Use and Misuse of Opioids in Chronic Pain.

The prescribing of opioid analgesics for pain management-particularly for management of chronic noncancer pain (CNCP)-has increased more than fourfold in the United States since the mid-1990s. Yet there is mounting evidence that opioids have only limited effectiveness in the management of CNCP, and the increased availability of prescribed opioids has contributed to upsurges in opioid-related addiction cases and overdose deaths. These concerns have led to critical revisiting and modification of prior pain management practices (e.g., guidelines from the Centers for Disease Control and Prevention), but the much-needed changes in clinical practice will be facilitated by a better understanding of the pharmacology and behavioral effects of opioids that underlie both their therapeutic effects (analgesia) and their adverse effects (addiction and overdose). With these goals in mind, this review first presents an overview of the contemporary problems associated with opioid management of CNCP and the related public health issues of opioid diversion, overdose, and addiction. It then discusses the pharmacology underlying the therapeutic and main adverse effects of opioids and its implications for clinical management of CNCP within the framework of recent clinical guidelines for prescribing opioids in the management of CNCP.

Scoring the best deal: Quantity discounts and street price variation of diverted oxycodone and oxymorphone.

PURPOSE: Diverted prescription opioids are significant contributors to drug overdose mortality. Street price has been suggested as an economic metric of the diverted prescription opioid black market. This study examined variables that may influence the street price of diverted oxycodone and oxymorphone. METHODS: A cross-sectional study was conducted utilizing data from the previously validated, crowdsourcing website StreetRx. Street price reports of selected oxycodone and oxymorphone products, between August 22, 2014 and June 30, 2016, were considered for analysis. Geometric means and 95% confidence intervals were calculated comparing prices per milligram of drug in US dollars. Univariate and multivariable regressions were used to examine the influence of dosage strength, drug formulation, and bulk purchasing on street price. RESULTS: A total of 5611 oxycodone and 1420 oxymorphone reports were analyzed. Across various dosages and formulations, geometric mean prices per milligram ranged between $0.12 and $1.07 for oxycodone and $0.73 and $2.90 for oxymorphone. For a 2-fold increase in dosage strength, there is a 24.0% (95% CI: -28.1%, -19.6%, P < 0.001) and a 22.5% (95% CI: -24.2%, -20.8%, P < 0.001) decrease on average in price per milligram for oxycodone and oxymorphone, respectively. Lower potency, high dosage strength, crush-resistant opioids, and those purchased in bulk were significantly cheaper. CONCLUSION: Street prices for diverted oxycodone and oxymorphone are influenced by multiple factors including potency, dosage, formulation, and bulk purchasing. Buyers who purchase large quantities of low potency, large dosage, crush-resistant formulation prescription opioids can expect to achieve the lowest price.

The diversion of nonscheduled psychoactive prescription medications in the United States, 2002 to 2017.

PURPOSE: Systematic studies of the diversion of nonscheduled drugs, except for gabapentin, are not apparent. We searched diversion case reports of all other nonscheduled psychoactive prescription drugs in the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System. METHODS: Case report data are drawn from a quarterly survey of prescription drug diversion completed by a national sample of law enforcement and regulatory agencies. Rates of diversion per 100 000 population were calculated for each year from 2002 to 2017 for prescription medications with greater than 400 reported cases during the period. RESULTS: Cyclobenzaprine, quetiapine, and trazodone met criteria for analysis. We found a significant and steady increase in the diversion of each drug over the period. The 2017 annual rates of diversion per 100 000 population for the three medications range from 0.0428 to 0.0726. Although these rates of diversion are much lower than the rate for total opioid analgesics, they are all more than five times higher in 2017 compared with 2002. While diversion rates for opioids have decreased in recent years, rates for cyclobenzaprine, quetiapine, and trazodone have continued to increase. CONCLUSIONS: A common attribute of the three nonscheduled drugs studied here is that all are used for the treatment and/or self-treatment of opioid withdrawal symptoms, and the increasing diversion of these drugs may be related to the ongoing opioid epidemic and to increasing levels of control over pharmaceutical opioid availability in the United States. Prescribers need to be aware of illicit markets for these medications and prescribe to their patients with appropriate caution.

Prescription drug diversion among people living with HIV: a systematic scoping review.

OBJECTIVES: Globally, people living with HIV (PLWH) are at greater risk for various infections and chronic pain, therefore, vulnerable to prescription drug diversion which might negatively impact HIV care. The study purpose is to gather evidence on prescription drug diversion among PLWH. STUDY DESIGN: This is a systematic scoping review. METHODS: Arksey and O'Malley's framework and recommendation by Levac et al. were used to guide this study. Literature was searched in PubMed, Google Scholar, EBSCOhost (Academic Search Complete, MEDLINE and Newspaper Source) and Open Access Theses and Dissertations. Studies reporting evidence of prescription drug diversion from January 1996 to July 2017 were included. Thematic content analysis was performed to summarize data on the prevalence. RESULTS: Twenty-nine studies were eligible for data synthesis. Twenty-six studies were conducted in the United States of America (USA), one study in France and two multicountry studies; one study in Kenya and Uganda and the other study in Botswana, Kenya, Malawi, South Africa; Zimbabwe, India, Thailand, Brazil and the USA. Research evidence shows high prevalence of prescription drug diversion for analgesics and antiretroviral drugs; meanwhile, stimulants and erectile dysfunction drugs were the least diverted drugs among PLWH. There is a research gap in low- to middle-income countries (LMICs) investigating prescription drug diversion among PLWH. CONCLUSION: Our findings reveal that diversion of various prescription drug classes among PWLH exists. There is lack of research in LMICs. We recommend research in LMICs where there is high HIV prevalence. PROSPERO REGISTRATION NUMBER: CRD42017074076.

Law enforcement-derived data on gabapentin diversion and misuse, 2002-2015: diversion rates and qualitative research findings.

PURPOSE: Recent limited epidemiologic and case reports suggest that gabapentin is being misused, especially among prescription opioid misusers. However, no apparent studies have reported data from law enforcement on the diversion and misuse of gabapentin. METHODS: Case report data are drawn from a quarterly survey of prescription drug diversion completed by a national sample of law enforcement and regulatory agencies who engage in drug diversion investigations. Rates of gabapentin diversion per 100 000 population were calculated for each quarter from 2002 through 2015. Qualitative data are drawn from a brief questionnaire completed by a subsample of survey respondents and were organized and presented by theme. RESULTS: In total, 407 new cases of diverted gabapentin were reported during the time period, with diversion rates steadily increasing from zero cases in the first 2 quarters of 2002 to a high of 0.027 cases per 100 000 population in the fourth quarter of 2015. Qualitative data suggest that gabapentin is being misused in conjunction with prescription opioids and that gabapentin and heroin are being combined and consumed together. Law enforcement reporters found these drug use trends to be contributing to gabapentin diversion. CONCLUSIONS: The recent increase in gabapentin diversion appears to be related to the opioid epidemic, based on law enforcement descriptions of gabapentin being misused in combination with opioids. Yet epidemiological data related to this finding is limited and research conducted among gabapentin misusers is needed to understand this problem in more depth. Greater monitoring of gabapentin abuse and diversion appear warranted.

Supervised dosing with a long-acting opioid medication in the management of opioid dependence.

BACKGROUND: Opioid dependence (OD) is an increasing clinical and public health problem worldwide. International guidelines recommend opioid substitution treatment (OST), such as methadone and buprenorphine, as first-line medication treatment for OD. A negative aspect of OST is that the medication used can be diverted both through sale on the black market, and the unsanctioned use of medications. Daily supervised administration of medications used in OST has the advantage of reducing the risk of diversion, and may promote therapeutic engagement, potentially enhancing the psychosocial aspect of OST, but costs more and is more restrictive on the client than dispensing for off-site consumption. OBJECTIVES: The objective of this systematic review is to compare the effectiveness of OST with supervised dosing relative to dispensing of medication for off-site consumption. SEARCH METHODS: We searched in Cochrane Drugs and Alcohol Group Specialised Register and Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, Web of Science from inception up to April 2016. Ongoing and unpublished studies were searched via ClinicalTrials.gov (www.clinicaltrials.gov) and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (http://www.who.int/ictrp/en/).All searches included non-English language literature. We handsearched references on topic-related systematic reviews. SELECTION CRITERIA: Randomised controlled trials (RCTs), controlled clinical trials (CCTs), and prospective controlled cohort studies, involving people who are receiving OST (methadone, buprenorphine) and comparing supervised dosing with dispensing of medication to be consumed away from the dispensing point, usually without supervision. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. MAIN RESULTS: Six studies (four RCTs and two prospective observational cohort studies), involving 7999 participants comparing supervised OST treatment with unsupervised treatment, met the inclusion criteria. The risk of bias was generally moderate across trials, but the results reported on outcomes that we planned to consider were limited. Overall, we judged the quality of the evidence from very low to low for all the outcomes.We found no difference in retention at any duration with supervised compared to unsupervised dosing (RR 0.99, 95% CI 0.88 to 1.12, 716 participants, four trials, low-quality evidence) or in retention in the shortest follow-up period, three months (RR 0.94; 95% CI 0.84 to 1.05; 472 participants, three trials, low-quality evidence). Additional data at 12 months from one observational study found no difference in retention between groups (RR 0.94, 95% CI 0.77 to 1.14; n = 300).There was no difference in abstinence at the end of treatment (self-reported drug use) (67% versus 60%, P = 0.33, 293 participants, one trial, very low-quality evidence); and in diversion of medication (5% versus 2%, 293 participants, one trial, very low-quality evidence).Regarding our secondary outcomes, we did not found a difference in the incidence of adverse effects in the supervised compared to unsupervised control group (RR 0.63; 96% CI 0.10 to 3.86; 363 participants, two trials, very low-quality evidence). Data on severity of dependence were very limited (244 participants, one trial) and showed no difference between the two approaches. Data on deaths were reported in two studies. One trial reported two deaths in the supervised group (low-quality evidence), while in the cohort study all-cause mortality was found lower in regular supervision group (crude mortality rate 0.60 versus 0.81 per 100 person-years), although after adjustment insufficient evidence existed to suggest that regular supervision was protective (mortality rate ratio = 1.23, 95% CI = 0.67 to 2.27).No studies reported pain symptoms, drug craving, aberrant opioid-related behaviours, days of unsanctioned opioid use and overdose. AUTHORS' CONCLUSIONS: Take-home medication strategies are attractive to treatment services due to lower costs, and place less restrictions on clients, but it is unknown whether they may be associated with increased risk of diversion and unsanctioned use of medication. There is uncertainty about the effects of supervised dosing compared with unsupervised medication due to the low and very low quality of the evidence for the primary outcomes of interest for this review. Data on defined secondary outcomes were similarly limited. More research comparing supervised and take-home medication strategies is needed to support decisions on the relative effectiveness of these strategies. The trials should be designed and conducted with high quality and over a longer follow-up period to support comparison of strategies at different stages of treatment. In particular, there is a need for studies assessing in more detail the risk of diversion and safety outcomes of using supervised OST to manage opioid dependence.

From dispensed to disposed: evaluating the effectiveness of disposal programs through a comparison with prescription drug monitoring program data.

BACKGROUND: Organized disposal of controlled medications, such as take-back events and permanent drug donation boxes, is a prevention strategy that has been widely used to reduce the availability of controlled medications for diversion or abuse. However, little is known as to whether this strategy actually reduces the overall availability of these medications for the purposes of diversion or abuse. OBJECTIVES: The objective of this study was to compare the number and types of controlled medications that were disposed through organized efforts to the number dispensed in local communities. METHODS: The quantity and type of controlled medication collected from three take-back events and permanent drug donation boxes over 4-week-long periods in five counties in south-central Kentucky was measured and compared to the number of controlled medications dispensed, as reported by Kentucky All Schedule Prescription Electronic Reporting system. RESULTS: In 2013, 21,121,658 controlled medications units were dispensed in the participating counties. Of those, 46.9% were opioid analgesics, 13.1% tranquilizers, and 37.3% "other." During the assessment periods, a total of 21,503 controlled medication units were collected. Of those, 39.9% were opioid analgesics, 2.7% tranquilizers, and 57.4% "other." Annually, controlled medications disposed were estimated to account for 0.3% of those dispensed. CONCLUSION: Controlled medications collected by take-back events and permanent drug donation boxes constituted a miniscule proportion of the numbers dispensed. Our findings suggest that organized drug disposal efforts may have a minimal impact on reducing the availability of unused controlled medications at a community level.

Diversion and Illicit Sale of Extended Release Tapentadol in the United States.

OBJECTIVE: Prescription opioid analgesics are commonly prescribed for moderate to severe pain. An unintended consequence of prescribing opioid analgesics is the abuse and diversion of these medications. Tapentadol ER is a recently approved centrally acting analgesic with synergistic mechanisms of action: µ-opioid receptor agonism and inhibition of norepinephrine reuptake. We assessed the amount of diversion and related cost of obtaining tapentadol IR (Nucynta®) and tapentadol ER (Nucynta ER®) as well as other Schedule II opioid medications in street transactions in the United States using the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS®) System. METHODS: The Drug Diversion Program measures the number of cases opened by 260 drug diversion investigators in 49 states. StreetRx(TM) uses a crowd-sourcing Website to collect the prices paid for licit or illicit drugs. RESULTS: The population-based rates of diversion were 0.003 (tapentadol IR), 0.001 (tapentadol ER), and 1.495 (other Schedule II opioid tablets) reports per 100,000 population. The tapentadol ER rate was lower than the other Schedule II opioid tablets (P < 0.001) and tapentadol IR (P= 0.004). Diversion rates based on drug availability were 0.03 (tapentadol IR), 0.016 (tapentadol ER), and 0.172 (other Schedule II opioid tablets) per 1,000 prescriptions dispensed. The median street price per milligram was $0.18 (tapentadol IR), $0.10 (tapentadol ER), and $1.00 (other Schedule II opioid tablets). DISCUSSION: Our results indicate that tapentadol ER is rarely sold illicitly in the United States. When sold illicitly, tapentadol ER costs less than other Schedule II opioid products.

Has Previous Abuse of Flunitrazepam Been Replaced by Clonazepam?

BACKGROUND AND AIMS: For many years, flunitrazepam was the benzodiazepine of choice among users of illegal drugs. The aim of this study was to investigate to which extent clonazepam use has increased in this population, and whether this was related to increased prescription or because of illegal availability. METHODS: We used data from three sources to study the changes in the use of clonazepam: (1) Presence and concentrations of clonazepam and flunitrazepam in blood samples collected from Norwegian drugged drivers; (2) Sales numbers (legal market) for clonazepam, extracted from the Norwegian prescription database (NorPD), and (3) Specific seizures (illegal market) for clonazepam in Norway. RESULTS: In 2004, 13.0% of the analysed blood samples from drugged drivers contained clonazepam, whereas this proportion had increased to 27.7% in 2013. In the same period, the frequency of flunitrazepam in drugged drivers decreased from 16.6% in 2004 to 3.2% in 2013. The number of clonazepam prescriptions decreased, while the number of seized tablets containing clonazepam increased considerably from 2004 to 2013. CONCLUSIONS: For the last 10 years, a significant increase in the illegal use of clonazepam has been seen, now replacing flunitrazepam as the most used illegal benzodiazepine in Norway.

Use and diversion of medical marijuana among adults admitted to inpatient psychiatry.

BACKGROUND: Marijuana use is associated with anxiety, depressive, psychotic, neurocognitive, and substance use disorders. Many US states are legalizing marijuana for medical uses. OBJECTIVE: To determine the prevalence of medical marijuana use and diversion among psychiatric inpatients in Colorado. METHODS: Some 623 participants (54.6% male) responded to an anonymous 15-item discharge survey that assessed age, gender, marijuana use, possession of a medical marijuana card, diversion of medical marijuana, perceived substance use problems, and effects of marijuana use. Univariate statistics were used to characterize participants and their responses. Chi-square tests assessed factors associated with medical marijuana registration. RESULTS: Of the total number of respondents, 282 (47.6%) reported using marijuana in the last 12 months and 60 (15.1%) reported having a marijuana card. In comparison to survey respondents who denied having a medical marijuana card, those respondents with a medical marijuana card were more likely to have initiated use before the age of 25, to be male, to have used marijuana in the last 12 months, and to have used at least 20 days in the past month. 133 (24.1%) respondents reported that someone with a medical marijuana card had shared or sold medical marijuana to them; 24 (41.4%) of respondents with a medical marijuana card reported ever having shared or sold their medical marijuana. CONCLUSION: Medical marijuana use is much more prevalent among adults hospitalized with a psychiatric emergency than in the general population; diversion is common. Further studies which correlate amount, dose, duration, and strain of use with particular psychiatric disorders are needed.

Understanding the rural-urban differences in nonmedical prescription opioid use and abuse in the United States.

Nonmedical prescription opioid misuse remains a growing public problem in need of action and is concentrated in areas of US states with large rural populations such as Kentucky, West Virginia, Alaska, and Oklahoma. We developed hypotheses regarding the influence of 4 factors: (1) greater opioid prescription in rural areas, creating availability from which illegal markets can arise; (2) an out-migration of young adults; (3) greater rural social and kinship network connections, which may facilitate drug diversion and distribution; and (4) economic stressors that may create vulnerability to drug use more generally. A systematic consideration of the contexts that create differences in availability, access, and preferences is critical to understanding how drug use context varies across geography.

Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic.

An epidemic of drug overdose deaths has led to calls for programs and policies to limit misuse and diversion of opioid medications. Any parallel call to consider the risk of iatrogenic addiction when treating pain has been muted in comparison. We have moved beyond questions of nonmedical use, abuse, and diversion to highlight the role of prescription opioids in causing addiction even when prescribed and used appropriately. Unfortunately, current evidence is insufficient, and a rapid expansion of longitudinal research is urgently needed to guide clinicians in balancing the need for opioids with the risk of adverse consequences. Meanwhile, medical education should place greater emphasis on the abuse liability of prescription opioids, and providers should endeavor to attenuate risk when possible.

Prescription drug diversion among substance-impaired pharmacists.

BACKGROUND AND OBJECTIVES: Prescription drug addiction is a significant problem affecting healthcare professionals. The purpose of the present study was to identify common mechanisms of prescription drug diversion by pharmacists, in order to facilitate the development of effective prevention programs and policies for this high-risk group. METHODS: A total of 32 pharmacists (71% male) who were being monitored by their State professional health program (PHP) due to substance-related impairment participated in anonymous guided group discussions. RESULTS: Participants documented six primary methods of drug diversion by pharmacists: (1) taking expired drugs that can no longer be sold by the pharmacy and are awaiting disposal; (2) assuming responsibility for managing the pharmacy inventory and/or changing inventory records to prevent detection of missing drugs; (3) forging prescriptions for themselves, family members, friends, or customers in order to gain access to the drugs; (4) using "sleight of hand" techniques to acquire drugs while filling prescriptions or shelving products; (5) blatantly stealing drugs from the pharmacy, even in front of coworkers or video cameras, and (6) collecting patients' unused medications and keeping them. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Efforts to address the problem of prescription drug abuse and diversion by pharmacists should be expanded in order to safeguard pharmacies and the patients they serve. Future research should extend this study to larger samples and assess best practices for decreasing prescription drug diversion by pharmacists with addiction.

Collaboration or coercion? Partnering to divert prescription opioid medications.

Diversion of prescription opioids is a widespread problem in the USA. While "doctor shopping" and pill brokering are well-described types of medication diversion, we sought to understand the social dynamic of diversion of prescription opioids and identify other diversion methods. Using qualitative data collected as part of a 12-week Rapid Assessment and Response study of prescription opioid overdose and abuse (the RARx Study) conducted in three communities in two New England states, we reviewed and thematically coded 195 interviews. Diversion took many forms: doctor shopping, pill brokering, and, most commonly, siphoning from the family medicine chest. Partnering-of patients with other "patients," of patients with "caregivers"- to obtain prescription opioids was also described. Motivations for partnering indicated doing so out of fear of violence, for financial benefit, or in exchange for transportation or other services. Partnering for prescription opioids exhibited a range of power differentials, from collaboration to coercion, and tended to involve vulnerable populations such as the elderly, disabled, or destitute. Increased awareness among health providers of the ease of access and diversion of prescription opioids is needed to promote patient safety and prevent interpersonal violence.

Error and bias in the evaluation of prescription opioid misuse: should the FDA regulate clinical assessment tools?

BACKGROUND: Clinicians who prescribe chronic opioid therapy are concerned about identifying patients who are at-risk for misusing, abusing, or diverting (i.e. selling) their pain medications. Experts have specifically recommended using clinical assessment tools as part of a comprehensive plan for mitigating opioid-related risks. These tools are typically short, standardized questionnaires that screen for the presence or absence of putatively aberrant medication-related behaviors thought to be predictive of addiction. Interestingly, these tools remain wholly unregulated by the Food and Drug Administration (FDA) or other authorities. OBJECTIVE: This paper reviews how these instruments are used and the normative assumptions informing their use, fully appreciating that these screening tools do not have the power to diagnose illness or an addiction disorder. CONCLUSION: We conclude that these clinical assessment tools should be regulated because, as we will argue, any screening tool that can assess patients for the potential for opioid-related aberrant behaviors are powerful instruments that merit additional scrutiny and oversight--perhaps by the FDA and other regulatory agencies.

'Diversion' of methadone or buprenorphine: 'harm' versus 'helping'.

BACKGROUND: 'Non-compliant' individuals in opioid maintenance treatment, OMT, are often met with tight control regimes to reduce the risk of 'diversion', which may lead to harm or death among persons outside of OMT. This article explores reported practices of, and motivations for, diversion of methadone and buprenorphine, in a group of imprisoned individuals in OMT. FINDINGS: 28 in-depths interviews were conducted among 12 OMT-enrolled, imprisoned individuals, most of whom were remand prisoners. All had experienced tight control regimes prior to imprisonment due to varying degrees of 'non-compliance' and illicit drug use during treatment. Their acquired norm of sharing with others in a drug using community was maintained when entering OMT. Giving one's prescription opioids to an individual in withdrawal was indeed seen as an act of helping, something that takes on particular significance for couples in which only one partner is included in OMT and the other is using illicit heroin. Individuals enrolled in OMT might thus be trapped between practicing norms of helping and sharing and adhering to treatment regulations. 'Diversion', as this term is conventionally used, is not typically understood as practices of giving and helping, but may nevertheless be perceived as such by those who undertake them. CONCLUSIONS: As we see it, the need to sustain oneself as a decent person in one's own eyes and those of others through practices such as sharing and helping should be recognized. Treatment providers should consider including couples in which both individuals are motivated for starting OMT.

Prevalence and correlates of prescription drug diversion and misuse among people living with HIV in the eThekwini district, KwaZulu-Natal, South Africa.

BACKGROUND: Prescription drug diversion, and misuse has increased over the past decade and is notably in high-income-countries and significantly contributes to the opioid epidemic. People living with HIV (PLWH) are particularly vulnerable to prescription drug diversion, and misuse as most experience chronic pain, mental health problems and HIV-related illnesses. The researchers investigated the prevalence and correlates of prescription drug diversion, and misuse among PLWH in the eThekwini district, KwaZulu-Natal. METHODS: A cross-sectional study was conducted among 392 PLWH, conveniently recruited from the public healthcare facilities located in rural, semi-urban and urban areas of the eThekwini district. Participants answered questions about their background, prescription medications, substance use, and prescription drug diversion, and misuse. Descriptive analysis was performed to estimate the prevalence of prescription drug diversion, and misuse. Multivariable logistic regression was used to identify predictors of prescription drug diversion, and misuse. FINDINGS: Overall, 13% of the participants reported lifetime prescription drug diversion. The most common type of diversion was using prescription medication not prescribed by a healthcare provider (11%), followed by sharing of prescription medication (9%) and buying prescription medication without a medical script (5%). Twenty-three per cent of the participants reported prescription drug misuse in the past 90 days, with using prescription medication without a healthcare providers' guidance (9%) and not following the scheduled time periods (8%) being the most common reported types of misuse. Self-medicating was identified as a risk factor for prescription drug misuse. There was no association between ART adherence and prescription drug diversion, and misuse. CONCLUSION: The study findings contribute to improving the limited data available on prescription drug diversion, and misuse among PLWH in South Africa. The prevalence underscores a need for urgent interventions when prescribing medications with potential risks. Addressing the risk of self-medicating is imperative for HIV care outcomes and to avert death.

Revising our attitudes towards agonist medications and their diversion in a time of pandemic.

The COVID-19 pandemic led government regulators to relax prescribing rules for buprenorphine and methadone, the agonist medications that effectively treat opioid use disorder, allowing for take home supplies of up to 28 days. These changes prioritized the availability of these medications over concerns about their misuse and diversion, and they provided a means for overdose prophylaxis during the highly uncertain conditions of the pandemic. In considering how to capitalize on this shift, research should determine the extent to which increased diversion has occurred as a result, and what the consequences may have been. The shifts also set the stage to consider if methadone can be safely prescribed in primary care settings, and if the monthly injectable formulation of buprenorphine is a suitable alternative to increased supplies of sublingual strips if concerns about diversion persist. The disruptions of the pandemic have caused a surge in overdose deaths, so carefully considering the prophylactic potential of agonist medications, in addition to their role as a treatment, may help us address this mortality crisis.

Prevalence of ADHD symptom malingering, nonmedical use, and drug diversion among college-enrolled adults with a prescription for stimulant medications.

Malingering of ADHD symptoms is a potential means of nonmedical use of prescription stimulants (NMUPS). The Subtle ADHD Malingering Screener (SAMS) provides a potential avenue for identification of symptom malingering. However, no real world evidence of this scale has been published to date. The goal of this study was to examine patterns of use of stimulant prescriptions and to evaluate the ability of the SAMS to identify NMUPS. This study employed a cross-sectional observational design to administer an online, self-administered survey instrument in a convenience sample of college-enrolled young adults with a prescription for stimulant medications at a campus pharmacy. Respondents were asked about their prescription characteristics, nonmedical use and drug diversion behavior, along with ratings on the SAMS. Over 33% of respondents self-reported past-year NMUPS and 18% reported past-year drug diversion. Over 35% of respondents rated NMUPS as being slight or no risk and 55% were classified by the SAMS as likely to be malingering or exaggerating their symptoms. Individuals reporting past-year NMUPS or diversion consistently scored higher on the SAMS. The SAMS showed potential for future application in the pharmacy setting. Further research is needed to evaluate the relationship of SAMS to NMUPS or drug diversion. The results of this study also highlight several growing issues with the diagnosis and treatment of ADHD among young adults enrolled in college. Addressing perception of risk, social norms, and providing healthcare professionals with tools to prevent misdiagnosis is critical to the management of this issue.