Characterization of peer support services for substance use disorders in 11 US emergency departments in 2020: findings from a NIDA clinical trials network site selection process.

INTRODUCTION: Emergency departments (ED) are incorporating Peer Support Specialists (PSSs) to help with patient care for substance use disorders (SUDs). Despite rapid growth in this area, little is published regarding workflow, expectations of the peer role, and core components of the PSS intervention. This study describes these elements in a national sample of ED-based peer support intervention programs. METHODS: A survey was conducted to assess PSS site characteristics as part of site selection process for a National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) evaluating PSS effectiveness, Surveys were distributed to clinical sites affiliated with the 16 CTN nodes. Surveys were completed by a representative(s) of the site and collected data on the PSS role in the ED including details regarding funding and certification, services rendered, role in medications for opioid use disorder (MOUD) and naloxone distribution, and factors impacting implementation and maintenance of ED PSS programs. Quantitative data was summarized with descriptive statistics. Free-text fields were analyzed using qualitative content analysis. RESULTS: A total of 11 surveys were completed, collected from 9 different states. ED PSS funding was from grants (55%), hospital funds (46%), peer recovery organizations (27%) or other (18%). Funding was anticipated to continue for a mean of 16 months (range 12 to 36 months). The majority of programs provided "general recovery support (81%) Screening, Brief Intervention, and Referral to Treatment (SBIRT) services (55%), and assisted with naloxone distribution to ED patients (64%). A minority assisted with ED-initiated buprenorphine (EDIB) programs (27%). Most (91%) provided services to patients after they were discharged from the ED. Barriers to implementation included lack of outpatient referral sources, barriers to initiating MOUD, stigma at the clinician and system level, and lack of ongoing PSS availability due to short-term grant funding. CONCLUSIONS: The majority of ED-based PSSs were funded through time-limited grants, and short-term grant funding was identified as a barrier for ED PSS programs. There was consistency among sites in the involvement of PSSs in facilitation of transitions of SUD care, coordination of follow-up after ED discharge, and PSS involvement in naloxone distribution.

Enhanced phenotypes for identifying opioid overdose in emergency department visit electronic health record data.

Background: Accurate identification of opioid overdose (OOD) cases in electronic healthcare record (EHR) data is an important element in surveillance, empirical research, and clinical intervention. We sought to improve existing OOD electronic phenotypes by incorporating new data types beyond diagnostic codes and by applying several statistical and machine learning methods. Materials and Methods: We developed an EHR dataset of emergency department visits involving OOD cases or patients considered at risk for an OOD and ascertained true OOD status through manual chart reviews. We developed and validated prediction models using Random Forest, Extreme Gradient Boost, and Elastic Net models that incorporated 717 features involving primary and second diagnoses, chief complaints, medications prescribed, vital signs, laboratory results, and procedural codes. We also developed models limited to single data types. Results: A total of 1718 records involving 1485 patients were manually reviewed; 541 (36.4%) patients had one or more OOD. Prediction performance was similar for all models; sensitivity varied from 94% to 97%; and area under the receiver operating characteristic curve (AUC) was 98% for all methods. The primary diagnosis and chief complaint were the most important contributors to AUC performance; primary diagnoses and medication class contributed most to sensitivity; chief complaint, primary diagnosis, and vital signs were most important for specificity. Models limited to decision support data types available in real time demonstrated robust prediction performance. Conclusions: Substantial prediction performance improvements were demonstrated for identifying OODs in EHR data. Our e-phenotypes could be applied in surveillance, retrospective empirical applications, or clinical decision support systems.

Surgical prescription opioid trajectories among state Medicaid enrollees.

OBJECTIVE: The objective of this study was to evaluate opioid use trajectories among a sample of 10,138 Medicaid patients receiving one of six index surgeries: lumbar spine, total knee arthroplasty, cholecystectomy, appendectomy, colon resection, and tonsillectomy. DESIGN: Retrospective cohort. SETTING: Administrative claims data. PATIENTS AND PARTICIPANTS: Patients, aged 13 years and older, with 15-month continuous Medicaid eligibility surrounding index surgery, were selected from single-state Medicaid medical and pharmacy claims data for surgeries performed between 2014 and 2017. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Baseline comorbidities and presurgery opioid use were assessed in the 6 months prior to admission, and patients' opioid use was followed for 9 months post-discharge. Generalized linear model with log link and Poisson distribution was used to determine risk of chronic opioid use for all risk factors. Group-based trajectory models identified groups of patients with similar opioid use trajectories over the 15-month study period. RESULTS: More than one in three (37.7 percent) patients were post-surgery chronic opioid users, defined as the dichotomous outcome of filling an opioid prescription 90 or more days after surgery. Key variables associated with chronic post-surgery opioid use include presurgery opioid use, 30-day post-surgery opioid use, and comorbidities. Latent trajectory modeling grouped patients into six distinct opioid use trajectories. Associates of trajectory group membership are reported. CONCLUSIONS: Findings support the importance of surgeons setting realistic patient expectations for post-surgical opioid use, as well as the importance of coordination of post-surgical care among patients failing to fully taper off opioids within 1-3 months of surgery.

Enhancing research data infrastructure to address the opioid epidemic: the Opioid Overdose Network (O2-Net).

Opioid Overdose Network is an effort to generalize and adapt an existing research data network, the Accrual to Clinical Trials (ACT) Network, to support design of trials for survivors of opioid overdoses presenting to emergency departments (ED). Four institutions (Medical University of South Carolina [MUSC], Dartmouth Medical School [DMS], University of Kentucky [UK], and University of California San Diego [UCSD]) worked to adapt the ACT network. The approach that was taken to enhance the ACT network focused on 4 activities: cloning and extending the ACT infrastructure, developing an e-phenotype and corresponding registry, developing portable natural language processing tools to enhance data capture, and developing automated documentation templates to enhance extended data capture. Overall, initial results suggest that tailoring of existing multipurpose federated research networks to specific tasks is feasible; however, substantial efforts are required for coordination of the subnetwork and development of new tools for extension of available data. The initial output of the project was a new approach to decision support for the prescription of naloxone for home use in the ED, which is under further study within the network.

New chronic opioid use in Medicaid patients following cholecystectomy.

Background: Commercial insurance data show that chronic opioid use in opioid-naive patients occurs in 1.5% to 8% of patients undergoing surgical procedures, but little is known about patients with Medicaid. Methods: Opioid prescription data and medical coding data from 4,788 Medicaid patients who underwent cholecystectomy were analyzed to determine opioid use patterns. Results: A total of 54.4% of patients received opioids prior to surgery, and 38.8% continued to fill opioid prescriptions chronically; 27.1% of opioid-naive patients continued to get opioids chronically. Patients who received ≥ 50 MME/d had nearly 8 times the odds of chronic opioid use. Each additional opioid prescription filled within 30 days was associated with increased odds of chronic use (odds ratio: 1.71). Conclusion: Opioid prescriptions are common prior to cholecystectomy in Medicaid patients, and 38.8% of patients continue to receive opioid prescriptions well after surgical recovery. Even 27.1% of opioid-naive patients continued to receive opioid prescriptions chronically.

Incidence and patterns of persistent opioid use in children following appendectomy.

BACKGROUND: The past 5 years have witnessed a concerted national effort to assuage the rising tide of the opioid misuse in our country. Surgical procedures often serve as the initial exposure of children to opioids, however the trajectory of use following these exposures remains unclear. We hypothesized that opioid exposure following appendectomy would increase the risk of persistent opioid use among publicly insured children. STUDY DESIGN: A retrospective longitudinal cohort study was conducted on South Carolina Medicaid enrollees who underwent appendectomy between January 2014 and December 2017 using administrative claims data. The primary outcome was chronic opioid use. Generalized linear models and finite mixture models were employed in analysis. RESULTS: 1789 Medicaid pediatric patients underwent appendectomy and met inclusion criteria. The mean age was 11.1 years and 40.6% were female. Most patients (94.6%) did not receive opioids prior to surgery. Opioid prescribing ≥90 days after surgery (chronic opioid use) occurred in 127 (7.1%) patients, of which 102 (80.3%) had no opioid use in the preexposure period. Risk factors for chronic opioid use included non-naïve opioid status, re-hospitalization more than 30 days following surgery, multiple opioid prescribers, age, and multiple antidepressants/antipsychotic prescriptions. Group-based trajectory analysis demonstrated four distinct post-surgical opioid use patterns: no opioid use (91.3%), later use (6.7%), slow wean (1.9%), and higher use throughout (0.4%). CONCLUSION: Opioid exposure after appendectomy may serve as a priming event for persistent opioid use in some children. Eighty percent of children who developed post-surgical persistent opioid use had not received opioids in the 90 days leading up to surgery. Several mutable and immutable factors were identified to target future efforts toward opioid minimization in this at-risk patient population. LEVEL OF EVIDENCE: III.

High-risk opioid analgesic dispensing to adolescents 12-18 years old in South Carolina: 2010-2017.

PURPOSE: To evaluate "high-risk" opioid dispensing to adolescents, including daily morphine milligram equivalents (MME) above recommended amounts, the percentage of extended-release opioid prescriptions dispensed to opioid-naïve adolescents, and concurrent use of opioids and benzodiazepines, and to evaluate changes in those rates over time. METHODS: Retrospective cohort study of one state's prescription drug monitoring program data (2010-2017), evaluating adolescents 12-18 years old dispensed opioid analgesic prescriptions. Outcomes of interest were the quarterly frequencies of the high-risk measures. We utilized generalized linear regression to determine whether the rate of the outcomes changed over time. RESULTS: The quarterly percentage of adolescents ages 12-18 years old dispensed an opioid who received ≥90 daily MME declined from 4.1% in the first quarter (Q1) of 2010 to 3.4% in the final quarter (Q4) of 2017 (p < 0.0001). The frequency of adolescents dispensed ≥50 daily MME changed little over time. In 2010, the percentage of adolescents receiving an extended-release opioid who were opioid naïve was 60.7%, declining to 50.6% by Q4 of 2017 (p > 0.10 overall change 2010-2017). The percentage of adolescent opioid days overlapping with benzodiazepine days was 1.6% in Q1 of 2010, declining to 1.1% by Q4 of 2017 (p < 0.001). CONCLUSIONS: Among persons 12-18 years old dispensed an opioid analgesic, receipt of ≥90 daily MME declined during the years 2010-2017, as did the percentage of adolescent opioid days that overlapped with benzodiazepines. More than half of the individuals who received extended-release opioid analgesics were identified as opioid naïve and, counter to guidelines, received products intended for opioid-tolerant individuals.

Pain Management for Dental Medicine in 2021: Opioids, Coronavirus and Beyond.

Over the past year our attention has inevitably been on the coronavirus pandemic, the health and welfare of our families, patients, and office staffs as well as the re-opening of our dental practices. In addition, the opioid crisis continues, is very likely to worsen as a result of the pandemic and continues to be a challenge to Dentistry. National public health issues and healthcare disparities continue and have created a global concern for providing evidence-based, adequate pain management in the dental setting. We have brought together a group of national thought leaders and experts in this field who will share their insights on the current state of opioid prescribing in Dentistry and describe some of the exciting work being done in advancing pain management. The learning objectives for this conference proceedings were: Describing the implications of current public health concerns for safe and effective pain management in dental medicine.Identifying risk factors and understanding the current guidelines for the use of opioid and non-opioid medications in dental medicine.Analyzing the interprofessional collaborations necessary for effective pain management in dental medicine.Recognizing the challenges and opportunities brought about by the COVID-19 pandemic for the dental profession.Applying evidence-based strategies for managing the complex pain patient in the dental setting.Appraising new and future modalities for the assessment and management of orofacial pain.

Trends in Dispensed Opioid Analgesic Prescriptions to Children in South Carolina: 2010-2017.

BACKGROUND AND OBJECTIVES: Despite published declines in opioid prescribing and dispensing to children in the past decade, in few studies have researchers evaluated all children in 1 state or examined changes in mean daily opioid dispensed. In this study, we evaluated changes in the rate of dispensed opioid analgesics and the mean daily opioid dispensed to persons 0 to 18 years old in 1 state over an 8-year period. METHODS: We identified opioid analgesics dispensed to children 0 to 18 years old between 2010 and 2017 using South Carolina prescription drug monitoring program data. We used generalized linear regression analyses to examine changes over time in the following: (1) rate of dispensed opioid prescriptions and (2) mean daily morphine milligram equivalents (MMEs) per prescription. RESULTS: From the first quarter of 2010 to the end of the fourth quarter of 2017, the quarterly rate of opioids dispensed decreased from 18.68 prescriptions per 1000 state residents to 12.03 per 1000 residents (P < .0001). The largest declines were among the oldest individuals, such as the 41.2% decline among 18-year-olds. From 2010 through 2017, the mean daily MME dispensed declined by 7.6%, from 40.7 MMEs per day in 2010 to 37.6 MMEs per day in 2017 (P < .0001), but the decrease was limited to children 0 to 9 years old. CONCLUSIONS: The rate of opioid analgesic prescriptions dispensed to children 0 to 18 years old in South Carolina declined by 35.6% over the years 2010-2017; however, the MME dispensed per day declined minimally, suggesting that more can be done to improve opioid prescribing and dispensing.

Increased availability of telehealth mental health and substance abuse treatment for peripartum and postpartum women: A unique opportunity to increase telehealth treatment.

Since the onset of the COVID-19 pandemic, several federal, state, and payor policy changes have facilitated the uptake of telehealth service delivery. These changes have resulted in a significant uptick in the utilization of maternal mental health and substance use disorder screening and treatment services for pregnant and postpartum women. The Medical University of South Carolina's [MUSC] Women's Reproductive Behavioral Health Program provides outpatient mental health and substance use treatment to pregnant and postpartum women within obstetric practices. With the onset of COVID-19, our program converted all of its screening for and treatment of mental health and substance use disorders to remote platforms. Lessons learned during this time may lay the foundation for transitioning to sustainable telehealth-based referral and delivery of substance use treatment more broadly.

Patterns of dispensed opioids after tonsillectomy in children and adolescents in South Carolina, United States, 2010-2017.

OBJECTIVES: Tonsillectomy (with or without adenoidectomy) is a common pediatric surgical procedure requiring post-operative analgesia. Because of the respiratory depression effects of opioids, clinicians strive to limit the use of these drugs for analgesia post-tonsillectomy. The objective of this study was to identify demographic and medication use patterns predictive of persistent opioid dispensing (as a proxy for opioid use) to pediatric patients post-tonsillectomy. PATIENTS AND METHODS: Retrospective cohort of South Carolina (USA) Medicaid-insured children and adolescents 0-18 years old without malignancy who had tonsillectomy in 2014-2017. We evaluated opioid dispensing pre-surgery and in the 30 days exposure period after hospital discharge. The main outcome, persistent opioid dispensing, was defined as any subject dispensed ≥1 opioid prescription 90-270 days after discharge. Group-based trajectory analyses described post-procedure opioid dispensing trajectories. RESULTS: There were 11,578 subjects representing 12,063 tonsillectomy procedures. Few (3.5%) procedures were followed by persistent opioid dispensing. Any opioid dispensing during the exposure period was associated with an increased odds of persistent opioid dispensing status during the follow up period (OR 1.51 for 1-6 days of exposure and OR 1.65 for 7-30 days of opioid exposure), as was pre-procedure opioid dispensing, having >1 tonsillectomy procedure, and having complex chronic medical conditions. Group-based trajectory analyses identified 4 distinct patterns of post-discharge opioid dispensing. CONCLUSIONS: Any opioid dispensing during the 30 days after tonsillectomy increased the odds of persistent opioid dispensing by > 50%. Multivariable and group-based trajectory analyses identified patient and procedure variables that correlate with persistent opioid dispensing, primarily driven by groups receiving pre-tonsillectomy opioids and a second group who experienced multiple episodes of tonsillectomy.

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

OBJECTIVE: Deaths due to opioids have continued to increase in South Carolina, with 816 opioid-involved overdose deaths reported in 2018, a 9% increase from the prior year. The objective of the current study is to examine longitudinal trends (quarter [Q] 1 2010 through Q4 2018) of opioid prescribing volume and high-risk opioid prescribing behaviors in South Carolina using comprehensive dispensing data available in the South Carolina Prescription Drug Monitoring Program (SC PDMP). DESIGN: Retrospective analyses of SC PDMP data were performed using general linear models to assess quarterly time trends and change in rate of each outcome Q1 2010 through Q4 2018. PARTICIPANTS: Opioid analgesic prescription fills from SC state residents between Q1 2010 and Q4 2018. MAIN OUTCOME MEASURES: High-risk prescribing behaviors included (1) opioid prescribing rate; (2) percentage of patients receiving opioids dispensed 90 or more average morphine milligram equivalents daily; (3) percentage of opioid prescribed days with overlapping opioid and benzodiazepine prescriptions; (4) rate per 100 000 residents of multiple provider episodes; and (5) percentage of patients prescribed extended release opioids who were opioid naive. RESULTS: A total of 33 027 461 opioid prescriptions were filled by SC state residents within the time period of Q1 2010 through Q4 2018. A 41% decrease in the quarterly prescribing rate of opioids occurred from Q1 2010 to Q4 2018. The decrease in overall opioid prescribing was mirrored by significant decreases in all 4 high-risk prescribing behaviors. CONCLUSION: PDMPs may represent the most complete data regarding the dispensing of opioid prescriptions and as such be valuable tools to inform and monitor the supply of licit opioids. Our results indicate that public health policy, legislative action, and multiple clinical interventions aimed at reducing high rates of opioid prescribing across the health care ecosystem appear to be succeeding in the state of South Carolina.

Substance Use Prevention Programming for Adolescents and Young Adults: A Mixed-Method Examination of Substance Use Perceptions and Use of Prevention Services.

BACKGROUND: Although substance use problems are highly prevalent among adolescents and emerging adults, this population does not regularly receive substance use prevention programming in their communities. Low perceived risk of substance use, which is linked to actual behavior, may contribute to low rates of engagement in community prevention efforts for substance use. To examine this, the current study used a mixed methods approach to: (1) examine the relationship between engagement in prevention education and substance use; and, (2) analyze qualitative data on education programs offered in the community to help identify strengths and gaps in prevention resources. Method: Quantitative and qualitative data were collected from adolescents (age 13-18) and young adults (age 19-25) living in the Southeast, recruited from local schools and community events to participate in a preventive intervention focused on prevention of HIV, substance use, and other risky behaviors. Prior to engagement in this intervention, self-report questionnaires were completed by adolescents assessing: substance use, perceived risk, and engagement in substance use education classes. Focus groups were also conducted with adolescents recruited from a local high school and young adults recruited from local colleges to obtain additional information about engagement in education programs. Results: Regarding perceived risk, 71.8% of adolescents reported moderate to great risk in having five or more drinks once or twice a week and 43% of adolescents reported moderate to great risk in smoking cannabis once or twice a week. Forty-four percent of adolescents had talked to one of their parents about the dangers of tobacco, alcohol, or drug use in the past year. Further, 18% of adolescents had been to a class or program on prevention of alcohol and other drug abuse in the past month and 50.7% had heard, read, or watched an advertisement about prevention of substance use in the past year. Qualitative results Eight overarching themes, each with its own sub-themes, emerged from the participant's responses during the focus groups. Each is described below with representative quotes provided throughout for illustrative purposes. Conclusions: Findings revealed several gaps in resources identified by adolescents and young adults that are needed to adequately address substance use, which provide important next steps for substance use prevention among youth.

Effect of Payor-Mandated Review of Prescription Drug Monitoring Program on Opioid Prescriber Rates.

OBJECTIVE: To evaluate the effect of a 2016 South Carolina payor mandate to query the state prescription drug monitoring program (PDMP) before prescribing controlled substances on the rate of opioid prescribers in South Carolina. METHODS: South Carolina PDMP datasets from 2010-2017 were evaluated using interrupted time series regression to compare changes in the rate of opioid prescribers before and after the 2016 mandate. The rate of opioid prescribers was defined as the number of prescribers who prescribed class II to IV opioids on any one prescription in each quarter divided by the total number of South Carolina prescribers who prescribed any one class II to IV medication. The rate of high-dose opioid prescribers was defined as the number of prescribers who prescribed ≥90-morphine milligram equivalent per day on any one prescription in each quarter divided by all of the prescribers who prescribed an opioid analgesic prescription. RESULTS: The rates of South Carolina opioid prescribers decreased from 75% in 2010 to 60% in 2017, with no significant change in slope (P = 0.24) after the 2016 payor mandates. The rates of South Carolina high-dose opioid prescribers decreased from 40% in 2010 to 32% in 2017, with a significant decrease in slope (P < 0.001) after the payor mandate. CONCLUSIONS: The slope of the South Carolina high-dose opioid prescriber rate significantly decreased after the 2016 South Carolina payor mandate, while the slope of the South Carolina opioid prescriber rate did not. The long-term outcomes related to the change in opioid prescriber rates are unknown and warrant further study.

The effect of targeted insurer-mandated prescription monitoring on opioid prescribing patterns.

OBJECTIVES: The purpose of this study was to determine the impact of a mandate from 2 large insurers in South Carolina for mandatory review of the state's prescription drug monitoring program (PDMP) for controlled substance (CS) prescriptions for more than 5 days' supply on the proportion of opioid prescriptions for less than or equal to 5 days in a statewide adult population. In addition, changes in the mean morphine milligram equivalents (MME) per day for prescriptions for 5 days or less were described to evaluate prescribing changes. DESIGN, SETTING AND PARTICIPANTS: All prescriptions for opioids written for and filled by adults (≥ 18 years of age) and reported to the PDMP from January 1, 2010, to December 31, 2017, were included in an interrupted time series analysis. OUTCOME MEASURES: An interrupted time series analysis was performed to determine if there was a significant change in the proportion of opioid prescriptions for less than or equal to 5 days' supply. RESULTS: Overall opioid prescriptions decreased over the time period by 11.5%, including a decreasing rate of opioid prescriptions for less than or equal to 5 days' supply. There was no statistical difference in the slope between the pre- and postmandate cohorts (P = 0.077, r2 = 0.951). There was not an identified corresponding increase in the MME per day of prescriptions. CONCLUSION: Our analysis found that 2 major insurer mandates that occurred in South Carolina in 2016, which required a review of the state PDMP for CS prescriptions for more than 5 days' supply, did not have a significant impact on the proportion of opioid prescriptions for less than or equal to 5 days' supply in the statewide population. In addition, we did not find any concern that prescribers attempted to circumvent the requirement by inappropriately adjusting dosing instructions.

Prescription Drug Abuse Among Patients in Rural Dental Practices Reported by Members of the National Dental PBRN.

PURPOSE: This study compared rural to nonrural dentists with respect to opioid prescribing practices, perceptions about prescription drug abuse among patients, and training relevant to pain management and addictions. METHODS: A web-based, cross-sectional questionnaire was administered to practicing dentist members of the National Dental Practice-Based Research Network (PBRN; N = 822) and linked with network enrollment questionnaire data regarding practitioner demographics and practice characteristics. Pain management prescribing practices and perceptions regarding relevance and scope of addiction and drug diversion among patients were assessed. Rural practice was defined as a practice whose ZIP Code has more than 50% of its population in either a nonmetropolitan county and/or a rural Census tract. FINDINGS: Rural dentists were significantly more likely than their nonrural counterparts to recommend nonsteroidal anti-inflammatory agents/acetaminophen in combination with prescribing an opioid [F (1,820) = 4.59, P = .03]. Compared to nonrural dentists, rural dentists were more likely to report that opioid abuse/diversion was a problem in their practices [χ2 [1, n = 807] = 6.85, P < .001], were more likely to have suspected a patient of abuse or diversion [χ2 [1, n = 807] = 10.12, P = .001], and were more likely to have refrained from prescribing due to suspicions of abuse or diversion [χ2 [1, n = 807] = 12.49, P < .001]. CONCLUSION: Rural dentists may be disproportionately impacted by patients' opioid abuse and represent a viable target for educational outreach that encourages screening, identification, and referral of patients in need of drug abuse treatment.

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

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

Gender differences in subjective stress and neuroendocrine response to a stress task among individuals with opioid dependence: A pilot study.

BACKGROUND: Opioid dependence is a significant public health problem in the United States and the number of opioid overdose deaths among women has increased dramatically in comparison to men in the last few years. In this context, understanding the biological mechanisms underlying gender differences in vulnerability to opioid dependence is essential. METHODS: The current pilot study examined gender differences in subjective stress, heart rate (HR), and cortisol/dephydroepiandrosterone (DHEA) response to a laboratory stressor (Trier Social Stress Test; TSST) or a no-stress condition, and drug cue paradigm among men (n = 21) and women (n = 18) with opioid dependence. RESULTS: Significant group (TSST vs. no stress) differences emerged in self-reported stress [F(1,35) = 23.8, p < .001], HR [F(1,31) = 12.3; p = .001] and cortisol (F1,34 = 5.0; p = .032) response, such that the TSST group was more reactive than the no-stress group. Women reported greater subjective stress [F(1,35) = 6.5, p <= .015] in response to the TSST compared to men. However, men evidenced marginally greater cortisol and DHEA responses to the TSST compared to women [F(1,34) = 2.7; p = .113 and F(1,31) = 3.4; p = .073, respectively]. CONCLUSIONS: Although women with opioid dependence reported greater subjective stress when exposed to a laboratory stress paradigm as compared to men, the neuroendocrine response was more robust in men. This pattern was similar to gender findings in men and women with cocaine and tobacco use disorders. The blunted cortisol combined with an increased subjective response among women may be a sign of HPA axis dysregulation which could increase vulnerability to relapse in women.