Association of state-level prescription drug monitoring program implementation with opioid prescribing transitions in primary care in Australia.

AIMS: This study aimed to evaluate whether voluntary and mandatory prescription drug monitoring program (PDMP) use in Victoria, Australia, had an impact on prescribing behaviour, focusing on individual patients' prescribed opioid doses and transition to prescribing of nonmonitored medications. METHODS: This was a retrospective cross-sectional study using routinely collected primary healthcare data. A 90-day moving average prescribed opioid dose in oral morphine equivalents was used to estimate opioid dosage. A Markov transition matrix was used to describe how patients prescribed medications transitioned between opioid dose groups and other nonopioid treatment options during 3 transition periods: transition between 2 control periods prior to PDMP implementation (T1 to T2); during the voluntary PDMP implementation (T2 to T3); and during mandatory PDMP implementation (T3 to T4). RESULTS: Among patients prescribed opioids in our study, we noted an increased probability of transitioning to not being prescribed opioids during the mandatory PDMP period (T3 to T4). This increase was attributed mainly to the ceasing of low-dose opioid prescribing. Membership in an opioid dose group remained relatively stable for most patients who were prescribed high opioid doses. For those who were only prescribed nonmonitored medications initially, the probability of being prescribed opioids increased during the mandatory PDMP when compared to other transition periods. CONCLUSION: The introduction of PDMP mandates appeared to have an impact on the prescribing for patients who were prescribed low-dose opioids, while its impact on individuals prescribed higher opioid doses was comparatively limited.

Impact of codeine rescheduling on prescribing of codeine and other opioids: Interrupted time series analyses using Australian general practice data.

AIMS: We aimed to determine the impact of codeine rescheduling on prescribing of codeine and other opioids, with a focus on demographic and diagnoses associated with codeine prescribing before and after rescheduling of codeine to prescription-only in February 2018. METHODS: We used interrupted time series analysis (February 2016-February 2020) and probit regression to examine prescribing of codeine and other opioids according to primary care data from 464 general practice clinics in Victoria, Australia. RESULTS: The rate of codeine prescribing increased in the month following rescheduling (additional 76 people/10000, 95% confidence interval [CI] 49-103), then declined to baseline rates (slope -2.02, 95% CI 3.79, -0.25). Prescribing of other opioids did not change. Post rescheduling, females were more likely to receive codeine prescriptions compared to males (ß = 0.094, 95% CI 0.08-0.108) and those aged 70-79 years were more likely to receive codeine compared to those aged <30 years. Those residing in the least disadvantaged areas had a greater probability of being prescribed codeine than those in more disadvantaged areas after rescheduling (ß = 0.154, 95% CI 0.129-0.179). A documented mental health diagnosis (ß = 0.067, 95% CI 0.052-0.082) or migraine diagnosis (ß = 0.057, 95% CI 0.037-0.078) was associated with increased likelihood of receiving a codeine prescription after rescheduling compared to before in contrast to those without such a diagnosis. CONCLUSION: Codeine rescheduling did not result in a sustained increase in codeine prescribing nor a change in the prescribing of other opioids. Patient factors associated with increased codeine prescribing after compared to before rescheduling included female sex, older age, migraine diagnosis and comorbid mental health conditions. REGISTRATION: EU PAS Register (EUPAS43218).

Trajectories of prescription opioid tapering in patients with chronic non-cancer pain: a retrospective cohort study, 2015-2020.

OBJECTIVE: To identify common opioid tapering trajectories among patients commencing opioid taper from long-term opioid therapy for chronic non-cancer pain and to examine patient-level characteristics associated with these different trajectories. DESIGN: A retrospective cohort study. SETTING: Australian primary care. SUBJECTS: Patients prescribed opioid analgesics between 2015 and 2020. METHODS: Group-based trajectory modeling and multinomial logistic regression analysis were conducted to determine tapering trajectories and to examine demographic and clinical factors associated with the different trajectories. RESULTS: A total of 3369 patients commenced a taper from long-term opioid therapy. Six distinct opioid tapering trajectories were identified: low dose / completed taper (12.9%), medium dose / faster taper (12.2%), medium dose / gradual taper (6.5%), low dose / noncompleted taper (21.3%), medium dose / noncompleted taper (30.4%), and high dose / noncompleted taper (16.7%). A completed tapering trajectory from a high opioid dose was not identified. Among patients prescribed medium opioid doses, those who completed their taper were more likely to have higher geographically derived socioeconomic status (relative risk ratio [RRR], 1.067; 95% confidence interval [CI], 1.001-1.137) and less likely to have sleep disorders (RRR, 0.661; 95% CI, 0.463-0.945) than were those who didn't complete their taper. Patients who didn't complete their taper were more likely to be prescribed strong opioids (eg, morphine, oxycodone), regardless of whether they were tapered from low (RRR, 1.444; 95% CI, 1.138-1.831) or high (RRR, 1.344; 95% CI, 1.027-1.760) doses. CONCLUSIONS: Those prescribed strong opioids and high doses appear to be less likely to complete tapering. Further studies are needed to evaluate the clinical outcomes associated with the identified trajectories.

Predictors of persistent opioid use in Australian primary care: A retrospective cohort study, 2018-2022.

OBJECTIVE: To examine the predictors of persistent opioid use ('persistence') in people initiating opioids for non-cancer pain in Australian primary care. DESIGN: A retrospective cohort study. SETTING: Australian primary care. SUBJECTS: People prescribed opioid analgesics between 2018-2022, identified through the Population Level Analysis and Reporting (POLAR) database. METHODS: Persistence was defined as receiving opioid prescriptions for at least 90 days with a gap of less than 60 days between subsequent prescriptions. Multivariable logistic regression was used to examine the predictors of persistent opioid use. RESULTS: The sample consisted of 343,023 people initiating opioids for non-cancer pain; of these, 16,527 (4.8%) developed persistent opioid use. Predictors of persistence included older age (≥75 vs 15-44 years: Adjusted odds ratio: 1.67, 95% CI: 1.58-1.78), concessional beneficiary status (1.78, 1.71-1.86), diagnosis of substance use disorder (1.44, 1.22-1.71) and chronic pain (2.05, 1.85-2.27), initiation of opioid therapy with buprenorphine (1.95, 1.73-2.20) and long-acting opioids (2.07, 1.90-2.25), provision of higher quantity of opioids prescribed at initiation (total OME of ≥ 750mg vs < 100mg: 7.75, 6.89-8.72), provision of repeat/refill opioid prescriptions at initiation (2.94, 2.77-3.12), and prescription of gabapentinoids (1.59, 1.50-1.68), benzodiazepines (1.43, 1.38-1.50) and z-drugs (e.g., zopiclone, zolpidem; 1.61, 1.46-1.78). CONCLUSIONS: These findings add to the limited evidence of individual-level factors associated with persistent opioid use. Further research is needed to understand the clinical outcomes of persistent opioid use in people with these risk factors to support the safe and effective prescribing of opioids.

Performance of the Medical Priority Dispatch System® in Identifying Patients Requiring Chest Compressions at Overdose Prevention Services: A Retrospective Cohort Study.

BACKGROUND AND AIMS: The Medical Priority Dispatch System (MPDS)® is used to triage 9-1-1 calls according to acuity, with certain coding receiving telecommunicator cardiopulmonary resuscitation (T-CPR) for suspected out-of-hospital cardiac arrest (OHCA). However, this may be challenging for those with drug poisoning emergencies, who may resemble OHCA. We sought to examine the performance of the system to correctly identify cases requiring T-CPR, specifically at overdose prevention services (OPS). METHODS: This retrospective cohort study included patients attended by the provincial emergency medical system (EMS) (May 1, 2019-January 31, 2023). We calculated the diagnostic performance of MPDS® assessment of whether the case required T-CPR instructions against the gold standard of whether the patient was found pulseless on EMS clinician arrival. We compared performance among subgroups, specifically OPS vs other locations and drug poisoning-classified cases vs other case classifications. RESULTS: Comparing OPS to other locations, the sensitivity of MPDS® was similar (66.7% vs 62.4%, p = 0.4), with lower specificity (87.3% vs 98.1%, p < 0.01) and positive predictive value (0.3% vs 35.7%, p < 0.01) and higher negative predictive value (99.9% vs 99.4%, p < 0.01). The negative likelihood ratio of MPDS® was 0.381 at OPS locations, compared with 0.383 at other locations, while the positive likelihood ratio was 5.24, compared with 32.36. In patients with drug poisoning emergencies, compared with other 9-1-1 events, MPDS® had higher sensitivity (83.6% vs 60.6%, p < 0.01) but lower specificity (77.6% vs 98.9%, p < 0.01) and positive predictive value (10.5% vs 48.5%, p < 0.01), and similar negative predictive value (99.33% vs 99.35%, p = 0.03). The negative likelihood ratio of MPDS® was 0.212 in drug poisoning emergencies compared with 0.398 for all other presentations, and the positive likelihood ratio was 3.73 compared with 57.88. DISCUSSION AND CONCLUSIONS: The ability of MPDS® to correctly identify patients needing telecommunicator cardiopulmonary resuscitation instructions differed between OPS settings and other locations, frequently recommending T-CPR for patients not suffering OHCA at an OPS. Different strategies developed in collaboration with people who use substances are required to better tailor dispatch instructions prior to EMS arrival to avoid delays in life-saving interventions.

Do video or telephone consultations impact attendance rates in an addiction medicine specialist outpatient clinic?

BACKGROUND: Effective alcohol and other drugs (AODs) treatment has been proven to increase productivity and reduce costs to the community. Telehealth has previously been proven effective at delivering AOD treatment in the right settings. Yet, Australia's current Medicare funding restricts telephone consultations. AIM: We hypothesise that treatment modality influences attendance rates. Specifically, telephone consultations can remove barriers to accessing treatment and, therefore, can increase attendance. METHODS: We conducted a retrospective audit on our addiction medicine specialist outpatient service from 1 July 2022 to 30 June 2023. A mixed-effects logistic regression model was used to analyse factors associated with attendance rates. RESULTS: There were 576 participants in the study, and 3354 appointments were booked over the 12-month study period. Of these, 2695 were face-to-face, 541 were telephone and 118 were video. The unadjusted raw attendance rate was highest in the telephone group (87.24%), followed by face-to-face (73.02%) and video (44.92%). After adjusting for covariates, telephone consultation was associated with significantly increased odds of attending compared to face-to-face (odds ratio (OR) = 2.60, 95% confidence interval (CI) = 1.90-3.54, P < 0.001). Video consultation was associated with a 69% reduction in the odds of attending compared to face-to-face (OR = 0.31, 95% CI = 0.019-0.49, P < 0.001). CONCLUSIONS: While physical attendance may be required for specific clinical care, telephone consultations are associated with increased attendance and can form an important adjunct to delivering addiction treatment. Given the substantial costs of substance use disorders, this could inform government policies and funding priorities to further improve access and treatment outcomes.

COVID-19 restrictions and the incidence and prevalence of prescription opioid use in Australia - a nationwide study.

The COVID-19 pandemic has disrupted seeking and delivery of healthcare. Different Australian jurisdictions implemented different COVID-19 restrictions. We used Australian national pharmacy dispensing data to conduct interrupted time series analyses to examine the incidence and prevalence of opioid dispensing in different jurisdictions. Following nationwide COVID-19 restrictions, the incidence dropped by -0.40 (95% confidence interval [CI]: -0.50, -0.31), -0.33 (95% CI: -0.46, -0.21) and -0.21 (95% CI: -0.37, -0.04) per 1000 people per week and the prevalence dropped by -0.85 (95% CI: -1.39, -0.31), -0.54 (95% CI: -1.01, -0.07) and -0.62 (95% CI: -0.99, -0.25) per 1000 people per week in Victoria, New South Wales and other jurisdictions, respectively. Incidence and prevalence increased by 0.29 (95% CI: 0.13, 0.44) and 0.72 (95% CI: 0.11, 1.33) per 1000 people per week, respectively in Victoria post-lockdown; no significant changes were observed in other jurisdictions. No significant changes were observed in the initiation of long-term opioid use in any jurisdictions. More stringent restrictions coincided with more pronounced reductions in overall opioid initiation, but initiation of long-term opioid use did not change.

Clinical practice guideline for deprescribing opioid analgesics: summary of recommendations.

INTRODUCTION: Long term opioids are commonly prescribed to manage pain. Dose reduction or discontinuation (deprescribing) can be challenging, even when the potential harms of continuation outweigh the perceived benefits. The Evidence-based clinical practice guideline for deprescribing opioid analgesics was developed using robust guideline development processes and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, and contains deprescribing recommendations for adults prescribed opioids for pain. MAIN RECOMMENDATIONS: Eleven recommendations provide advice about when, how and for whom opioid deprescribing should be considered, while noting the need to consider each person's goals, values and preferences. The recommendations aim to achieve: implementation of a deprescribing plan at the point of opioid initiation; initiation of opioid deprescribing for persons with chronic non-cancer or chronic cancer-survivor pain if there is a lack of overall and clinically meaningful improvement in function, quality of life or pain, a lack of progress towards meeting agreed therapeutic goals, or the person is experiencing serious or intolerable opioid-related adverse effects; gradual and individualised deprescribing, with regular monitoring and review; consideration of opioid deprescribing for individuals at high risk of opioid-related harms; avoidance of opioid deprescribing for persons nearing the end of life unless clinically indicated; avoidance of opioid deprescribing for persons with a severe opioid use disorder, with the initiation of evidence-based care, such as medication-assisted treatment of opioid use disorder; and use of evidence-based co-interventions to facilitate deprescribing, including interdisciplinary, multidisciplinary or multimodal care. CHANGES IN MANAGEMENT AS A RESULT OF THESE GUIDELINES: To our knowledge, these are the first evidence-based guidelines for opioid deprescribing. The recommendations intend to facilitate safe and effective deprescribing to improve the quality of care for persons taking opioids for pain.

Impact of Prescription Medicines on Work-Related Outcomes in Workers with Musculoskeletal Disorders or Injuries: A Systematic Scoping Review.

PURPOSE: Medicines are often prescribed to workers with musculoskeletal disorders (MSDs) and injuries to relieve pain and facilitate their recovery and return to work. However, there is a growing concern that prescription medicines may have adverse effects on work function. This scoping review aimed to summarize the existing empirical evidence on prescription medicine use by workers with MSD or injury and its relationship with work-related outcomes. METHODS: We identified studies through structured searching of MEDLINE, EMBASE, PsycINFO, CINAHL Plus, Scopus, Web of Science and Cochrane library databases, and via searching of dissertations, theses, and grey literature databases. Studies that examined the association between prescription medicine and work-related outcomes in working age people with injury or MSDs, and were published in English after the year 2000 were eligible. RESULTS: From the 4884 records identified, 65 studies were included for review. Back disorders and opioids were the most commonly studied musculoskeletal conditions and prescription medicines, respectively. Most studies showed a negative relationship between prescription medicines and work outcomes. Opioids, psychotropics and their combination were the most common medicines associated with adverse work outcomes. Opioid prescriptions with early initiation, long-term use, strong and/or high dose and extended pre- and post-operative use in workers' compensation setting were consistently associated with adverse work function. We found emerging but inconsistent evidence that skeletal muscle relaxants and non-steroidal anti-inflammatory drugs were associated with unfavorable work outcomes. CONCLUSION: Opioids and other prescription medicines might be associated with adverse work outcomes. However, the evidence is conflicting and there were relatively fewer studies on non-opioid medicines. Further studies with more robust design are required to enable more definitive exploration of causal relationships and settle inconsistent evidence.

Opioid agonist treatment for people who are dependent on pharmaceutical opioids.

BACKGROUND: There are ongoing concerns regarding pharmaceutical opioid-related harms, including overdose and dependence, with an associated increase in treatment demand. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin.  OBJECTIVES: To assess the effects of maintenance opioid agonist pharmacotherapy for the treatment of pharmaceutical opioid dependence. SEARCH METHODS: We updated our searches of the following databases to January 2022: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, four other databases, and two trial registers. We checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA: We included RCTs with adults and adolescents examining maintenance opioid agonist treatments that made the following two comparisons. 1. Full opioid agonists (methadone, morphine, oxycodone, levo-alpha-acetylmethadol (LAAM), or codeine) versus different full opioid agonists or partial opioid agonists (buprenorphine) for maintenance treatment. 2. Full or partial opioid agonist maintenance versus non-opioid agonist treatments (detoxification, opioid antagonist, or psychological treatment without opioid agonist treatment). DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. MAIN RESULTS: We identified eight RCTs that met inclusion criteria (709 participants). We found four studies that compared methadone and buprenorphine maintenance treatment, and four studies that compared buprenorphine maintenance to either buprenorphine taper (in addition to psychological treatment) or a non-opioid maintenance treatment comparison. We found low-certainty evidence from three studies of a difference between methadone and buprenorphine in favour of methadone on self-reported opioid use at end of treatment (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.28 to 0.86; 165 participants), and low-certainty evidence from four studies finding a difference in favour of methadone for retention in treatment (RR 1.21, 95% CI 1.02 to 1.43; 379 participants). We found low-certainty evidence from three studies showing no difference between methadone and buprenorphine on substance use measured with urine drug screens at end of treatment (RR 0.81, 95% CI 0.57 to 1.17; 206 participants), and moderate-certainty evidence from one study of no difference in days of self-reported opioid use (mean difference 1.41 days, 95% CI 3.37 lower to 0.55 days higher; 129 participants). There was low-certainty evidence from three studies of no difference between methadone and buprenorphine on adverse events (RR 1.13, 95% CI 0.66 to 1.93; 206 participants). We found low-certainty evidence from four studies favouring maintenance buprenorphine treatment over non-opioid treatments in terms of fewer opioid positive urine drug tests at end of treatment (RR 0.66, 95% CI 0.52 to 0.84; 270 participants), and very low-certainty evidence from four studies finding no difference on self-reported opioid use in the past 30 days at end of treatment (RR 0.63, 95% CI 0.39 to 1.01; 276 participants). There was low-certainty evidence from three studies of no difference in the number of days of unsanctioned opioid use (standardised mean difference (SMD) -0.19, 95% CI -0.47 to 0.09; 205 participants). There was moderate-certainty evidence from four studies favouring buprenorphine maintenance over non-opioid treatments on retention in treatment (RR 3.02, 95% CI 1.73 to 5.27; 333 participants). There was moderate-certainty evidence from three studies of no difference in adverse effects between buprenorphine maintenance and non-opioid treatments (RR 0.50, 95% CI 0.07 to 3.48; 252 participants). The main weaknesses in the quality of the data was the use of open-label study designs, and difference in follow-up rates between treatment arms. AUTHORS' CONCLUSIONS: There is  very low- to moderate-certainty evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. Methadone or buprenorphine did not differ on some outcomes, although on the outcomes of retention and self-reported substance use some results favoured methadone. Maintenance treatment with buprenorphine appears more effective than non-opioid treatments. Due to the overall very low- to moderate-certainty evidence and small sample sizes, there is the possibility that the further research may change these findings.

Patient and clinician perspectives of factors that influence the delivery of alcohol brief interventions in Australian primary care: a qualitative descriptive study.

BACKGROUND: Brief interventions (BIs) delivered in primary care can reduce harmful alcohol consumption. Yet, clinicians do not routinely offer BIs to reduce harmful alcohol use. OBJECTIVE: We explored the perspectives of clinicians and patients about the use of alcohol BIs during consultations in Australian primary care. METHODS: Semi-structured interviews and focus groups (face-to-face and virtual) were undertaken with 34 general practitioners, eight practice nurses and 17 patients. Field notes were made from audio-recordings and themes were identified using a descriptive qualitative approach with the field notes as the point of data analysis. RESULTS: Participants identified barriers within the consultation, practice setting and wider healthcare system plus across the community which reduce the delivery of BIs in primary care including: Australian drinking norms; inconsistent public health messaging around alcohol harm; primary care not recognized as a place to go for help; community stigma towards alcohol use; practice team culture towards preventive health, including systems for recording alcohol histories; limitations of clinical software and current patient resources. CONCLUSION: Multiple layers of the healthcare system influence the use of BIs in primary care. Identified facilitators for embedding BIs in primary care included: (i) raising community and clinician awareness of the health harms of alcohol, (ii) reinforcing a primary care culture that promotes prevention and, (iii) supportive resources to facilitate discussion about alcohol use and strategies to reduce intake. Alcohol BIs in primary care could be further supported by community public health messages about alcohol use.

Alcohol is a major source of harm in the community and primary care (including family doctor and general practice settings) can play a role in reducing harmful alcohol use. When clinicians talk to their patients about alcohol use, research has shown they can reduce how much they drink each week. We spoke with general practitioners, nurses and patients in Australia to work out what is getting in the way of conversations about alcohol in primary care. We found that both clinicians and patients think we need to raise community awareness about the health harms of alcohol, that there are health system barriers, and there could be better resources to use in consultations. Low-income patients are particularly disadvantaged by financial costs associated with alcohol and counselling services when they seek help. To increase conversations about alcohol in primary care, it could be more helpful to target the broader community, the health system and primary care.

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.

Adapting harm reduction services during COVID-19: lessons from the supervised injecting facilities in Australia.

The COVID-19 crisis has had profound impacts on health service provision, particularly those providing client facing services. Supervised injecting facilities and drug consumption rooms across the world have been particularly challenged during the pandemic, as have their client group-people who consume drugs. Several services across Europe and North America closed due to difficulties complying with physical distancing requirements. In contrast, the two supervised injecting facilities in Australia (the Uniting Medically Supervised Injecting Centre-MSIC-in Sydney and the North Richmond Community Health Medically Supervised Injecting Room-MSIR-in Melbourne) remained open (as at the time of writing-December 2020). Both services have implemented a comprehensive range of strategies to continue providing safer injecting spaces as well as communicating crucial health information and facilitating access to ancillary services (such as accommodation) and drug treatment for their clients. This paper documents these strategies and the challenges both services are facing during the pandemic. Remaining open poses potential risks relating to COVID-19 transmission for both staff and clients. However, given the harms associated with closing these services, which include the potential loss of life from injecting in unsafe/unsupervised environments, the public and individual health benefits of remaining open are greater. Both services are deemed 'essential health services', and their continued operation has important benefits for people who inject drugs in Sydney and Melbourne.

Community pharmacy naloxone supply, before and after rescheduling as an over-the-counter drug: sales and prescriptions data, 2014-2018.

OBJECTIVES: To characterise the community pharmacy supply of naloxone by supply type - individual prescription, prescriber bag, and non-dispensed (supplied over the counter or expired) - during 2014-2018; to examine whether the 2016 rescheduling of naloxone as an over-the-counter drug influenced non-dispensed naloxone supply volume. DESIGN, SETTING: Analysis of monthly naloxone prescriptions (Pharmaceutical Benefits Scheme) and sales data (IQVIA), 2014-2018, for Australia and by state and territory; time series analysis of non-dispensed naloxone supply to assess effect of rescheduling on naloxone supply. MAJOR OUTCOMES: Total naloxone supply to community pharmacies; prescribed and non-dispensed naloxone supply. RESULTS: During 2014-2018, 372 351 400 µg units of naloxone were sold to community pharmacies: non-dispensed naloxone accounted for 205 866.5 units (55.3%), prescriber bags for 155 841 units (41.8%), and individual prescriptions for 10 643.5 units (2.9%). Population-adjusted national naloxone sales to community pharmacies increased between 2014 and 2018 (per year: incidence rate ratio [IRR], 1.15; 95% CI, 1.09-2.22). This increase was primarily attributable to increased volumes of prescriber bag naloxone (IRR, 1.63; 95% CI, 1.50-1.78) and, to a lesser extent, increased individual prescription supply (IRR, 2.04; 95% CI, 1.85-2.26). Non-dispensed naloxone supply volume was unchanged at the national level (IRR, 0.93; 95% CI, 0.85-1.01); changes in non-dispensed supply immediately following rescheduling and subsequently were not statistically significant in time series analyses for most jurisdictions. CONCLUSIONS: Total naloxone supply to community pharmacies in Australia increased between 2014 and 2018, but rescheduling that enabled over-the-counter access did not significantly influence the volume of non-dispensed naloxone.

Validity and Reliability of the Computer-Administered Routine Opioid Outcome Monitoring (ROOM) Tool.

OBJECTIVE: The Routine Opioid Outcome Monitoring (ROOM) tool measures outcomes with opioids using an established framework which includes domains such as pain, mood, opioid use disorder, alcohol use, and constipation. This study aims to validate and establish the test-retest reliability of the computer-administered ROOM tool. DESIGN AND SETTING: Cross-sectional analysis of an online sample. SUBJECTS: Participants comprised those with chronic noncancer pain who regularly used prescription opioids. METHODS: Participants self-completed the online ROOM tool along with other validated measures (validation questionnaire), and those who were agreeable also completed the online test-retest questionnaire approximately two weeks later. Subcomponents of the ROOM tool (i.e., pain, mood, alcohol use, opioid use disorder, and constipation) were validated against longer measures of the same construct using Pearson correlation coefficients. Intraclass correlation coefficients were used to assess the stability of the ROOM tool over time. RESULTS: A total of 324 participants completed the validation questionnaire, of whom 260 also completed the test-retest questionnaire. The opioid use disorder domain showed good sensitivity (73.6) and specificity (75.8) against the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, any opioid use disorder. All ROOM components showed moderate correlation (r = 0.55-0.73) with their longer counterparts. Test-retest reliability was fair (0.58-0.75), indicating that responses were relatively stable over time. Reliability did vary, however, based on the components being measured and how certain tools were scored. CONCLUSION: The computer-administered ROOM tool is a valid approach for brief monitoring of outcomes with prescribed opioids in primary care settings and appears to be acceptable to people who are using prescribed opioids for chronic pain.

Validation of the OWLS, a Screening Tool for Measuring Prescription Opioid Use Disorder in Primary Care.

OBJECTIVE: The OWLS is a screening tool for prescription opioid use disorder designed for use in primary care. This study aimed to confirm the optimal wording, scoring methods, and cutoff for the OWLS. DESIGN AND SETTING: Cross-sectional analysis of an online sample. SUBJECTS: Participants comprised those with chronic noncancer pain who regularly used prescription opioids. METHODS: Eligible participants self-completed an online version of the OWLS prescription opioid use disorder screening tool and the Composite International Diagnostic Interview Substance Abuse module. Receiver operating characteristics were calculated for three scoring methods for the OWLS, and these were compared with DSM-5 classification of any use disorder and moderate to severe opioid use disorder. RESULTS: Among the sample (N = 324), utilizing scoring method (i) (i.e., positive endorsement ≥ response option "a little bit") and a cutoff of 3 increased the percentage of correctly classified participants, with concurrent increases in specificity and decreases in false discovery rate, and false positive rate. CONCLUSION: OWLS utilizing scoring method (i) with a cutoff of 3 was shown to be the optimal version and scoring method of this tool. This represents a time-efficient, simple scoring method, allowing for quick and accurate screening for opioid use disorder to occur.

Acute Experimental Pain Responses in Methadone- and Buprenorphine/Naloxone-Maintained Patients Administered Additional Opioid or Gabapentin: A Double-Blind Crossover Pilot Study.

OBJECTIVE: The study objective was to identify the analgesic efficacy of three different pharmacological strategies in patients receiving methadone or buprenorphine as opioid agonist treatment (OAT). The three pharmacological approaches, a) increasing maintenance methadone/buprenorphine dose by 30%, b) adding oxycodone, or c) adding a single dose of gabapentin, were compared with a control condition of the participant's usual OAT dose. DESIGN: A randomized, controlled, double-blinded, double-dummy, within-subject crossover study. SUBJECTS: Nine participants on stable doses of methadone and eight participants on stable doses of buprenorphine were recruited. SETTING: An outpatient opioid treatment clinic in inner city Sydney, Australia. METHODS: The cold pressor tolerance test was used to examine experimental pain threshold and tolerance. Ratings of subjective drug effects and safety measures (physiological and cognitive) were assessed. RESULTS: There was no difference in the primary outcome measures of pain thresholds or tolerance between the conditions examined. Interindividual variability was evident. Differences in some subjective measures were identified, including lower pain recall, lower "bad effects," and higher global satisfaction in the additional methadone condition. In the buprenorphine arm, increased drug liking and "bad effects" were detected with oxycodone administration, while increased subjective intoxication was identified with gabapentin. CONCLUSIONS: There was no evidence of an objective improvement in analgesia with any condition compared with control. Further research is required to optimize pain management strategies in this population.

Development of a Brief Patient-Administered Screening Tool for Prescription Opioid Dependence for Primary Care Settings.

OBJECTIVE: To develop a short, patient-administered screening tool that will allow for earlier assessment of prescription opioid dependence (often referred to as addiction) in primary care settings. DESIGN AND SETTING: Cross-sectional analysis (N = 1,134) from the two-year time point of the Pain and Opioids IN Treatment (POINT) cohort was used in the scale development. SUBJECTS: Participants who completed two-year interviews in the POINT study, a prospective cohort study that followed people with chronic noncancer pain over a five-year period, and who were prescribed strong opioids for a minimum of six weeks at baseline. METHODS: An advisory committee provided advice on wording and content for screening in primary care settings. Univariate logistic regression identified individual items that were significantly associated with meeting ICD-11 criteria for prescription opioid dependence. Exploratory and confirmatory factor analysis (EFA and CFA) were conducted, and items were reduced to identify a small item set that were discriminative and shared a simple underlying structure. RESULTS: Sixty-four variables associated with ICD-11 criteria for prescription opioid dependence were initially identified. Four rounds of EFA were performed, resulting in five items remaining. CFA identified two possible four-item combinations, with the final combination chosen based on greater item endorsement and the results of goodness-of-fit indices. CONCLUSIONS: Addressing prescription opioid dependence is an important part of the global public health challenge surrounding rising opioid-related harm. This study addresses an important initial requisite step to develop a brief screening tool. Further studies are required to validate the tool in clinical settings.

Pharmacotherapies for Cannabis Use Disorders: Clinical Challenges and Promising Therapeutic Agents.

This chapter reviews pharmacotherapies that have been trialled for cannabis dependence, identifying those that warrant further research and those of little or uncertain value. A diverse range of medicines have been tested, representing a broad range of pharmacological strategies. These include tetrahydrocannabinol preparations, various types of antidepressant, anxiolytics, a glutamatergic modulator and the neuropeptide oxytocin. Cannabinoid agonists warrant further research. For the FAAH inhibitor PF-04457845, oxytocin, varenicline and gabapentin, although there is a signal to indicate further research is warranted, these medications do not yet have sufficient evidence to support clinical use, and larger, longer-term trials are needed in representative treatment-seeking populations. Special populations that warrant consideration are those with cannabis dependence and concurrent mental health conditions and those that develop dependence through therapeutic use.

Understanding the evidence for medical cannabis and cannabis-based medicines for the treatment of chronic non-cancer pain.

The use of medical cannabis and cannabis-based medicines has received increasing interest in recent years; with a corresponding surge in the number of studies and reviews conducted in the field. Despite this growth in evidence, the findings and conclusions of these studies have been inconsistent. In this paper, we outline the current evidence for medical cannabis and cannabis-based medicines in the treatment and management of chronic non-cancer pain. We discuss limitations of the current evidence, including limitations of randomised control trials in the field, limits on generalisability of previous findings and common issues such as problems with measurements of dose and type of cannabinoids. We discuss future directions for medicinal cannabinoid research, including addressing limitations in trial design; developing frameworks to monitor for use disorder and other unintended outcomes; and considering endpoints other than 30% or 50% reductions in pain severity.