Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain.

BACKGROUND: After decades of increased opioid pain reliever prescribing, providers are rapidly reducing prescribing. We hypothesized that reduced access to prescribed opioid pain relievers among patients previously reliant upon opioid pain relievers would result in increased illicit opioid use. METHODS AND FINDINGS: We conducted a retrospective cohort study among 602 publicly insured primary care patients who had been prescribed opioids for chronic non-cancer pain for at least three consecutive months in San Francisco, recruited through convenience sampling. We conducted a historical reconstruction interview and medical chart abstraction focused on illicit substance use and opioid pain reliever prescriptions, respectively, from 2012 through the interview date in 2017-2018. We used a nested-cohort design, in which patients were classified, based on opioid pain reliever dose change, into a series of nested cohorts starting with each follow-up quarter. Using continuation-ratio models, we estimated associations between opioid prescription discontinuation or 30% increase or decrease in dose, relative to no change, and subsequent frequency of heroin and non-prescribed opioid pain reliever use, separately. Models controlled for demographics, clinical and behavioral characteristics, and past use of heroin or non-prescribed opioid pain relievers. A total of 56,372 and 56,484 participant-quarter observations were included from the 597 and 598 participants available for analyses of heroin and non-prescribed opioid pain reliever outcomes, respectively. Participants discontinued from prescribed opioids were more likely to use heroin (Adjusted Odds Ratio (AOR) = 1.57, 95% CI: 1.25-1.97) and non-prescribed opioid pain relievers (AOR = 1.75, 1.45-2.11) more frequently in subsequent quarters compared to participants with unchanged opioid prescriptions. Participants whose opioid pain reliever dose increased were more likely to use heroin more frequently (AOR = 1.67, 1.32-2.12). Results held throughout sensitivity analyses. The main limitations were the observational nature of results and limited generalizability beyond safety-net settings. CONCLUSIONS: Discontinuation of prescribed opioid pain relievers was associated with more frequent non-prescribed opioid pain reliever and heroin use; increased dose was also associated with more frequent heroin use. Clinicians should be aware of these risks in determining pain management approaches.

"Chasing the pain relief, not the high": Experiences managing pain after opioid reductions among patients with HIV and a history of substance use.

BACKGROUND: Opioid overdose mortality continues to increase in the United States despite significant investments to reverse the epidemic. The national response to-date has focused primarily on reducing opioid prescribing, yet reductions in prescribing have been associated with patients reporting uncontrolled pain, psychological distress, and transition to illicit substances. The aim of this study is to qualitatively explore chronic pain management experiences among PLWH with a history of illicit substance use after long-term opioid therapy reductions or discontinuations. METHODS: We analyzed 18 interviews, stopping upon reaching thematic saturation, with HIV-positive participants with a history of substance use who were enrolled in a longitudinal cohort study to assess the impact of prescribing changes among patients with chronic pain. Participants in this nested qualitative study had been reduced/discontinued from opioid pain relievers (OPRs) within the 12 months prior to interview. Interviews were audio-recorded and transcribed verbatim. Two analysts coded all interviews, interrater reliability was measured, and coding discrepancies discussed. The study took place in San Francisco, California in 2018. RESULTS: Eleven participants were male with a mean age of 55; 8 were African American and 8 were White. All participants were HIV-positive, actively engaged in primary care, and had a lifetime history of illicit substance use. Twelve reported using illicit substances within the past year, including non-prescription opioids/heroin (10), and stimulant use (10). After being reduced/discontinued from their long-term opioid therapy, patients reported developing complex multimodal pain management systems that often included both nonpharmacological approaches and illicit substance use. Participants encountered a range of barriers to nonpharmacological therapies including issues related to accessibility and availability. Participants often reported attempts to replicate their prior OPR prescription by seeking out the same medication and dose from illicit sources and reported transitioning to heroin after exhausting other options. CONCLUSION: After being reduced/discontinued from OPRs, HIV-positive patients with a history of substance use reported experimenting with a range of pain management modalities including nonpharmacological therapies and illicit substance use to manage symptoms of opioid withdrawal and pain. Providers should consider that any change to a patients' long-term opioid therapy may result in experimentation with pain management outside of the medical setting and may want to employ patient-centered, holistic approaches when managing patients' opioid prescriptions and chronic pain.

Acceptability and feasibility of naloxone prescribing in primary care settings: A systematic review.

Naloxone access through established healthcare settings is critical to responding to the opioid crisis. We conducted a systematic review to assess the acceptability and feasibility of prescribing naloxone to patients in primary care. We queried PubMed, EmBase and CINAHL for US-based, peer-reviewed, full-length, original articles relating to acceptability or feasibility of prescribing naloxone in primary care. Searches yielded 270 unduplicated articles; one analyst reviewed all titles and abstracts. Two analysts independently reviewed eligible articles for study design, study outcome, and acceptability and/or feasibility. Analyses were compared and a third reviewer consulted if discrepancies emerged. Seventeen articles were included. Providers' willingness to prescribe naloxone appeared to increase over time. Most studies provided prescribers in-person naloxone trainings, including how to write a prescription and indications for prescribing. Most studies implemented universal prescribing, whereby anyone prescribed long-term opioids or otherwise at risk for overdose was eligible for naloxone. Patient education was largely provided by prescribers and most studies provided take-home educational materials. Providers reported concerns around naloxone prescribing including lack of knowledge around prescribing and educating patients. Providers also reported benefits such as improving difficult conversations around opioids and resetting the culture around opioids and overdose. Current literature supports the acceptability and feasibility of naloxone prescribing in primary care. Provision of naloxone through primary care may help normalize such medication safety interventions, support larger opioid stewardship efforts, and expand access to patients not served by a community distribution program.