Opioid prescription following radical orchiectomy associated with new persistent opioid use.

INTRODUCTION: Opioid dependence represents a public health crisis and can be observed after outpatient urologic procedures. The purpose of this study was to evaluate the risk of persistent opioid usage after radical orchiectomy for testicular cancer. MATERIALS AND METHODS: The TriNetX Research network database was queried for men between 15 and 45 years undergoing radical orchiectomy for a diagnosis of testicular cancer. All patients with N+ or M+ disease, prior opioid use, and patients who underwent chemotherapy, radiotherapy, or retroperitoneal lymph node dissection were excluded. Patients were stratified whether they were prescribed opioids or not at time of orchiectomy. The incidence of new, persistent opioid use, defined as a prescription for opioids between 3 and 15 months after orchiectomy, was evaluated. RESULTS: A total of 2,911 men underwent radical orchiectomy for testicular cancer, of which 89.8% were prescribed opioids at time of orchiectomy. After propensity score matching for age, race, and history of psychiatric diagnosis, 592 patients were included (296 received opioids, 296 did not). Overall, 0% of patients who did not receive postoperative opioids developed new persistent opioid use, whereas 10.5% of patients who received postoperative opioids developed new persistent opioid use. Patients prescribed postoperative opioids for orchiectomy had statistically higher risk difference of developing new persistent opioid use (Risk Difference: 10.5%; 95% CI: 7.0-14.0; Z: 5.7; P < 0.01). CONCLUSIONS: Postoperative opioid prescription following radical orchiectomy is significantly associated with developing new persistent opioid use, with 1 in 10 young men who received postoperative opioids obtaining a new prescription for opioids well beyond the postoperative period. Future efforts should emphasize nonopioid pathways for pain control following this generally minor procedure.

Drug Overdose Death Following Substance Use Disorder Treatment Termination in New York City: A Retrospective Longitudinal Cohort Study.

Drug overdose death rates are the highest recorded in New York City (NYC). Substance use disorder (SUD) treatment termination can confer increased risk of drug overdose death. Our objective was to determine the probability of, and factors associated with, drug overdose death following SUD treatment termination. Using a retrospective longitudinal cohort design, we identified those who had NYC-based SUD treatment terminated (01/2016-06/2019) using Chief Medical Examiner and SUD treatment data. Using survival analyses, we examined drug overdose deaths ≤ 14 and ≤ 90 days following SUD treatment termination, respectively. Of 51,171 patients with SUD treatment termination, 140 and 342 had a drug overdose death < 14 and ≤ 90 days, respectively. The crude drug overdose death rate was 26.7 per 1000 person-years at-risk in the ≤ 90-day period and was 71.6 per 1000 person-years at-risk in the ≤ 14-day period. In adjusted Cox proportional hazard model examining death ≤ 14 days, those unemployed (compared to employed) and those terminated from residential treatment (compared to medically supervised withdrawal, opioid treatment programs, and outpatient treatment) were more likely to have had a drug overdose death (all p-values < 0.01). In adjusted Cox proportional hazard model examining death ≤ 90 days, non-Hispanic White people (compared to non-Hispanic Black people), those not stably housed (compared to stably housed), those unemployed and those terminated from residential treatment were more likely to have had a drug overdose death (all p-values < 0.01). Strategies to improve retention including the reassessment of program treatment termination criteria along with strategies to promote ongoing OUD treatment, engagement in harm reduction, and distribution of naloxone are needed.

Federal opioid agonist therapy policy: interrupted time series analysis of the impact of the methadone exemption removal across eight provinces in Canada.

BACKGROUND: Federal deregulation of opioid agonist therapies are an attractive policy option to improve access to opioid use disorder care and achieve widespread beneficial impacts on growing opioid-related harms. There have been few evaluations of such policy interventions and understanding effects can help policy planning across jurisdictions. METHODS: Using health administrative data from eight of ten Canadian provinces, this study evaluated the impacts of Health Canada's decision in May 2018 to rescind the requirement for Canadian health professionals to obtain an exemption from the Canadian Drugs and Substance Act to prescribe methadone for opioid use disorder. Over the study period of June 2017 to May 2019, we used descriptive statistics to capture overall trends in the number of agonist therapy prescribers across provinces and we used interrupted time series analysis to determine the effect of this decision on the trajectories of the agonist therapy prescribing workforces. RESULTS: There were important baseline differences in the numbers of agonist therapy prescribers. The province with the highest concentration of prescribers had 7.5 more prescribers per 100,000 residents compared to the province with the lowest. All provinces showed encouraging growth in the number of prescribers through the study period, though the fastest growing province grew 4.5 times more than the slowest. Interrupted time series analyses demonstrated a range of effects of the federal policy intervention on the provinces, from clearly positive changes to possibly negative effects. CONCLUSIONS: Federal drug regulation policy change interacted in complex ways with provincial health professional regulation and healthcare delivery, kaleidoscoping the effects of federal policy intervention. For Canada and other health systems such as the US, federal policy must account for significant subnational variation in OUD epidemiology and drug regulation to maximize intended beneficial effects and mitigate the risks of negative effects.

Medicaid expansion and opioid prescriptions: Evidence from the Medical Expenditure Panel Survey.

Evidence is mixed on whether increased access to insurance, specifically through the ACA's Medicaid expansion, exacerbated the opioid public health crisis through increased opioid prescribing. Using survey data on retail prescription drug fills from 2008 to 2019, we did not find a significant relationship between Medicaid expansion and opioid prescribing in the newly eligible Medicaid population. It may be that the dangers of opioids were known well enough by the time of the Medicaid expansion that lack of access to care was no longer a binding constraint on opioid prescription receipt.

Impact of opioid overdoses on US life expectancy and years of life lost, by demographic group and stimulant co-involvement: a mortality data analysis from 2019 to 2022.

Background: The United States' opioid crisis is worsening, with the number of deaths reaching 81,806 in 2022 after more than tripling over the past decade. This study aimed to comprehensively characterize changes in burden of opioid overdose mortality in terms of life expectancy reduction and years of life lost between 2019 and 2022, including differential burden across demographic groups and the contribution of polysubstance use. Methods: Using life tables and counts for all-cause and opioid overdose deaths from the National Center for Health Statistics, we constructed cause-eliminated life tables to estimate mortality by age in the absence of opioid-related deaths. We calculated the loss in life expectancy at birth (LLE) and total years of life lost (YLL) due to opioid overdose deaths by state of residency, sex, racial/ethnic group, and co-involvement of cocaine and psychostimulants. Findings: Opioid-related deaths in the US led to an estimated 3.1 million years of life lost in 2022 (38 years per death), compared to 2.0 million years lost in 2019. Relative to a scenario with no opioid mortality, we estimate that opioid-related deaths reduced life expectancy nationally by 0.67 years in 2022 vs 0.52 years in 2019. This LLE worsened in all racial/ethnic groups during the study period: 0.76 y-0.96 y for white men, 0.36 y-0.55 y for white women, 0.59 y-1.1 y for Black men, 0.27 y-0.53 y for Black women, 0.31 y-0.82 y for Hispanic men, 0.19 y-0.31 y for Hispanic women, 0.62 y-1.5 y for American Indian/Alaska Native (AI/AN) men, 0.43 y-1 y for AI/AN women, 0.09 y-0.2 y for Asian men, and 0.08 y-0.13 y for Asian women. Nearly all states experienced an increase in years of life lost (YLL) per capita from 2019 to 2022, with YLL more than doubling in 16 states. Cocaine or psychostimulants with abuse potential (incl. methamphetamines) were involved in half of all deaths and years of life lost in 2022, with substantial variation in the predominant drug class by state and racial/ethnic group. Interpretation: The burden of opioid-related mortality increased dramatically in the US between 2019 and 2022, coinciding with the period of the COVID-19 pandemic and the associated disruptions to social, economic, and health systems. Opioid overdose deaths are an important contributor to decreasing US life expectancy, and Black, Hispanic, and Native Americans now experience mortality burdens approaching or exceeding white Americans. Funding: None.

Opioid-related deaths in Northern Ontario in the early COVID-19 pandemic period.

OBJECTIVES: In the first year of pandemic measures, opioid-related deaths across Ontario's (ON) 34 public health units (PHUs) increased by 60%. Death rates for all seven Northern ON PHUs were above the provincial average. This study describes and compares factors surrounding opioid-related deaths before and after pandemic measures were introduced, for Northern ON compared to the rest of ON. METHODS: Aggregate data were provided for Northern ON and the rest of the province by the Office of the Chief Coroner/Ontario Forensic Pathology Services. Opioid-related deaths were cohorted by date of death for the year before and after pandemic measures were introduced on March 16, 2020. Chi-square tests were used to compare between cohorts and geographies to determine significant differences for each variable, and for dichotomized levels within variables. P-values < 0.05 were considered statistically significant a priori. RESULTS: In Northern ON, the number of opioid-related deaths approximately doubled from the pre-pandemic cohort (n = 185) to the early pandemic cohort (n = 365). Compared to the rest of ON, higher proportions of deaths occurred in Northern ON among individuals who lived and died in private residences, among women (although the majority of decedents were male) and among individuals employed in mining, quarrying, and oil and gas industries. Compared to the pre-pandemic year, in Northern ON, higher proportions of opioid-related deaths involved fentanyl and stimulants as direct contributors, and the majority involved evidence of inhaled drugs. CONCLUSION: Differences between the circumstances of death in Northern ON and in the rest of ON suggest opportunities to tailor interventions.

RéSUMé: OBJECTIFS: Au cours de la première année des mesures de lutte contre la pandémie, les décès liés aux opioïdes dans les 34 bureaux de santé publique (BSP) de l'Ontario ont augmenté de 60 %. Les taux de mortalité dans les sept unités de santé publique du Nord de l'Ontario étaient plus élevés de la moyenne provinciale. Cette étude décrit et compare les facteurs entourant les décès liés aux opioïdes avant et après l'introduction des mesures de lutte contre la pandémie, dans le Nord de l'Ontario par rapport au reste de la province. MéTHODES: Les données pour le Nord de l'Ontario et le reste de la province ont été fournies par le Bureau du coroner en chef/Service de médecine légale de l'Ontario. Les décès liés aux opioïdes ont été classés par date de décès pour l'année précédant et suivant l'introduction des mesures de lutte contre la pandémie le 16 mars 2020. Des tests du khi carré ont été utilisés pour comparer les cohortes et les zones géographiques afin de déterminer les différences significatives pour chaque variable et pour les niveaux dichotomisés au sein des variables. Les valeurs p < 0,05 ont été considérées statistiquement significatives. RéSULTATS: Dans le Nord de l'Ontario, le nombre de décès liés aux opioïdes a approximativement doublé entre la cohorte prépandémique (n=185) et la cohorte du début de la pandémie (n=365). Comparativement au reste de l'Ontario, des proportions plus élevées de décès sont survenus dans le Nord de l'Ontario chez les personnes qui vivaient et sont décédées dans des résidences privées, chez les femmes (bien que la majorité des personnes décédées étaient des hommes) et chez les personnes employées dans les mines, les carrières et les industries pétrolières et gazières. Comparativement à l'année prépandémique, dans le Nord de l'Ontario, des proportions plus élevées de décès liés aux opioïdes impliquaient le fentanyl et les stimulants comme contributeurs directs, et la majorité d'entre eux impliquaient des preuves de drogues inhalées. CONCLUSION: Les différences entre les circonstances des décès dans le Nord de l'Ontario et dans le reste de la province suggèrent des possibilités d'adapter les interventions.

Fentanyl-Related Deaths in Ontario, Canada: Toxicological Findings and Circumstances of Death in 4395 Cases (2020-2022).

Over the last 20 years there has been a significant increase in fentanyl related deaths in Ontario, Canada. This report examines toxicological findings in a series of death investigations in which fentanyl was quantitated to identify the prevalence, trends and demographic data associated with fentanyl in Ontario, Canada, and to highlight the changes in these trends since fentanyl began appearing in casework in Ontario in the early 2000s. A retrospective study of all cases in which fentanyl was quantitated in blood, using liquid chromatography-tandem mass spectrometry, was conducted for the time period between January 1, 2020, and December 31, 2022. A total of 4395 cases were included, 77% of the decedents were male and 23% were female with ages ranging from 0 to 95. The most frequently classified cause of death was mixed drug toxicity (69%) followed by fentanyl intoxication at 19%. Less than 10% of cases where fentanyl was quantitated were classified as non-drug related deaths. Fentanyl concentrations in all cases ranged from 1.3 to > 2000 ng/mL. Other drugs were frequently detected with fentanyl. In mixed drug toxicity cases, stimulants were the most frequently encountered class of drugs: cocaine was identified in 51.8% and methamphetamine was observed in 43.0% of cases, respectively. Detailed reports for select cases were included to provide additional insight into the different case types and to show the difficulty in interpreting blood concentrations without additional detailed case histories. This study provides valuable information for the scientific and medical community regarding the continued use of fentanyl and how patterns of fentanyl use have evolved since it began to appear in forensic casework.

Dose-specific clinical outcomes in patients with opioid use disorder treated with 24-32 mg/day of buprenorphine.

BACKGROUND/AIMS: In people with opioid use disorder (OUD), buprenorphine is a vital treatment to decrease opioid use and overdose. The US Food and Drug Administration's prescribing information for buprenorphine advises dosing up to 24 mg/day; however, doses of buprenorphine up to 32 mg have been shown to be safe and effective. We compared outcomes associated increased dosing from 24 to 32 mg/day. DESIGN: Prospective cohort investigation. SETTING: Low-barrier buprenorphine clinic in Washington, District of Columbia, USA. PARTICIPANTS: Participants in the ANCHOR study (people with hepatitis C virus (HCV), OUD, and active opioid misuse who were treated for HCV and offered buprenorphine) who received buprenorphine at doses of 24 and/or 32 mg/day. 72 participants were included in the analysis: 24 (33%) patients stabilized on 24 mg, and 48 (67%) patients stabilized on 32 mg. Patients were predominantly male (78%), Black (96%), unstably housed (57%), and used opioids by injection (93%). MEASUREMENTS: Patient-reported drug use, use frequency, triggers for use, and urine drug screens were collected at each visit. For analysis, the cohort was divided into individuals stabilized on 24 mg (24 mg cohort) or 32 mg (32 mg cohort). Drug use outcomes were assessed between cohorts at 24 mg dosing and at respective maximum dosing. Within the 32 mg cohort, outcomes were compared at 24 mg versus 32 mg dosing. FINDINGS: Within the 32 mg cohort, increased dosing from 24 to 32 mg was associated with a decline in opioid use (68.5% [5.2%] at 24 mg vs 59.5% [5.6%] at 32 mg; P = 0.02), frequency of use per week (1.58 [0.19] at 24 mg vs. 1.15 [0.16] at 32 mg; P = 0.0002) and physiologic triggers for use (38.2% [6.0%] at 24 mg vs 7.0% [1.9%] at 32 mg; P < 0.0001). At the end of the study period, there were significantly more patients retained in the 32 mg cohort (78.7%) compared with the 24 mg cohort (50.0%, P = 0.02). CONCLUSION: Higher buprenorphine dosing (32 mg/day) appears to improve outcomes in people with opioid use disorder, even in the absence of abstinence.

The Opioid Epidemic and Faith-Based Responses in Southern Appalachia, USA: An Exploration of Factors for Successful Cross-Sector Collaboration.

This study aimed to identify factors for successful cross-sector collaboration with faith-based responses to the opioid epidemic in southern Appalachia. In-depth interviews were conducted with representatives from organizations responding to the opioid epidemic (N = 25) and persons who have experienced opioid dependency (N = 11). Stakeholders perceived that collaboration is hindered by stigma, poor communication, and conflicting medical and spiritual approaches to opioid dependency. Collaborations are facilitated by cultivating compassion and trust, sharing information along relational lines, and discerning shared commitments while respecting different approaches. The study concludes with theoretical and practical implications for both religious leaders and potential cross-sector collaborators.

Reducing perceived barriers to scaling up overdose education and naloxone distribution and medications for opioid use disorder in the United States in the HEALing (Helping End Addiction Long-Term®) communities study.

BACKGROUND: Scaling up overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) is needed to reduce opioid overdose deaths, but barriers are pervasive. This study examines whether the Communities That HEAL (CTH) intervention reduced perceived barriers to expanding OEND and MOUD in healthcare/behavioral health, criminal-legal, and other/non-traditional venues. METHODS: The HEALing (Helping End Addiction Long-Term®) Communities Study is a parallel, wait-list, cluster randomized trial testing the CTH intervention in 67 communities in the United States. Surveys administered to coalition members and key stakeholders measured the magnitude of perceived barriers to scaling up OEND and MOUD in November 2019-January 2020, May-June 2021, and May-June 2022. Multilevel linear mixed models compared Wave 1 (intervention) and Wave 2 (wait-list control) respondents. Interactions by rural/urban status and research site were tested. RESULTS: Wave 1 respondents reported significantly greater reductions in mean scores for three outcomes: perceived barriers to scaling up OEND in Healthcare/Behavioral Health Venues (-0.26, 95% confidence interval, CI: -0.48, -0.05, p = 0.015), OEND in Other/Non-traditional Venues (-0.53, 95% CI: - 0.84, -0.22, p = 0.001) and MOUD in Other/Non-traditional Venues (-0.34, 95% CI: -0.62, -0.05, p = 0.020). There were significant interactions by research site for perceived barriers to scaling up OEND and MOUD in Criminal-Legal Venues. There were no significant interactions by rural/urban status. DISCUSSION: The CTH Intervention reduced perceived barriers to scaling up OEND and MOUD in certain venues, with no difference in effectiveness between rural and urban communities. More research is needed to understand facilitators and barriers in different venues.

Dangerous Variation or Patient-Centered Care? Palliative Care and Pain Providers' Comfort, Experiences, and Approaches when Treating Cancer Pain With Coexisting Aberrant Behaviors.

BACKGROUND: Patients with cancer-related pain are at high risk for aberrant drug use behaviors (ADB), including self-escalation, diversion and concurrent illicit substance or opioid misuse; however, limited evidence is available to guide opioid prescribing for patients with life-limiting illness and concurrent or suspected ADB. We sought to characterize how specialists evaluate for and manage these high-risk behaviors in patients with cancer-related pain. METHODS: We conducted telephonic semi-structured interviews with palliative care and pain medicine providers. Participants discussed their own comfort and experience level with identifying and managing ADB in patients with life-limiting illness. They were subsequently presented with a series of standardized scenarios and asked to describe their concerns and management strategies. RESULTS: 95 interdisciplinary pain and palliative care specialists were contacted; 37 agreed to participate (38.9%). Analysis of interview contents revealed several central themes: (1) widespread discomfort and anxiety regarding safe and compassionate opioid prescribing for high-risk patients, (2) belief that widely used risk-mitigation tools such as opioid contracts and urine drug screens provided inadequate support for decision-making, and (3) lack of institutional and organizational support and guidance for safe prescribing strategies. Most clinicians reported self-education regarding addiction and alternative prescribing/pain management strategies. Providers varied widely in their willingness to discontinue opioid prescribing in a patient with aberrant behavior and pain associated with life-limiting illness. CONCLUSION: Providers caring for patients demonstrating ADB and cancer-related pain struggle to balance safe prescribing with symptom management. Increased guidance is needed regarding opioid prescribing, monitoring, and discontinuation in high-risk patients.

The Opioid Industry Documents Archive: Advancing Public Health Through Industry Document Disclosure.

More than twenty-five years after the first signs of potential harm, the US remains locked in the grip of an opioid epidemic, with more Americans dying from overdoses than ever before.1 Diversion of prescription opioids plays an important role in opioid-related harms. Much of the scientific and public health focus on diversion has been on end-users, given how commonly non-medical prescription opioid use occurs, as well as the proportion of individuals who report that their source of non-medical opioids was friends or family. However, diversion of opioids, as well as their rampant oversupply, can be discerned higher up the supply chain, including among wholesalers, pharmacies and rogue prescribers whose behavior may trigger well-described "flags" warranting further evaluation and action.

How Ohio public library systems respond to opioid-related substance use: a descriptive analysis of survey results.

BACKGROUND: Public libraries in the United States have experienced increases in opioid-related substance use in their communities and on their premises. This includes fatal and non-fatal overdose events. Some libraries have adopted response measures in their branches to deter substance use or prevent overdose. A small number of libraries around the nation have decided to stock the opioid antagonist naloxone (Narcan) for staff to administer to patrons who experience overdose. This response measure has generated extensive media attention. Although Ohio ranks fourth in age-adjusted drug mortality rate in the United States, there has been no investigation of whether Ohio libraries are observing opioid-related transactions, consumption, and/or overdose events, or which measures they have adopted in response to these activities. We conducted a multimethod survey with Ohio public library directors to identify the response measures they have adopted. We present descriptive findings from the quantitative and qualitative items in our survey. METHODS: We conducted a cross-sectional 54-item multimethod survey of public library system directors (one per system) in Ohio. Directors of each of Ohio's public library systems were invited to participate via email. RESULTS: Of 251 library systems, 56 responded (22.3% response rate), with 34 respondents (60.7%) indicating awareness of opioid-related transactions, consumption, and/or overdose on their premises. Most (n = 43, 76.8%) did not stock naloxone in their buildings. Over half (n = 34, 60.7%) reported implementing one or more non-naloxone response measures. These measures focus on improving security for staff and patrons, deterring opioid-related transactions (purchases and exchanges) and consumption, and providing educational events on substance use. Nearly half (n = 25, 47.2%) partner with community organizations to provide opioid response measures. A similar proportion reported adequate funding to respond to opioid-related substance use (n = 23, 45.1%), and most (n = 38, 74.5%) reported adequate support from their boards and communities. Few respondents have implemented evaluations of their response measures. CONCLUSIONS: Ohio public libraries are responding to evidence of opioid-related transactions, consumption, and/or overdose on their premises with a range of measures that focus on substance use prevention and deterrence. Most Ohio library systems do not stock naloxone. Respondents indicated they prefer to call 911 and let first responders handle overdose events. The majority of respondents indicated their library systems have political capacity to respond to evidence of opioid-related substance use on their premises, but have limited operational and functional capacity. Findings suggest the need to revisit assumptions that public libraries are willing to stock naloxone to respond to overdose events, and that libraries have the resources to respond robustly to opioid-related transactions, consumption, and/or overdose on their premises.

The impact of more restrictive hydrocodone rescheduling on unintentional pediatric opioid exposures.

PURPOSE: To evaluate the impact of rescheduling hydrocodone combination products (HCPs) from schedule III of the Controlled Substances Act to the more restrictive schedule II on unintentional pediatric exposures (≤5 years old). METHODS: Using U.S. data on outpatient retail pharmacy dispensing, emergency department (ED) visits, and poison center (PC) exposure cases, we assessed trends in prescriptions dispensed and unintentional pediatric exposure cases involving hydrocodone (rescheduled from III to II) compared to oxycodone (schedule II) and codeine (schedule III for combination products) using descriptive and interrupted time-series (ITS) analyses during the 16 quarters before and after the October 2014 rescheduling of HCPs. RESULTS: Dispensing of hydrocodone products was declining before rescheduling but declined more steeply post-rescheduling. In ITS analyses, both hydrocodone and oxycodone had significant slope decreases in PC case rates in the post versus pre-period that was larger for hydrocodone, while codeine had a small but significant slope increase in PC case rates. An estimated 4202 ED visits for pediatric hydrocodone exposures occurred in the pre-period and 2090 visits occurred in the post-period, a significant decrease of 50.3%. Oxycodone exposures showed no significant decrease. CONCLUSIONS: Pediatric hydrocodone unintentional exposure ED visits and PC cases decreased after HCP rescheduling more than would be expected had the pre-rescheduling trend continued; the acceleration in the decrease in hydrocodone PC cases was partially offset by a slowing in the decrease in codeine-involved cases. The trend changes were likely due to multiple factors, including changes in dispensing that followed the rescheduling. Unintentional pediatric medication exposures and poisonings remain a public health concern requiring ongoing, multifaceted mitigation efforts.

Fentanyl and its derivatives: Pain-killers or man-killers?

Fentanyl is a synthetic µ-opioid receptor agonist approved to treat severe to moderate pain with faster onset of action and about 100 times more potent than morphine. Over last two decades, abuse of fentanyl and its derivatives has an increased trend, globally. Currently, the United States (US) faces the most serious situation related to fentanyl overdose, commonly referred to as the opioid epidemic. Nowadays, fentanyl is considered as the number one cause of death for adults aged 18-45 in the US. Synthesis and derivatization of fentanyl is inexpensive to manufacture and easily achievable. Indeed, more than 1400 fentanyl derivatives have been described in the scientific literature and patents. In addition, accessibility and efficacy of fentanyl and its derivatives can play a potential role in misuse of these compounds as a chemical weapon. In this review, the properties, general pharmacology, and overdose death cases associated with fentanyl and selected derivatives are presented. Moreover, current opioid epidemic in the US, Moscow theatre hostage crisis, and potential misuse of fentanyl and its derivatives as a chemical weapon are disclosed.

Predictors of persistent opioid use in bladder cancer patients undergoing radical cystectomy: A SEER-Medicare analysis.

PURPOSE: To evaluate patient and provider characteristics that predict persistent opioid use following radical cystectomy for bladder cancer including non-opioid naïve patients. METHODS: Patients undergoing cystectomy between July 2007 and December 2015 were identified using the SEER-Medicare database. Opioid exposure was identified before and after cystectomy using Medicare Part D data. Multivariable analyses were used to identify predictors of the primary outcomes: persistent opioid use (prescription 3-6 months after surgery) and postoperative opioid prescriptions (within 30 days of surgery). Secondary outcomes included physician prescribing practices and rates of persistent opioid use in their patient cohorts. RESULTS: A total of 1,774 patients were included; 29% had prior opioid exposure. Compared to opioid-naïve patients, non-opioid naïve patients were more frequently younger, Black, and living in less educated communities. The percentage of persistent postoperative use was 10% overall and 24% in non-opioid naïve patients. Adjusting for patient factors, opioid naïve individuals were less likely to develop persistent use (OR 0.23) while a 50-unit increase in oral morphine equivalent per day prescribed following surgery nearly doubled the likelihood of persistent use (OR 1.98). Practice factors such as hospital size, teaching affiliation, and hospital ownership failed to predict persistent use. 29% of patients filled an opioid prescription postoperatively. Opioid naïve patients (OR 0.13) and those cared for at government hospitals (OR 0.59) were less likely to fill an opioid script along with those residing in the Northeast. Variability between physicians was seen in prescribing practices and rates of persistent use. CONCLUSIONS: Non-opioid naïve patients have higher rates of post-operative opioid prescription than opioid-naïve patients. Physician prescribing practices play a role in persistent use, as initial prescription amount predicts persistent use even in non-opioid naïve patients. Significant physician variation in both prescribing practices and rates of persistent use suggest a role for standardizing practices.

Moving forward with pain: an interview with John D Loeser.

John D Loeser speaks to Thomas York, Journal Development Editor of Pain Management. John D Loeser is Professor, emeritus, of Neurological Surgery and Anesthesiology and Pain Medicine at the University of Washington where he has been a faculty member since 1969. He was the Director of the Multidisciplinary Pain Center at the University of Washington from 1983 to 1997. He has been active in research, teaching and patient care in the field of Pain Management for over 45 years. He was a founding member and served as president of the American Pain Society and the International Association for the Study of Pain. He has authored or co-authored over 400 peer-reviewed articles, 129 book chapters and 8 books. He is particularly interested in multidisciplinary pain management and the development of rational strategies for the treatment of patients with chronic pain.

Piloting an Opioid Risk Screening Tool in Clinical Practice.

Background: Despite much research and many interventions, the opioid epidemic continues to plague the United States. According to the Centers for Disease Control and Prevention (2021), 136 people die daily from both prescription and illicit opioids. Objective: The goal of this pilot quality improvement project is to examine how the implementation of the Opioid Risk Tool (ORT) in clinical practice might impact the beliefs and attitudes of nurse practitioners (NPs) toward prescribing opioid therapy. Methods: A pre-post design was utilized. A convenience sample recruited participants from a private NP Facebook group. The intervention included a prerecorded presentation on the ORT and the use of the ORT for 8 weeks. Results: While 46 NPs completed the presurvey, only 19 NPs completed the postsurvey. Statistical results did not yield significance, but there were several significant clinical trends discovered. Conclusion: Utilizing the ORT to screen for opioid misuse risks has been shown to improve providers' confidence in opioid prescribing. ORT guides providers in discerning patient risk for developing dependence on opioids. Implications for Nursing: Screening for opioid misuse risk is feasible. ORT adds to the clinical context in deciding a course of treatment in pain management.

Acute opioid overdose in pediatric patients.

Recent increases in pediatric and adolescent opioid fatalities mandate an urgent need for early consideration of possible opioid exposure and specific diagnostic and management strategies and interventions tailored to these unique populations. In contrast to adults, pediatric methods of exposure include accidental ingestions, prescription misuse, and household exposure. Early recognition, appropriate diagnostic evaluation, along with specialized treatment for opioid toxicity in this demographic are discussed. A key focus is on Naloxone, an essential medication for opioid intoxication, addressing its unique challenges in pediatric use. Unique pediatric considerations include recognition of accidental ingestions in our youngest population, critical social aspects including home safety and intentional exposure, and harm reduction strategies, mainly through Naloxone distribution and education on safe medication practices. It calls for a multifaceted approach, including creating pediatric-specific guidelines, to combat the opioid crisis among children and to work to lower morbidity and mortality from opioid overdoses.