No decline in drug overdose deaths in Norway: An ecological approach to understanding at-risk groups and the impact of interventions.

Aim: This Norwegian case study examines groups at risk of drug overdose deaths, evidence-based harm reduction interventions, low-threshold services and treatment implemented, as well as trends in drug overdose deaths between 2010 and 2021. We aimed to explore the relevance of interventions for at-risk groups and discuss their potential impact on drug overdose trends. Method/data: Using an ecological approach, we analysed the following: (1) groups identified through latent profile analysis (LPA) among a sample of 413 high-risk drug users collected in 2010-2012, supplemented with other relevant studies up to 2021; (2) published information on harm-reduction interventions, low-threshold services and treatment in Norway; and (3) nationwide drug overdose mortality figures supplemented with published articles on the topic. Results: High-risk drug users in 2010-2012 commonly engaged in frequent illegal drug use, injecting and poly-drug use (including pharmaceutical opioids), which continued into following decade. The interventions implemented between 2010 and 2021 were relevant for at-risk groups identified in the surveys. However, there was no decrease in the trend of drug overdose deaths up to 2021. While relevant interventions may have mitigated a theoretical increase in mortality, new at-risk groups may have contributed to fatal outcomes associated with pharmaceutical opioids. Conclusion: The interventions were relevant to the risk groups identified among high-risk drug users and potentially effective in preventing an increase in drug overdose trends. However, tailored interventions are needed for individuals at risk of death from prescribed opioids. Comprehensive studies encompassing all at-risk populations, including both legal and non-medical users of prescription opioids, are needed.

"Pressed OXY M30 Pills, Great Press, Potent, Fast Shipping!!!": Availability of Counterfeit and Pharmaceutical Oxycodone Pills on One Major Cryptomarket.

From 2018 to 2021, seizures of counterfeit oxycodone pills containing non-pharmaceutical fentanyl or other novel synthetic opioids increased significantly contributing to continuing increases in overdose mortality in Northern America. Evidence suggests that counterfeit pills are distributed through cryptomarkets. This article presents data regarding the availability and characteristics of oxycodone pills advertised on one major cryptomarket between January and March 2022. Collected data were processed using a dedicated Named Entity Recognition algorithm to identify oxycodone listings and categorized them as either counterfeit or pharmaceutical. Frequency of listings, average number of pills advertised, average prices per milligram, number of sales, and geographic indicators of shipment origin and destination were analyzed. In total, 2,665 listings were identified as oxycodone. 48.2% (1,285/2,665) of these listings were categorized as counterfeit oxycodone, advertising a total of 652,699 pills (93,242.7 pills per datapoint) offered at a lower price than pharmaceutical pills. Our data indicate the presence of a large volume of counterfeit oxycodone pills both in retail- and wholesale-level amounts mostly targeting US and Canadian customers. These exploratory findings call for more research to develop epidemiological surveillance systems to track counterfeit pill and other drug availability on the Dark web environment.

Trajectories of non-prescribed buprenorphine and other opioid use: A multi-trajectory latent class growth analysis.

INTRODUCTION: With the increasing use of non-prescribed buprenorphine (NPB), we need more data to identify the longitudinal patterns of NPB use. The goal of this natural history study is to characterize heterogeneity in trajectories of NPB, other opioid use, and participation in medication for opioid disorder (MOUD) treatment among a community-recruited sample of individuals with current opioid use disorder (OUD). METHODS: The study recruited a community-based sample of 357 individuals with OUD who used NPB in the past 6 months in Ohio, United States, for baseline and follow-up assessments (every 6 months for 2 years) of drug use, treatment participation, and other health and psychosocial characteristics. The study used multiple imputation to handle missing data. We used a multi-trajectory latent class growth analysis (MT-LCGA) to find salient groupings of participants based on the trajectories of NPB, other opioid use, and treatment participation. RESULTS: Over time, NPB use frequency declined from a mean of 14.6 % of days at baseline to 3.6 % of days at 24-month follow-up along with declines in heroin/fentanyl (56.4 % to 23.6 % of days) and non-prescribed pharmaceutical opioid (NPPO) use (11.6 % to 1.5 % of days). Participation in MOUD treatment increased from a mean of 17.0 % of days at baseline to 52.4 % of days at 24 months. MT-LCGA identified a 6-class model. All six classes showed declines in NPB use. Class 1 (28 %) was characterized by high and increasing MOUD treatment utilization. Class 2 (21 %) showed sustained high levels of heroin/fentanyl use and had the lowest levels of NPB use (2.2 % of days) at baseline. Class 3 (3 %) was characterized as the primary NPPO use group. Class 4 (5 %) transitioned from high levels of NPB use to increased MOUD treatment utilization. It had the highest levels of NPB use at baseline (average of 80.7 % of days) that decreased to an average of 12.9 % of days at 24 months. Class 5 (16 %) showed transition from high levels of heroin/fentanyl use to increased MOUD treatment utilization. Class 6 (27 %) showed decreased heroin/fentanyl use over time and low MOUD treatment utilization. Classes showed varying levels of improvement in psychosocial functioning, polydrug use, and overdose risks. CONCLUSION: Overall, our findings suggest that NPB use was generally self-limiting with individuals reducing their use over time as some engage in greater utilization of MOUD treatment. A need exists for continuing improvements in MOUD treatment access and retention.

Individuals Dying of Overdoses Related to Pharmaceutical Opioids Differ from Individuals Dying of Overdoses Related to Other Substances: A Population-Based Register Study.

BACKGROUND: Pharmaceutical opioid (PO) overdose deaths have increased in many Western countries. There are indications that those dying from a PO overdose differ from those dying from other types of overdoses. These differences might pose a challenge as the majority of current preventive measures are tailored toward those with the characteristics of "conventional" overdose deaths. OBJECTIVE: We investigated differences in the characteristics of persons who died from PO overdoses compared to all other overdoses. MATERIAL AND METHODS: Using the Norwegian Cause of Death Registry, we retrieved information on overdoses classified according to ICD-10 and identified PO overdoses (T40.2; T40.4) and all other overdoses (T40.X; T43.6) in 2010-2019. By linking data from nationwide registers, we analyzed data on opioid dispensations and the history of mental and behavioral disorders. 1,224 persons were registered with PO overdoses and 1,432 persons with other overdoses. RESULTS: Persons in the PO overdose group were older and were more frequently women (35.0% vs. 20.5%) than persons with other overdoses. They had a higher prevalence of chronic pain (35.8% vs. 13.2%), history of cancer (8.1% vs. 1.8%), filled prescriptions of analgetic opioids more frequently the month before death (38.8% vs. 12.0%), and used threefold higher doses of prescribed opioids compared to individuals in all other overdose group (66 vs. 26 oral morphine equivalents/day). In the PO overdose group, oxycodone and fentanyl were more frequently dispensed, while codeine was more frequently dispensed in the other overdose groups. A lower proportion of those in the PO overdose group had recorded diagnoses of substance use disorders, schizophrenia, and hyperkinetic disorder compared to the other overdose groups. CONCLUSION: Persons dying from overdoses on POs often differ from the population targeted by existing prevention strategies, as they are more frequently older women with chronic pain and using high doses of prescription opioids.

Increasing trend in accidental pharmaceutical opioid overdose deaths and diverging overdose death correlates following the opioid prescription policy liberalization in Norway 2010-2018.

BACKGROUND: During the last decade, opioid prescription policies in Norway have been liberalised and pharmaceutical opioid (PO) dispensing has increased. Against this backdrop, we examined the trends in and the correlates of accidental overdose deaths attributable to PO in the period 2010-2018 in comparison with traditional heroin overdose deaths. METHODS: Accidental overdose deaths attributable to PO or heroin were identified through the Norwegian Cause of Death Registry (n = 1267) and cross-linked with population and patient registries. Overdose death correlates were examined using multivariable logistic regression. FINDINGS: The trend in accidental overdose deaths attributable to PO increased significantly from 2010 to 2018. Females, people aged 50 years or older, disability pension recipients and/or those with the highest net wealth had a greater risk of a PO vs. heroin overdose death, while those dying in public spaces, living in urban areas, having recent specialized drug treatment encounters, and/or criminal charge(s) had a lower risk. Among those with primary health care encounters, those with back problems and accidents and injuries had a greater risk of a PO vs. heroin overdose death, while those with a substance use disorder had a lower risk. CONCLUSION: The increase in accidental overdose deaths attributable to PO coincides with the period of opioid prescription policy liberalization and an increase in PO consumption in Norway. The PO and heroin overdose deaths differed in terms of the associated sociodemographic characteristics, primary and secondary health care encounters, diagnoses, and criminal charges, indicating a need for additional interventions aimed at preventing PO overdose deaths specifically.

"They say it's fentanyl, but they honestly look like Perc 30s": Initiation and use of counterfeit fentanyl pills.

BACKGROUND: Worsening of the overdose crisis in the USA has been linked to the continuing proliferation of non-pharmaceutical fentanyl (NPF). The recent wave of NPF spread in the USA has been fueled by an increased presence of counterfeit pills that contain NPF. This qualitative study aims to characterize the motivation and practices of counterfeit NPF pill initiation and use among individuals using illicit opioids in Arizona. METHODS: Between October 2020 and May 2021, semi-structured interviews were conducted with 22 individuals meeting the following eligibility criteria: (1) 18 years or older; (2) residence in Arizona; and (3) use of illicit opioids in the past 30 days and/or opioid use disorder treatment in the past 12 months. Participants were recruited through referrals by a harm reduction organization, craigslist ads, and referrals by other participants. Interviews were conducted virtually via Zoom. Qualitative interviews were transcribed and analyzed thematically using NVivo. RESULTS: Out of 22 participants, 64% were male, and 45% were ethnic minorities. Age ranged between 25 and 51 years old. Participants noted significant recent increases in the availability of counterfeit NPF pills ("blues," "dirty oxys") that were most commonly used by smoking. The majority indicated first trying NPF pills in the past year, and the first use often occurred in situations of reduced access to heroin or pharmaceutical opioids. Participant decisions to switch over to more frequent NPF pill use or to maintain some levels of heroin use were shaped by local drug availability trends and personal experiences with NPF effects. They were also influenced by conflicting views of social acceptability of pharmaceutical-like drugs, perceived harms of NPF in terms of overdose risks and increased difficulty of quitting, and perceived benefits of switching to the non-injection route of opioid administration (e.g., from injecting heroin to smoking NPF pills). CONCLUSION: Our findings highlight the need for the implementation of novel policy, treatment, and harm reduction approaches to address the growing unpredictability of drug supply and NPF pill-specific risks, attitudes, and behaviors.

Pharmaceutical opioid poisonings in Victoria, Australia: Rates and characteristics of a decade of emergency department presentations among nine pharmaceutical opioids.

BACKGROUND AND AIMS: Pharmaceutical opioids are a significant contributor to the global 'opioid crisis', yet few studies have comprehensively distinguished between opioid types. We measured whether a range of common pharmaceutical opioids varied in their contribution to the rates and characteristics of harm in a population-wide indicator of non-fatal overdose. DESIGN: Retrospective observational study of emergency department (ED) patient care records in the Victorian Emergency Minimum Data set (VEMD), July 2009 to June 2019. SETTING: Victoria, Australia. CASES: ED presentations for non-fatal overdose related to pharmaceutical opioid use (n = 5403), where the specific pharmaceutical opioid was documented. MEASUREMENTS: We compared harms across the nine individual pharmaceutical opioids most commonly sold, and considered where multiple opioids contributed to the overdose. We calculated supply-adjusted rates of ED presentations using Poisson regression and used multinomial logistic regression to compare demographic and clinical characteristics of presentations among nine distinct pharmaceutical opioids and a 10th category where multiple opioids were documented for the presentation. FINDINGS: There were wide differences, up to 27-fold, between supply-adjusted rates of overdose. When considering presentations with sole opioids, the highest supply-adjusted overdose rates [per 100 000 oral morphine equivalents (OME); 95% confidence interval (CI)] were for codeine (OME = 0.078, 95% CI = 0.073-0.08) and oxycodone (OME =0.029, 95% CI = 0.027-0.030) and the lowest were for tapentadol (OME = 0.004, 95% CI = 0.003-0.006) and fentanyl (OME = 0.003, 95% CI = 0.002-0.004). These rates appeared related to availability rather than opioid potency. Most (62%) poisonings involved females. Codeine, oxycodone and tramadol were associated with younger presentations (respectively, 59.5%, 41.7% and 49.8% of presentations were 12-34 years old), and intentional self-harm (respectively 65.2%, 50.6%, and 52.8% of presentations). Relative to morphine, fentanyl [ 0.32 relative risk ratio (RRR)] and methadone ( 0.58 RRR) presentations were less likely to be coded as self-harm. Relative to morphine-buprenorphine, codeine, oxycodone and tramadol presentations were significantly more likely to be associated with the less urgent triage categories (respectively 2.18, 1.80, 1.52, 1.65 RRR). CONCLUSIONS: In Victoria, Australia, rates and characteristics of emergency department presentations for pharmaceutical opioids show distinct variations by opioid type.

The use of diverted pharmaceutical opioids is associated with reduced risk of fentanyl exposure among people using unregulated drugs in Vancouver, Canada.

BACKGROUND: Although non-medical use of pharmaceutical opioids (POs) is associated with a number of risks, in the context of the opioid-overdose crisis, it may have the secondary benefit of decreasing the risk of exposure to more potent opioids from unregulated sources. The aim of this study was to assess the effects of using diverted POs on fentanyl exposure. METHODS: Using data from two prospective community-recruited cohorts of people who use drugs (PWUD) in Vancouver, Canada, we estimated the independent relationship between using diverted POs and fentanyl exposure (assessed through urine drug test [UDT]) between 2016 and 2018. We also explored if participant characteristics modified this relationship. RESULTS: Over the study period, among 1150 participants, 241 (21.0%) reported using diverted POs in 292 (12.8%) occasions. In adjusted analyses, PWUD using diverted POs had decreased odds of fentanyl exposure (Adjusted odds ratio [AOR] = 0.70, 95% CI: 0.52-0.94). The reduced odds of fentanyl exposure persisted among participants with morphine positive UDT (AOR = 0.57, 95% CI: 0.40-0.82), but not among those with negative morphine UDT (AOR = 0.91, 95% CI: 0.54-1.55). CONCLUSION: PWUD using diverted POs in our sample were 30% less likely to be exposed to fentanyl. This reduced likelihood was primarily observed among PWUD with morphine positive UDT, which could partially be explained by longer duration of action and lower street cost of slow-release oral morphine relative to other POs and fentanyl. Findings suggest that access to a regulated supply of pharmaceutical-grade opioids may serve to reduce fentanyl-related harms.

Transitioning from pharmaceutical opioids: A discrete-time survival analysis of heroin initiation in suburban/exurban communities.

INTRODUCTION: Research identifying pathways to heroin use has typically been conducted among urban populations. This study examined heroin initiation following pharmaceutical opioid use in three suburban/exurban Southern California counties. METHODS: Interviewer-administered surveys collected data among 330 participants (65.9 % male; 63.9 % non-Hispanic white) whose initial use of any opioid was a pharmaceutical opioid. Retrospective discrete-time survival analysis identified predictors of heroin initiation, measured as self-reported age of first heroin use. RESULTS: Median age of first pharmaceutical opioid use was 17 years; 50.6 % initially acquired pharmaceutical opioids from an illicit source, 56.7 % first used pharmaceutical opioids for recreational purposes, and 86 % initiated heroin use. Average time from first pharmaceutical opioid use to first heroin use was 8.2 years. Drug/alcohol treatment (adjusted Hazard Ratio [aHR]: 0.67, 95 % CI: 0.50, 0.88) was associated with delayed time to heroin initiation. Obtaining opioids from non-medical sources (aHR: 2.21, 95 % CI: 1.55, 3.14) was associated with accelerated time to heroin initiation. Reporting supply problems with obtaining pharmaceutical opioids (e.g., unable to acquire pharmaceutical opioids) was associated with accelerated time to heroin initiation, but the magnitude of this effect was dependent on one's history of methamphetamine use (p < 0.05). CONCLUSIONS: Time to heroin initiation following pharmaceutical opioid use was accelerated among those reporting supply problems and delayed among those with exposure to substance use treatment. Interventions interrupting supply of opioids might benefit from coordination with evidence-based medication-assisted treatment to minimize the risk of transitioning to heroin use, particularly among those with a long history of non-prescribed pharmaceutical opioid use.

Comparing rates and characteristics of ambulance attendances related to extramedical use of pharmaceutical opioids in Australia: a protocol for a retrospective observational study.

INTRODUCTION AND AIMS: Extramedical use of, and associated harms with pharmaceutical opioids are common. Analysis of coded ambulance clinical records provides a unique opportunity to examine a national population-level indicator of relative harms. This protocol describes an observational study with three aims: (1) to compare supply adjusted rates of pharmaceutical opioid-related ambulance attendances for buprenorphine, codeine, fentanyl, oxycodone, oxycodone-naloxone, morphine, pethidine, tramadol and tapentadol; (2) to compare presentation characteristics for these commonly used pharmaceutical opioids and (3) to describe the context surrounding ambulance presentations related to oxycodone, a widely used opioid with an established abuse liability, and tapentadol, a more recent 'atypical' opioid on the Australian market, with fewer studies that have directly examined signals of extramedical use. METHOD: Trained coders extract data from clinical records for ambulance presentations relating to extramedical use of commonly used pharmaceutical opioids. These data form the basis of a large, national database that captures alcohol-related and drug-related harms. Supply adjusted rates of presentations will be examined using Poisson regression. Multinomial logistic regression will be used to compare severity and other characteristics of attendances relating to different pharmaceutical opioids. Tapentadol-related and oxycodone-related cases will be qualitatively examined to understand the situationally specific contexts of the ambulance attendances outside of the characteristics captured in routinely coded variables. ETHICS AND DISSEMINATION: Ethics approval related to analysis of ambulance attendance data was obtained from the Eastern Health Human Research Ethics Committee (E122 08-09), with an amendment specific to the qualitative analysis. Findings will be submitted for peer review in 2019. The understanding of risk profiles in real-world settings is of international public health importance. The analysis and publication of findings from this national dataset of clinical records will provide one of the most nuanced analyses to date of relative harms across nine pharmaceutical opioids over a 6-year period.

Trends in methamphetamine and opioid use among clients of needle-syringe programs in Queensland, Australia: 2007-2015.

INTRODUCTION AND AIMS: Needle-syringe programs (NSP) are an underutilized source of data on drug injection trends; these data are essential for informing public health interventions. We examine trends in NSP service occasions from 2007-2015. DESIGN AND METHODS: Using standardised data from 26 NSP outlets through the Queensland NSP Minimum Data Set (QNSPMDS), trends in service occasions among clients intending to inject methamphetamine, heroin, opioid substitution therapy (OST) medications and other pharmaceutical opioids were assessed using multilevel mixed-effects negative binomial regression, adjusting for month, year, age and clustering by site. RESULTS: Over 1.5 million service occasions were recorded in 2007-2015. Methamphetamine was the main 'drug intended to inject' (33.7%), however cf. 2007, the incidence rate ratio decreased to 0.64 (95% CI: 0.62, 0.66) in 2009, remaining low until 2015. Among clients reporting methamphetamine injection, there was a shift in the form from base to the higher-potency crystal methamphetamine since 2012. Heroin injection (22.5% service occasions) initially increased (cf. 2007), followed by a decline to 0.77 (95% CI: 0.75, 0.79) in 2015. Significant and sustained increases in OST and other pharmaceutical opioids injection were observed throughout the study period, accounting for 7.2% and 19.8% of total visits, respectively. DISCUSSION AND CONCLUSIONS: The QNSPMDS provides unique, routinely collected, jurisdiction-wide and standardised data on the demographics of people who inject drugs, types of drugs injected and regional variations; these data are essential in informing policy, planning and program implementation. There remains significant opportunity to enhance engagement and linkage to care alongside needle-syringe provision.

Dynamic Thinking Approach of Non-medical Use of Pharmaceutical Opioids.

Unsteady increase in using pharmaceutical opioids is a phenomenon that has existed in human societies for a long time. Furthermore, the ever-growing trend of addiction to opioids affects communities in various economic, social, and cultural aspects. Since abusing pharmaceutical opioids is a complex dynamic problem, it is extremely difficult to recognize the factors influencing this abuse. Thus, applying such dynamic models as system dynamics (SD) plays an important role in addressing these complex dynamic problems. System dynamics model falls in two categories of qualitative and quantitative system dynamics. In this paper, causal loop diagrams (CLDs), which are conceptual qualitative stages were applied, and variables were elicited from literatures; then, the initial CLDs were generated, and afterward, some experts were interviewed in order for the CLDs model to be evaluated. Ultimately, a meeting was held for discussing the variables and validating the diagrams. In this study, variables are connected by causal relationships called reinforcing and balancing. Then, the CLD model clearly depicted how the variables interact with one another indifferent stages of the process. The CLDs model is a fundamental issue in developing quantitative system dynamic, assisting policymakers in forecasting the process of non-medical use of pharmaceutical opioids and finding some measures to reduce their usage.

Accurate identification of opioid overdose deaths using coronial data.

INTRODUCTION: Defining drug-related mortality is complex as these deaths can include a wide range of diseases and circumstances. This paper outlines a method to identify deaths that are directly due to fatal opioid toxicity (i.e. overdose), utilising coronial data. MATERIALS AND METHODS: The National Coronial Information System (NCIS), an online coronial database containing information on all deaths that are reported to a coroner in Australia, is used to develop methods to more accurately identify opioid overdose deaths. The NCIS contains demographic information, Medical Cause of Death, and associated documentation on toxicology, clinical and police investigations. RESULTS: Identifying overdose deaths using the coroner determined Medical Cause of Death provided greater capture, and specificity, of opioid overdose deaths. Distinguishing morphine from heroin-related deaths presented challenges, requiring analysis of clinical and investigative information in addition to toxicology results. One-quarter of the deaths attributed to morphine were recorded to heroin as a result of further investigation. There was also some underestimation of codeine-related deaths. Access to clinical and investigative information also yields important information in relation to comorbid conditions among these decedents, such as history of chronic pain, substance use issues and mental health problems. CONCLUSIONS: Reliance on toxicology results alone leads to an underestimate of heroin-related deaths. Differentiating between heroin and pharmaceutical opioid (e.g. morphine) overdose deaths has important public health and policy implications, particularly in relation to prescribing practices and development of a strategic response. Understanding comorbidities among these decedents is also important in efforts to reduce preventable causes of death such as opioid overdose.

Intravenous fentanyl use among people who inject drugs in Australia.

INTRODUCTION AND AIMS: There is a current epidemic of pharmaceutical opioid (PO) misuse, particularly fentanyl and fentanyl analogues, globally. Fentanyl is a highly potent synthetic opioid with rapid onset and significantly higher risk of overdose compared with other opioids. Contexts and correlates of fentanyl use among people who inject drugs (PWID) in Australia are under-researched. DESIGN AND METHODS: The Australian Needle Syringe Program Survey is conducted annually. Consenting PWID complete a self-administered questionnaire and provide a capillary dried blood spot for human immunodeficiency virus and hepatitis C virus antibody testing. Bivariate and multivariate logistic regressions determined correlates of recent (last 6 months) fentanyl injection in 2014. RESULTS: Recent fentanyl injection was reported by 8% (n = 193) of the total sample. Among the 848 PWID who recently injected POs, 23% injected fentanyl. Compared with PO injectors who had not injected fentanyl, those who had injected fentanyl were significantly more likely to identify as Indigenous Australian [adjusted odds ratio (AOR) 1.61; 95% confidence interval (CI) 1.04, 2.51; P = 0.034], inject daily or more frequently (AOR 1.92; 95% CI 1.30, 2.83; P = 0.005), inject in public (AOR 1.43; 95% CI 1.01, 2.02; P = 0.042) and to have overdosed in the past year (AOR 2.16; 95% CI 1.48, 3.13; P < 0.001), but were significantly less likely to receptively share syringes (AOR 0.56; 95% CI 0.36, 0.87; P = 0.010). DISCUSSION AND CONCLUSIONS: Fentanyl injectors in Australia are significantly more likely to identify as Indigenous, report frequent injection, inject in public and experience overdose. Increased access to harm reduction interventions, including naloxone distribution, wheel filters and supervised injection facilities, are likely to benefit this population.

Pharmaceutical opioid overdose deaths and the presence of witnesses.

BACKGROUND: In the past two decades, rates of pharmaceutical opioid use and harms resulting from their use (including death) have risen. The present study identified a series of fatal opioid overdoses where there was evidence that witnesses had noted symptoms consistent with overdose, and examined associated contextual factors. METHODS: A retrospective review was undertaken utilising the Coroners Court of Victoria's Overdose Deaths Register for pharmaceutical opioid overdose deaths between 2011 and 2013. Information on the source of pharmaceutical opioids, co-contributing drugs, history of drug dependence, and mental illness was extracted and coded. RESULTS: Pharmaceutical opioids were involved in 587 deaths, and within these, 125 cases (21%) were witnessed. The majority of these witnessed deaths (77.6%) occurred at the deceased's residence, with the witness being a partner or unrelated acquaintance who did not realise the significance of what they were witnessing. The most common contributing pharmaceutical opioids were methadone (49.6%), codeine (32.0%), and oxycodone (19.2%), with the source more often prescribed than diverted. Co-contributing drugs were involved in 110 cases, with the most common being benzodiazepines. Evidence of current dependence and mental illness was found in 53.6% of cases. CONCLUSION: Most pharmaceutical opioid overdose deaths with a witness present occurred in the deceased's home, with symptoms of overdose being noted, but not acted upon. These findings support the trialling of education and/or naloxone to partners and family members of people who use pharmaceutical opioids in order to reduce overdose deaths.

Pharmaceutical opioid use among oral and intravenous users in Australia: A qualitative comparative study.

BACKGROUND: Between 1992 and 2012 dispensing episodes for pharmaceutical opioids (PO) in Australia increased from 500000 to 7500000. In the US, increases in the prescription of PO have been linked to increases in opioid-related morbidity and mortality and transitions to heroin injection. However, Australian data indicate that morbidity and mortality related to PO are relatively low, particularly when compared to heroin and other drugs. This paper explores the characteristics and patterns of non-medical pharmaceutical opioid (NMPO) use among a sample of young people in Sydney, Australia. METHODS: During 2015, we conducted in-depth qualitative interviews with 34 young people who use PO non-medically by oral (n=22) and intravenous (n=12) routes of administration. RESULTS: Oral NMPO users were a more affluent group who clustered around the Northern, Inner and Eastern suburbs of Sydney, while the intravenous users came from a range of locations including rural/regional areas of NSW and socioeconomically disadvantaged suburbs of South Western Sydney. Oral users were characterised by intermittent and largely self-limiting NMPO use and reported few health and social consequences. Intravenous users reported heavy and frequent drug, including NMPO, use and a range of adverse health and social consequences including overdose, injecting risk behaviour, hepatitis C virus (HCV) infection and residential instability. CONCLUSION: Results highlight the significance of social and structural factors in trajectories of opioid use and related harms. Factors such as stable housing and family relationships, disposable income and close social networks observed in young oral NMPO users may help to explain differences in patterns of NMPO use and related outcomes between the two groups.

Patterns of, and Factors Associated With, Illicit Pharmaceutical Opioid Analgesic Use in a Prospective Cohort of People Who Inject Drugs in Melbourne, Australia.

BACKGROUND: People who inject drugs (PWID) are a key population engaging in pharmaceutical opioid analgesic (PO) use, yet little is known about patterns of illicit PO use among this group. OBJECTIVES: The aims of this research were to measure the prevalence and frequency of lifetime and past-month illicit PO use and injection in a sample of regular PWID, to examine patterns of past-month illicit PO use within individuals over time, and to identify factors independently associated with past-month illicit PO use. METHODS: Data were drawn from a prospective cohort study of regular PWID (N = 666) in Melbourne, Australia. Data from five waves of annual data collection (including baseline) were analyzed descriptively and using generalized estimating equations (GEE). RESULTS: At baseline, 59% of participants reported lifetime illicit PO use and 20% reported past-month use, predominantly through injecting. Most illicit PO users at baseline transitioned to nonuse of illicit POs across the study period. In multivariable GEE analysis, factors associated with past-month illicit PO use included past-year arrest [adjusted odds ratio (AOR): 1.39], opioids other than heroin as drug of choice (AOR: 5.14), experiencing poorer physical health (AOR: 0.98) and a range of other drug use variables. CONCLUSIONS: We found little evidence of ongoing illicit PO use among those followed up, with illicit PO use linked to polydrug use more broadly. Nonetheless, trends in illicit PO use among PWID should continue to be monitored and harm reduction interventions implemented to reduce the associated public health risks.

The characteristics of a cohort who tamper with prescribed and diverted opioid medications.

AIMS: To describe the methods and baseline characteristics of a cohort of people who tamper with pharmaceutical opioids, formed to examine changes in opioid use following introduction of Reformulated OxyContin®. METHODS: Participants were 606 people from three Australian jurisdictions who reported past month injecting, snorting, chewing or smoking of a pharmaceutical opioid and had engaged in these practices at least monthly in the past 6 months. Baseline interviews were conducted prior to introduction of Reformulated OxyContin® in April 2014. Patterns of opioid use and cohort characteristics were examined according to whether participants were prescribed opioid medications, or exclusively used diverted medication. RESULTS: The cohort reported high levels of moderate/severe depression (61%), moderate/severe anxiety (43%), post-traumatic stress disorder (42%), chronic pain or disability (past 6 months, 54%) and pain (past month, 47%). Lifetime use of oxycodone, morphine, opioid substitution medications and codeine were common. Three-quarters (77%) reported ICD-10 lifetime pharmaceutical opioid dependence and 40% current heroin dependence. Thirteen percent reported past year overdose, and 70% reported at least one past month opioid injection-related injury or disease. The cohort displayed complex clinical profiles, but participants currently receiving opioid substitution therapy who were also prescribed other opioids particularly reported a wide range of risk behaviors, despite their health service engagement. CONCLUSIONS: Findings highlight the heterogeneity in the patterns and clinical correlates of opioid use among people who tamper with pharmaceutical opioids. Targeted health interventions are essential to reduce the associated harms.

Methods and predictors of tampering with a tamper-resistant controlled-release oxycodone formulation.

BACKGROUND: In April 2014, a tamper-resistant controlled-release oxycodone formulation was introduced into the Australian market. This study aimed to identify the level and methods of tampering with reformulated oxycodone, demographic and clinical characteristics of those who reported tampering with reformulated oxycodone, and perceived attractiveness of original and reformulated oxycodone for misuse (via tampering). METHODS: A prospective cohort of 522 people who regularly tampered with pharmaceutical opioids and had tampered with the original oxycodone product in their lifetime completed two interviews before (January-March 2014: Wave 1) and after (May-August 2014: Wave 2) introduction of reformulated oxycodone. RESULTS: Four-fifths (81%) had tampered with the original oxycodone formulation in the month prior to Wave 1; use and attempted tampering with reformulated oxycodone amongst the sample was comparatively low at Wave 2 (29% and 19%, respectively). Reformulated oxycodone was primarily swallowed (15%), with low levels of recent successful injection (6%), chewing (2%), drinking/dissolving (1%), and smoking (<1%). Participants who tampered with original and reformulated oxycodone were socio-demographically and clinically similar to those who had only tampered with the original formulation, except the former were more likely to report prescribed oxycodone use and stealing pharmaceutical opioid, and less likely to report moderate/severe anxiety. There was significant diversity in the methods for tampering, with attempts predominantly prompted by self-experimentation (rather than informed by word-of-mouth or the internet). Participants rated reformulated oxycodone as more difficult to prepare and inject and less pleasant to use compared to the original formulation. CONCLUSION: Current findings suggest that the introduction of the tamper-resistant product has been successful at reducing, although not necessarily eliminating, tampering with the controlled-release oxycodone formulation, with lower attractiveness for misuse. Appropriate, effective treatment options must be available with increasing availability of abuse-deterrent products, given the reduction of oxycodone tampering and use amongst a group with high rates of pharmaceutical opioid dependence.

Factors associated with the development of depression in chronic non-cancer pain patients following the onset of opioid treatment for pain.

BACKGROUND AND AIMS: Pharmaceutical opioid prescription rates are increasing globally, however knowledge of their long-term effects on mental health, in particular depression remains limited. This study aimed to identify factors associated with the onset of depression post-opioid use that differ to factors associated with depression post-pain. METHOD: Participants (N = 1418) were a national sample prescribed opioids for chronic non-cancer pain. Age at onset of depression, pain and commencement of opioid medications were collected via structured interview. RESULTS: Six in 10 (61%) reported lifetime depression; of those, almost half developed depression after pain and after they started opioid medications (48%). Variables associated with post-opioid depression included lower pain self-efficacy and poorer social support, younger onset of opioid use, and difficulties and concerns with opioid medications. CONCLUSIONS: The findings highlight the importance of monitoring for the emergence of mood dysfunction, particularly for those starting opioids for pain at a younger age, and consideration of psychological treatments that address self-efficacy that appears to be associated with post-opioid depression.