Co-use of Opioid Medications and Alcohol Prevention Study (COAPS).

While there is limited research in the field regarding the various dimensions of co-use of alcohol and opioid medication, particularly related to co-use and levels of severity, our research has shown 20% to 30% of community pharmacy patients receiving opioid pain medications are engaged in co-use. Co-use of alcohol and opioid medications is a significant risk factor for opioid-related overdose. Community pharmacy is a valuable yet underutilized resource and setting for addressing the US opioid epidemic, with an untapped potential for identification of and intervention for risks associated with co-use of alcohol and opioids. This commentary describing the "Co-use of Opioid Medications and Alcohol Prevention Study (COAPS)" offers an innovative and promising approach to mitigating serious risks associated with co-use of alcohol (risk and non-risk use) and opioids in community pharmacy. COAPS aim 1involves adapting an existing opioid misuse intervention to target co-use of alcohol and opioid mediations. COAPS aim 2 involves testing the adapted intervention within a small-scale pilot randomized controlled trial (N = 40) to examine feasibility, acceptability and preliminary efficacy of the intervention versus standard care. COAPS aim 3 involves conducting key informant interviews related to future implementation of larger scale studies or service delivery in community pharmacy settings.

Patients' Perceptions of Physical Therapists Addressing Opioid Misuse.

INTRODUCTION: In the US, rising numbers of patients who misuse illicit or prescribed opioids provides opportunities for physical therapists (PTs) to be engaged in their care. Prior to this engagement, it is necessary to understand the perceptions of patients who access physical therapy services about their PTs playing such a role. This project examined patients' perceptions of PTs addressing opioid misuse. METHODS: We surveyed patients, newly encountering outpatient physical therapy services in a large University-based healthcare setting, via anonymous, web-based survey. Within the survey, questions were rated on a Likert scale (1 = completely disagree to 7 = completely agree) and we evaluated responses of patients who were prescribed opioids versus those who were not. RESULTS: Among 839 respondents, the highest mean score was 6.2 (SD = 1.5) for "It is OK for physical therapists to refer their patients with prescription opioid misuse to a specialist to address the opioid misuse." The lowest mean score was 5.6 (SD = 1.9) for "It is OK for physical therapists to ask their patient why they are misusing prescription opioids." Compared to those with no prescription opioid exposure while attending physical therapy, patients with prescription opioid exposure had lower agreement that it was OK for the physical therapist to refer their patients with opioid misuse to a specialist (ß = -.33, 95% CI = -0.63 to -0.03). CONCLUSIONS: Patients attending outpatient physical therapy seem to support PTs addressing opioid misuse and there are differences in support based on whether the patients had exposure to opioids.

Research Priorities for Expansion of Opioid Use Disorder Treatment in the Community Pharmacy.

In the last decade, the U.S. opioid overdose crisis has magnified, particularly since the introduction of synthetic opioids, including fentanyl. Despite the benefits of medications for opioid use disorder (MOUD), only about a fifth of people with opioid use disorder (OUD) in the U.S. receive MOUD. The ubiquity of pharmacists, along with their extensive education and training, represents great potential for expansion of MOUD services, particularly in community pharmacies. The National Institute on Drug Abuse's National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) convened a working group to develop a research agenda to expand OUD treatment in the community pharmacy sector to support improved access to MOUD and patient outcomes. Identified settings for research include independent and chain pharmacies and co-located pharmacies within primary care settings. Specific topics for research included adaptation of pharmacy infrastructure for clinical service provision, strategies for interprofessional collaboration including health service models, drug policy and regulation, pharmacist education about OUD and OUD treatment, including didactic, experiential, and interprofessional curricula, and educational interventions to reduce stigma towards this patient population. Together, expanding these research areas can bring effective MOUD to where it is most needed.

Mindfulness and Savoring: A Commentary on Savoring Strategies and Their Implications for Addiction Treatment.

Background: A central facet of the popular understanding of mindfulness practice is the non-judgmental observation of all thoughts and feelings. Savoring is a cognitive practice developed out of economics and positive psychology, which involves the conscious mental engagement with positively-valenced interoceptive and exteroceptive stimuli, which in turn amplifies the derived pleasure experience. Results: When incorporated into mindfulness-based interventions (MBIs), savoring holds promise in improving outcomes related to reward processing, such as positive affect and well-being. The growing body of mindfulness literature also suggests that the inclusion of savoring in MBIs may be key in treating disorders of reward dysregulation, such as addiction. If savoring does indeed reduce craving, this phenomenon offers a point of union for divergent neurobiological theories of addiction. Conclusion: In this commentary, we explore the existing literature on savoring and mindfulness practices as it relates to addictive disorders, posit underlying neurocognitive mechanisms, and present future areas of research.

Associations between elevated depressive symptoms and substance use, prescription opioid misuse, overdose history, pain, and general health among community pharmacy patients prescribed opioids.

Background: Individuals with pain prescribed opioids experience high rates of comorbid depression. The aim of this study was to characterize pain, substance use, and health status as a function of depressive symptom level in individuals filling an opioid prescription at a community pharmacy. Methods: Participants (N = 1268) filling an opioid prescription enrolled in a study validating a prescription drug monitoring metric completed an online survey assessing sociodemographics, depressive symptoms, substance use, prescription opioid misuse, overdose history, general health, and pain severity and interference. Results: Approximately one-fifth (19.3%) had a positive depression screen result. In covariate-adjusted logistic regression analyses, individuals with a positive depression screen result were more likely to have moderate/high substance use risk scores for prescription opioids (adjusted odds ratio [AOR] = 2.06; 95% confidence interval [CI], 1.51-2.79); street opioids (AOR = 7.18; 95% CI, 2.57-20.01); cannabis (AOR = 2.00; 95% CI, 1.34-3.00); cocaine (AOR = 3.46; 95% CI, 1.46-8.22); tobacco (AOR = 1.59; 95% CI, 1.18-2.15); methamphetamine (AOR = 7.59; 95% CI, 2.58-22.35); prescription stimulants (AOR = 2.95; 95% CI, 1.59-5.49); and sedatives (AOR = 3.41; 95% CI, 2.43-4.79). Individuals with a positive depression screen were more likely to misuse prescription opioids (AOR = 3.46; 95% CI, 2.33-5.15), experience a prior overdose (AOR = 2.69; 95% CI, 1.76-4.11), report poorer general health (AOR = 0.25, 95% CI, 0.18-0.35), and report moderate/severe pain severity (AOR = 4.36, 95% CI, 2.80-6.77) and interference (AOR = 6.47, 95% CI, 4.08-10.26). Conclusions: Individuals prescribed opioids with heightened depression were more likely to report other substance use, prescription opioid misuse, prior overdose, greater pain, and poorer health.

Physical therapists' attitudes are associated with their confidence in and the frequency with which they engage in prescription opioid medication misuse management practices with their patients. A cross-sectional study.

Background: In the US, prescription opioid medication misuse (POMM) necessitates engagement of physical therapists (PTs). We (1) evaluated the attitudes of (PT) related to their management of patients with POMM and (2) examined the association between these attitudes and PTs confidence in POMM-related management abilities and the frequency with which they engaged in POMM-related management practices. Methods: We conducted a national survey of PTs that included a modified Drug and Drug Problems Perception Questionnaire (DDPPQ). Confidence in POMM-related abilities and the frequency of engaging in POMM-related management practices were measured. Logistic regression evaluated the association between the DDPPQ subscales (role adequacy, role legitimacy, role self-esteem, role support, job satisfaction) and confidence and frequency outcomes. Results: The analysis included 402 respondents. Role adequacy and legitimacy subscales were associated with confidence and frequency outcomes (p<.05), indicating that more favorable role adequacy and legitimacy attitudes are associated with greater odds of having more confidence in POMM-related management abilities and of engaging in more frequent POMM-related management practices. Conclusions: PTs with a greater sense of preparedness to engage in POMM-related management were more likely to report greater confidence in POMM-related management abilities and engage in POMM-related management practices with greater frequency.

Attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation: A comparison of health care professionals in rural communities.

Background: Health care professionals (HCPs) play an important role in opioid misuse and opioid use disorder (OUD) screening/identification, mitigation, and referral to treatment. This study compared attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation among pregnancy and non-pregnancy HCPs in rural communities. Methods: We conducted a secondary analysis of cross-sectional, self-report survey data of HCPs in two rural counties in southern Utah. Pregnancy HCPs were identified by a question asking whether they provide care to pregnant patients. HCPs' attitudes toward their patients with opioid misuse/OUD were measured using the Survey of Attitudes and Perceptions questionnaire. Self-efficacy and practices related to opioid risk assessment and mitigation were captured with questions asking about assessment and screening of opioid use, advisement to change opioid use behavior, and referral to treatment for OUD. We used linear regression analyses to estimate associations between HCPs' attitudes toward patients with opioid misuse/OUD and their self-efficacy and use of opioid risk assessment and mitigation practices. Results: This sample included a total of 132 HCPs, including 82 pregnancy HCPs and 50 non-pregnancy HCPs. Attitudes domains were similar among pregnancy and non-pregnancy HCPs. Among pregnancy HCPs, role adequacy (ß = .48, 95% CI = .16-.80), role legitimacy (ß = .72, 95% CI = .21-1.22), motivation (ß = .68, 95% CI = .14-1.21), and positive task-specific self-esteem (ß = 1.52, 95% CI = .70-2.35) were positively associated with more frequent use of opioid risk assessment and mitigation practices, while attitudes were not associated with these practices among non-pregnancy HCPs. Conclusions: Training initiatives that lead to improved HCP attitudes could improve opioid care management among rural pregnancy HCPs. More research is needed to determine approaches to increase the use of opioid risk assessment and mitigation practices among rural non-pregnancy HCPs.

Predicting Mortality Risk After a Hospital or Emergency Department Visit for Nonfatal Opioid Overdose.

BACKGROUND: Survivors of opioid overdose have substantially increased mortality risk, although this risk is not evenly distributed across individuals. No study has focused on predicting an individual's risk of death after a nonfatal opioid overdose. OBJECTIVE: To predict risk of death after a nonfatal opioid overdose. DESIGN AND PARTICIPANTS: This retrospective cohort study included 9686 Pennsylvania Medicaid beneficiaries with an emergency department or inpatient claim for nonfatal opioid overdose in 2014-2016. The index date was the first overdose claim during this period. EXPOSURES, MAIN OUTCOME, AND MEASURES: Predictor candidates were measured in the 180 days before the index overdose. Primary outcome was 180-day all-cause mortality. Using a gradient boosting machine model, we classified beneficiaries into six subgroups according to their risk of mortality (< 25th percentile of the risk score, 25th to < 50th, 50th to < 75th, 75th to < 90th, 90th to < 98th, ≥ 98th). We then measured receipt of medication for opioid use disorder (OUD), risk mitigation interventions (e.g., prescriptions for naloxone), and prescription opioids filled in the 180 days after the index overdose, by risk subgroup. KEY RESULTS: Of eligible beneficiaries, 347 (3.6%) died within 180 days after the index overdose. The C-statistic of the mortality prediction model was 0.71. In the highest risk subgroup, the observed 180-day mortality rate was 20.3%, while in the lowest risk subgroup, it was 1.5%. Medication for OUD and risk mitigation interventions after overdose were more commonly seen in lower risk groups, while opioid prescriptions were more likely to be used in higher risk groups (both p trends < .001). CONCLUSIONS: A risk prediction model performed well for classifying mortality risk after a nonfatal opioid overdose. This prediction score can identify high-risk subgroups to target interventions to improve outcomes among overdose survivors.

Abuse-Deterrent Opioid Formulations and the Opioid Crisis: A Pharmacist's Perspective.

BACKGROUND: For over 20 years, the United States has suffered the detrimental effects of an opioid epidemic. Extended-release opioid products are particularly prone to abuse due to the high amount of opioid present. By bypassing the controlled-release mechanisms and nonoral administration, individuals experience intense and dangerous "highs." Abuse-deterrent opioid formulations have been recommended as a potential solution to the crisis, but widespread utilization has been stunted and their role in therapy remains unclear owing to limited real-world efficacy data and affordability issues. This review discusses abuse-deterrent opioid formulations, the mechanisms and data underlying available products, and a pharmacist's perspective of their role in the opioid crisis. METHODS: The authors reviewed PubMed, MEDLINE, and Google Scholar electronic databases for premarketing and postmarketing studies on OxyContin, Xtampza ER, and Hysingla ER. RESULTS: Studies showed lower rates of abuse (19% reduction), opioid use disorder (27%), overdose (34%), and fatalities (85%) with the reformulated OxyContin when compared with the original product and comparator opioids. However, these studies revealed the potential for bypassing abuse-deterrent mechanisms and diverting abuse to other drugs. Postmarketing studies are unavailable for Xtampza ER or Hysingla ER, although premarketing studies suggested that some controlled-release properties persist when the product is manipulated, indicating that abuse may be more difficult and less rewarding. CONCLUSIONS: Abuse-deterrent opioid products may lead to reductions in abuse, overdose, and overdose fatalities. However, cost, loopholes in deterrence mechanism, and possible diversion to other substances hinder their role in the opioid crisis. Multiple approaches must be used to improve opioid safety, and further postmarketing and real-world analyses should be performed on available opioid formulations to assess their impact on abuse-related adverse events.

Integrated Psychosocial Group Treatment: A Randomized Pilot Trial of a Harm Reduction and Preventive Approach for Patients with Chronic Pain at Risk of Opioid Misuse.

OBJECTIVE: To examine the benefits of an integrated psychosocial group treatment (IPGT) model for patients with chronic pain at risk of opioid misuse. DESIGN: This study was a small-scale, single-blinded, two-group randomized controlled trial. SETTING: Outpatient. SUBJECTS: Adults with chronic pain of >3 months' duration who were currently prescribed opioid medication and were at risk of opioid misuse. METHODS: Patients with chronic pain who were at risk of opioid misuse (n = 30) were randomly assigned to IPGT or treatment as usual. IPGT consists of six group sessions of psychoeducation, motivational interviewing, cognitive behavioral therapy, mindfulness, and peer support. Participants were assessed at baseline, first follow-up at 6 weeks, and a posttreatment follow-up at 9 weeks. Outcomes included feasibility, acceptability, and preliminary efficacy. Data were analyzed with descriptive and multivariate analyses. RESULTS: All intervention components were delivered to 87% of the participants, and IPGT recipients reported a high level of satisfaction. Results of the multivariate analyses demonstrated nonsignificant improvements in pain severity (ß = 0.22, 95% CI: -0.24 to 0.66, P = 0.35). However, we observed significant treatment × time interactions on pain interference (ß = 3.32, 95% confidence interval [CI]: 0.01 to 6.65, P = 0.05) and pain catastrophizing (ß = 2.74, 95% CI: 0.49 to 4.99, P = 0.02). Lastly, we detected no significant differences in opioid misuse (adjusted odds ratio = 0.69, 95% CI: -0.26 to 1.64, P = 0.16). CONCLUSION: This study provides support for the IPGT intervention being acceptable and feasible for delivery in patients with chronic pain at risk of opioid misuse. Efficacy was achieved in pain interference and pain catastrophizing.

Pain Appraisals in Patients with Physical Injury: Assessing the Role of Distress Tolerance in the Relationship between Depression and Pain Catastrophizing.

Pain is a complex construct contributing to significant impairment, particularly among physically injured patients seeking treatment in trauma and orthopedic surgery settings in which social workers are an integral component of care. The biopsychosocial theory, fear-avoidance, and cognitive mediation models of pain suggest that psychological factors (for example, depression) affect one's ability to tolerate distress, leading to negative pain appraisals, such as catastrophizing. This study examined whether distress tolerance serves as a mechanism by which depression is associated with pain catastrophizing. We administered a health survey to outpatient trauma and orthopedic surgery clinic patients who were using opioid medications; 84 patients were included in the final analysis; 39.3 percent screened positive for depression. A multilevel mediation model using structural equation modeling revealed a significant direct effect from depression to pain catastrophizing (ß = .31, z = 3.96, p < .001) and a significant indirect effect by distress tolerance (Δß = .27, z = 3.84, p < .001). These results, which suggest that distress tolerance partially mediated the path from depression to pain catastrophizing, can inform social workers and other members of the multidisciplinary team about both the critical role of psychosocial factors after injury and interventions to improve postinjury recovery.

An Exploratory Study of Pharmacist Perceptions of Opioid Interventions for Acute Pain.

Background: As the last health care provider encountered before an opioid is dispensed, pharmacists have a vital role in reducing unnecessary opioid exposure while facilitating access to non-opioid alternatives. Objective: To characterize pharmacist perceptions in providing interventions for patients with an opioid prescription for acute pain. Methods: This cross-sectional survey was administered over 3 months to pharmacy preceptors affiliated with the University of Tennessee Health Science Center College of Pharmacy. The electronic survey utilized 7 demographical and baseline questions, 1 open-ended question, and 5 Likert-type scales to assess the following domains: responsibility in making decisions, willingness to provide information, comfort in speaking to patients, willingness to use a standing order, and importance of following up with patients. Results: Of the 380 participants invited to participate, 126 responded to at least one question and 90 completed all survey questions. Most participants were PharmD graduates practicing in hospital and community settings. Participants felt that opioids are frequently overprescribed and pharmacist interventions are often necessary. Most participants reported that pharmacists and physicians share similar responsibilities in making opioid-related decisions. Participants were willing to provide information about opioid alternatives but were only somewhat comfortable speaking to patients. Responses to the open-ended question revealed the following themes: Significance of educating the patient; Importance of alternatives to opioid medications; Impacts of pharmacist interventions; and Need for enhanced collaboration with physicians. Conclusions: Pharmacists face complex issues with limited clinical guidance when providing opioid-related interventions. Future research is needed to develop evidence-based clinical support tools and collaborative practice models.

Forecasting Opioid Use Disorder at 25 Years of Age in 16-Year-Old Adolescents.

OBJECTIVE: To evaluate the accuracy of detecting 16-year-old male (n = 465) and female (n = 162) youths who subsequently manifest opioid use disorder (OUD) at 25 years of age. We hypothesized that the combined measures of 2 components of etiology, heritable risk, and substance use, accurately detect youths who develop OUD. STUDY DESIGN: Heritable risk was measured by the transmissible liability index (TLI). Severity of the prodrome presaging OUD was quantified by the revised Drug Use Screening Inventory containing the consumption frequency index (CFI) documenting substance use events during the past month and the overall problem density (OPD) score indicating co-occurring biopsychosocial problems. Diagnosis of OUD was formulated by a clinical committee based on results of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition in conjunction with medical and social history records. RESULTS: Bivariate analysis shows that the TLI, CFI, and OPD scores at 16 years of age predict OUD at 25 years. Multivariate modeling indicates that the TLI combined with the CFI predict OUD with 86% accuracy (sensitivity = 87%; specificity = 62%). The TLI and CFI at 16 years of age mediate the association between parental substance use disorder and OUD in offspring at 25 years of age, indicating that these measures respectively evaluate risk and prodrome. CONCLUSIONS: These results demonstrate the feasibility of identifying youths requiring intervention to prevent OUD.

Associations Between the Specialty of Opioid Prescribers and Opioid Addiction, Misuse, and Overdose Outcomes.

OBJECTIVE: To examine associations between opioid prescriber specialty and patient likelihood of opioid use disorder (OUD), opioid misuse, and opioid overdose. DESIGN: Longitudinal retrospective study using Pennsylvania Medicaid data (2007-2015). METHODS: We constructed an incident cohort of 432,110 enrollees initiating prescription opioid use without a history of OUD or overdose six months before opioid initiation. We attributed patients to one of 10 specialties using the first opioid prescriber's specialty or, alternatively, the specialty of the dominant prescriber writing the majority of the patient's opioid prescriptions. We estimated adjusted rates for OUD, misuse, and overdose, adjusting for demographic variables and medical (including pain) and psychiatric comorbidities. RESULTS: The unadjusted incidence rates of OUD, misuse, and overdose were 7.13, 4.73, and 0.69 per 100,000 person-days, respectively. Patients initiating a new episode of opioid treatment with Pain Medicine/Anesthesiology (6.7 events, 95% confidence interval [CI] = 5.5 to 8.2) or Physical Medicine and Rehabilitation (PM&R; 6.1 events, 95% CI = 5.1 to 7.2) had higher adjusted rates for OUD per 100,000 person-days compared with Primary Care practitioners (PCPs; 4.4 events, 95% CI = 4.1 to 4.7). Patients with index prescriptions from Pain Medicine/Anesthesiology (15.9 events, 95% CI = 13.2 to 19.3) or PM&R (15.8 events, 95% CI = 13.5 to 18.4) had higher adjusted rates for misuse per 100,000 person-days compared with PCPs (9.6 events, 95% CI = 8.8 to 10.6). Findings were largely similar when patients were attributed to specialty based on dominant prescriber. CONCLUSIONS: Differences in opioid-related risks by specialty of opioid prescriber may arise from differences in patient risk factors, provider behavior, or both. Our findings inform targeting of opioid risk mitigation strategies to specific practitioner specialties.

Derivation and assessment of the opioid use disorder severity scale: prediction of health, psychological and social adjustment problems.

Background: Severity of substance use disorder (SUD) is typically evaluated by tabulating the number of symptoms. The resulting estimate of disorder severity is, however, biased due to intercorrelations among symptoms and their unequal salience. Objective. Employing item response theory (IRT) methodology, opioid use disorder symptoms were calibrated to derive the Opioid Use Disorder Severity Scale (OUDSS) and assess its predictive ability in men and women separately. Methods: A two-parameter IRT model was utilized to derive the OUDSS from DSM-IV symptoms recorded on the Structured Clinical Interview for DSM-IV (SCID) in 438 men and 429 women who reported at least one lifetime opioid consumption event. The predictive ability of the OUDSS was evaluated using the 10 health, psychological, and social adjustment domains of the revised Drug Use Screening Inventory (DUSI-R) assessed 2 years later. Results: The OUDSS score predicted the severity of problems in all 10 DUSI-R domains in men and women. The OUDSS also predicted the DUSI-R diagnostic cutoff score of overall problem density score in men and women (OR = 2.21 and OR = 4.83, respectively). Withdrawal was the most frequently endorsed symptom in this sample of opioid users. The other symptoms' frequencies, while somewhat lower than withdrawal's, did not differ from it substantially, indicating a similar severity threshold. Conclusions: OUDSS enables dimensional measurement of opioid use severity on an interval scale. The OUDSS and DUSI-R together can identify problem areas requiring prevention or treatment.

Psychiatric comorbidity and co-occurring opioid misuse: Depression mediates the relationship between post-traumatic stress disorder and opioid misuse in community pharmacy settings.

AbstractsBackground: Individuals who misuse opioids frequently have comorbid psychiatric issues, including post-traumatic stress disorder (PTSD) and depression. However, little is known about the mechanisms by which these disorders are associated with opioid misuse and specifically in community pharmacy settings. The current study examined whether depression mediated the relationship between PTSD and opioid misuse in patients filling opioid prescriptions. Methods: We administered a health survey in four community pharmacies among patients filling opioid medications in southwestern Pennsylvania. Univariate statistics were used to assess relationships among demographic and clinical characteristics of PTSD, depression, and opioid misuse behaviors. We then examined whether depression mediated the relationship between PTSD and opioid misuse using ordinary least squares path analysis with bootstrapping. Results: A total of 333 participants completed the health survey. Opioid misuse was reported among 15.9% of all participants, 33.3% among those with a positive PTSD screen, and 29.3% of those who screened positive for depression. Depression significantly mediated the relationship between PTSD and opioid misuse. Specifically, there was a statistically significant indirect effect (ab) of PTSD on opioid misuse through a pathway mediated by depression (ab = .06, SEab = .02, 95% CI = .02-.10). The direct effect (c') of PTSD on opioid misuse was also significant (c' = .12, SEc' = .05, P = .01, 95% CI = .03-.22), suggesting partial mediation. Conclusions: Results suggest an indirect pathway by which clinical intervention may help ameliorate outcomes in patients with PTSD. Further, there is an increased need for screening, assessment, and intervention protocols for this patient population in which community pharmacy is a novel setting to expand future efforts within the patient population.

Medication treatment for opioid use disorder and community pharmacy: Expanding care during a national epidemic and global pandemic.

Medications for opioid use disorder (MOUD), such as methadone and buprenorphine, are effective strategies for treatment of opioid use disorder (OUD) and reducing overdose risk. MOUD treatment rates continue to be low across the US, and currently, some evidence suggests access to evidence-based treatment is becoming increasingly difficult for those with OUD as a result of the 2019 novel corona virus (COVID-19). A major underutilized source to address these serious challenges in the US is community pharmacy given the specialized training of pharmacists, high levels of consumer trust, and general availability for accessing these service settings. Canadian, Australian, and European pharmacists have made important contributions to the treatment and care of those with OUD over the past decades. Unfortunately, US pharmacists are not permitted to prescribe MOUD and are only currently allowed to dispense methadone for the treatment of pain, not OUD. US policymakers, regulators, and practitioners must work to facilitate this advancement of community pharmacy-based through research, education, practice, and industry. Advancing community pharmacy-based MOUD for leading clinical management of OUD and dispensation of treatment medications will afford the US a critical innovation for addressing the opioid epidemic, fallout from COVID-19, and getting individuals the care they need.

Opioid use patterns and risk characteristics among injured patients.

Background: Injured patients are at risk for prolonged opioid use after discharge from care. Limited evidence exists regarding how continued opioid use may be related to opioid medication misuse and opioid use disorder (OUD) following injury. This pilot study characterized opioid consumption patterns, health characteristics, and substance use among patients with active prescriptions for opioid medications following injury care. Methods: This study was a cross-sectional screening survey combined with medical record review from February 2017 to March 2018 conducted among outpatient trauma and orthopedic surgery clinic patients. Eligible patients were 18-64 years of age, admitted/discharged for an injury or trauma-related orthopedic surgery, returning for clinic follow-up ≤6 months post hospital discharge after the index injury, prescribed opioid pain medication at discharge, and currently taking an opioid medication (from discharge or a separate prescription post discharge). Data collected included demographic, substance use, mental health, and physical health information. Descriptive and univariate statistics were calculated to characterize the population and opioid-related risks. Results: Seventy-one participants completed the survey (92% response). Most individuals (≥75%) who screened positive for misuse or OUD reported no nonmedical/illicit opioid use in the year before the index injury. A positive depression screen was associated with a 3.88 times increased likelihood for misuse or OUD (95% confidence interval [CI] = 1.1-13.5). Nonopioid illicit drug use (odds ratio [OR] = 1.89, 95% CI = 1.1-3.4) and opioid craving (OR = 1.29, 95% CI = 1.1-1.5) were also associated with increased likelihood for misuse or OUD. Number of emergency department visits in the 3 years previous to the index injury was associated with a 22% likelihood of being misuse or OUD positive (95% CI = 1.0-1.5). Conclusions: Patients with behavioral health concerns and greater emergency department utilization may have heightened risk for experiencing adverse opioid-related outcomes. Future research must further establish these findings and possibly develop protocols to identify patients at risk prior to pain management planning.

The Role of Primary Care in Improving Access to Medication-Assisted Treatment for Rural Medicaid Enrollees with Opioid Use Disorder.

BACKGROUND: The opioid epidemic has disproportionately affected rural areas, where a limited number of health care providers offer medication-assisted treatment (MAT), the mainstay of treatment for opioid use disorder (OUD). Rural residents with OUD may face multiple barriers to engagement in MAT including long travel distances. OBJECTIVE: To examine the degree to which rural residents with OUD are engaged with primary care providers (PCPs), describe the role of rural PCPs in MAT delivery, and estimate the association between enrollee distance to MAT prescribers and MAT utilization. DESIGN: Retrospective cohort study. PARTICIPANTS: Medicaid-enrolled adults diagnosed with OUD in 23 rural Pennsylvania counties. MAIN MEASURES: Primary care utilization, MAT utilization, distance to nearest possible MAT prescriber, mean distance traveled to actual MAT prescribers, and continuity of pharmacotherapy. KEY RESULTS: Of the 7930 Medicaid enrollees with a diagnosis of OUD, a minority (18.6%) received their diagnosis during a PCP visit even though enrollees with OUD had 4.1 visits to PCPs per person-year in 2015. Among enrollees with an OUD diagnosis recorded during a PCP visit, about half (751, 50.8%) received MAT, most of whom (508, 67.6%) received MAT from a PCP. Enrollees with OUD with at least one PCP visit were more likely than those without a PCP visit to receive MAT (32.7% vs. 25%; p < 0.001), and filled more buprenorphine and naltrexone prescriptions (mean = 11.1 vs. 9.3; p < 0.001). The median of the distances traveled to actual MAT prescribers was 48.8 miles, compared to a median of 4.2 miles to the nearest available MAT prescriber. Enrollees traveling a mean distance greater than 45 miles to MAT prescribers were less likely to receive continuity of pharmacotherapy (OR = 0.71, 95% CI = 0.56-0.91, p = 0.007). CONCLUSIONS: PCP utilization among rural Medicaid enrollees diagnosed with OUD is high, presenting a potential intervention point to treat OUD, particularly if the enrollee's PCP is located nearer than their MAT prescriber.