fewer asked for an early prescription renewal (4.61% [95% CI, 4.19%-5.03%] to 13.97% [95% CI, 13.24%-14.70%]). In any given interview, between 3.06% (95% CI, 2.72%-3.40%) and 7.86% (95% CI, 7.31%-8.41%) of respondents reported tampering and between 0.47% (95% CI, 0.33%-0.60%) and 1.39% (95% CI, 1.16%-1.62%) reported diversion to others. Between 8.28% (95% CI, 7.71%-8.84%) and 13.06% (95% CI, 12.35%-13.77%) met criteria for opioid dependence at each interview. Opioid cessation increased across interviews, from year 1 (9.15% [95% CI, 8.55%-9.74%]) to year 5 (20.02% [19.14%-20.89%]). There was considerable incidence and cessation in all behaviors from 1 interview to the next: most who engaged in any of these behaviors only did so at only 1 interview. For pharmaceutical opioid dependence, between 55.26% (95% CI, 53.81%-56.71%) and 64.44% (95% CI, 62.87%-66.00%) of cases in 1 interview did not meet dependence criteria in the following interview. Conclusions and Relevance: These findings suggest considerable fluidity in opioid use, extramedical behaviors, and opioid dependence among people with CNCP. This reinforces the need for reassessment of the effectiveness and safety of prescription opioid use over time.

Prevalence of childhood maltreatment among people with opioid use disorder: A systematic review and meta-analysis.

BACKGROUND: Experience of childhood maltreatment (CM) is a risk factor for opioid use disorder (OUD). CM is also associated with comorbid mental disorders and poor treatment outcomes among people with OUD. To our knowledge, this is the first systematic review and meta-analysis to estimate the prevalence of CM among people with OUD. METHODS: We searched MEDLINE, EMBASE, and PsycINFO to identify observational studies that evaluated CM among people with OUD from January 1990 to June 2020. Prevalence of each CM type, sample characteristics, and methodological factors were extracted from each eligible study. Random-effects meta-analyses were used to pool prevalence estimates. Stratified meta-analyses were used to assess heterogeneity. RESULTS: Of the 6,438 publications identified, 113 studies reported quantitative CM data among people with OUD and 62 studies (k = 62; N = 21,871) were included in primary analyses. Among people with OUD, the estimated prevalence of sexual abuse was 41% (95% CI 36-47%; k = 38) among women and 16% (95% CI 12-20%; k = 25) among men. Among all people with OUD, prevalence estimates were 38% (95% CI 33-44%; k = 48) for physical abuse, 43% (95% CI 38-49%; k = 31) for emotional abuse, 38% (95% CI 30-46%; k = 17) for physical neglect, and 42% (95% CI 32-51%; k = 17) for emotional neglect. Sex, history of injecting drug use, recruitment methods, and method of assessing CM were associated with substantial heterogeneity. CONCLUSIONS: People with OUD frequently report the experience of CM, supporting the need for trauma-informed interventions among this population. Future research should consider the impact of CM on OUD presentations and when assessment is appropriate, use of validated instruments.

Clinical correlates and outcomes associated with pregabalin use among people prescribed opioids for chronic non-cancer pain: A five-year prospective cohort study.

AIMS: Pregabalin has become widely used as an alternative to opioids in treating certain types of chronic non-cancer pain, but few studies have examined its clinical efficacy outside trials. We address this gap by examining the utilization, correlates and clinical outcomes of pregabalin use among an Australian community-based cohort of people prescribed opioids for chronic non-cancer pain. METHODS: Through a five-year prospective cohort study (n = 1514) we examined associations between pregabalin use and pain severity and interference, mental health, opioid dose and past month use of ambulance and emergency department services. We used fixed-effects regression models to examine within-participant differences, and random-effects regression models to examine within- and between-participant differences in clinical outcomes. RESULTS: In an analysis of cases with complete data over five-years (n = 896), the prevalence of pregabalin use ranged from 16% at cohort entry to 29% at 36- and 48-months, and 46% reported pregabalin use at any time during the five years. Pregabalin use was associated with greater pain severity and interference and greater use of high-risk opioid doses (>90 oral morphine equivalents/day). Pregabalin use was not associated with changes in mental health symptoms, ambulance or emergency department attendance in the fixed or random effects models. CONCLUSIONS: Pregabalin use was common, but for most people use was not associated with clinically meaningful improvements in pain or functioning.