Perceptions Toward Naloxone Among Patients With Cancer Receiving Opioids.

CONTEXT: Naloxone nasal spray is recommended for patients with risk factors for opioid overdose. However, cancer patients' perceptions and beliefs regarding naloxone prescriptions and their self-perceived risks for overdose are understudied. OBJECTIVE: To determine the proportion of cancer patients at risk for overdose who perceived naloxone as beneficial. METHODS: Between July 2020 and April 2022, we surveyed 150 adult patients from the supportive care ambulatory clinic at a tertiary cancer center in the United States who received a co-prescription of naloxone nasal spray. We measured patients' knowledge of overdose risk-factors, attitudes, beliefs, and education received on naloxone. Risk-factors between beneficial vs. nonbeneficial groups were analyzed. The survey was administered on paper or via a telephone interview. RESULTS: Of the 150 patients, 55% were male, 70% were white, and 81% had advanced cancer. The majority of patients believed naloxone was beneficial (100/150, 67%). When compared to the nonbeneficial group, more patients from the beneficial group agreed that the concurrent use of alcohol (100% vs. 90%; P = 0.004) or sedating drugs (96% vs. 85%; P = 0.04) with opioids could result in overdoses and felt safe having naloxone at home (95% vs. 60%; P <0.0001). More patients from the nonbeneficial group associated naloxone prescription with being suspected of misusing opioids (12/50 vs. 8/100; P = 0.01), and fewer had confidence in their caregivers' ability to administer naloxone (69% vs. 95%; P < 0.0001). CONCLUSION: Most patients understood the benefits of naloxone and felt safe having one at home. More research is needed to identify knowledge gaps and develop educational strategies for those who find it nonbeneficial.

Patient and navigator experiences with the opioid use disorder treatment system in Philadelphia, PA.

BACKGROUND: In 2022, 1413 people in Philadelphia died of an unintentional drug overdose. Addressing the complex challenges within the opioid use disorder (OUD) treatment system requires a comprehensive grasp of multiple system-level siloes from the perspective of patients who are accessing services and certified recovery specialists. Identifying facilitators and barriers to treatment entry and retention are critical. METHODS: We conducted 13 focus groups with 70 people with a history of opioid use in Philadelphia, Pennsylvania. The study recruited participants from non-profit organizations, OUD treatment programs, and street intercept. Certified Recovery Specialists (CRS), people with experience in residential, outpatient, methadone, and buprenorphine programs in Philadelphia, identity-specific groups with Black women, Black men, and Latino men, pregnant and parenting people, and people accessing harm reduction services participated in focus groups. Focus group guides varied by group, but the overarching focus remained on understanding participants' experiences in navigating the OUD treatment system. The research team summarized and edited CRS focus groups and coded all other focus groups for thematic analysis. RESULTS: Most focus group participants (mean age = 45.1 years; 52.9 % men, 40 % Black) had a history with multiple treatment types and reported experiences with different modalities. Salient themes that emerged from analysis included frustrations with the assessment process; reflections on facilitators and barriers by treatment type (residential, methadone, and buprenorphine); and recommendations across treatment modalities. Assessment centers, rather than being easy points of treatment entry, were identified as a major barrier to OUD treatment initiation; issues discussed included length of assessment, limited operating hours, and inadequate withdrawal management. DISCUSSION: The data from the present study were used to develop recommendations for policymakers and other stakeholders of OUD treatment programs to improve care across the spectrum of services. Expansion of residential programs that can support patients with complex comorbid conditions and wounds is needed to prevent delays for patients deemed ineligible for lower levels of care. Housing and income were identified as significant deterrents to initiating drug treatment and greater resources are needed. Greater investment in the OUD workforce is needed, especially expanding staff with lived experience. Findings can enhance OUD treatment programs elsewhere.

Influence of gabapentin on the degree of sedation, physiological variables and propofol dosage in cats premedicated with acepromazine and methadone: a randomized, prospective, blinded, clinical study.

This study evaluated the influence of gabapentin on sedation, propofol dosage, and physiological variables in cats premedicated with acepromazine and methadone. Thirty-four cats were randomly assigned to receive 100 mg of oral gabapentin (Gabapentin group) or placebo (Control group) 100 min before intramuscular premedication with acepromazine (0.05 mg/kg) plus methadone (0.3 mg/kg). Variables recorded included sedation, using the Dynamic Interactive Visual Analog Scale (DIVAS, range 0-100 mm) and a Numeric Descriptive Scale (NDS, range 0-14), heart rate, respiratory rate and Doppler systolic arterial pressure (SAP). All variables were measured before (T0), 100 min after administration of gabapentin or placebo (T1), and 30 min after premedication (T2). Physiological variables were also recorded after anesthetic induction with propofol (T3). At T2, NDS scores were higher in Gabapentin than the Control group [median (interquartile range): 4 (2-5) versus 2 (1-4), p = 0.028], whereas DIVAS scores were not significantly different [Control: 9 (4-13); Gabapentin: 12 (5-32)]. Despite the significant difference between groups in NDS scores, overall sedation scores were mild at T1 and T2 regardless of gabapentin administration. The propofol dosage did not differ between groups. The most concerning adverse effect was arterial hypotension (SAP < 90 mmHg), recorded only at T3 in 71% of cats in the Control group and 100% in the Gabapentin group, without significant difference between groups. Administration of gabapentin before premedication with acepromazine and methadone in healthy cats did not result in a clinically significant influence on sedation levels, physiological variables, or propofol dosage required for anesthesia induction.

Experimental Evidence on Age-related Differential Outcomes Associated With Substance Abuse.

Growing evidence indicates that adolescent substance abuse is now an alarming concern that imposes a considerable socio-economic burden on societies. On the other hand, numerous studies have shown that due to specific neurophysiological features, the brain is more vulnerable to the adverse effects of psychoactive drugs at an early age. Unfortunately, these negative effects are not limited to the period of drug use, but can persistently affect the brain's responsiveness to future exposures to the same or other types of drug. For researchers to develop pharmacological strategies for managing substance abuse disorders, they need to gain a deep understanding of the differences in behavioral outcomes associated with each type of drug across different age groups. The present study was conducted to review the experimental evidence revealing the mentioned differential effects with an emphasis on common drugs of abuse, including cocaine, nicotine, cannabis, and opioids. Although the cellular mechanisms underlying age-related effects have not been exclusively addressed for each drug, the most recent results are presented and discussed. Future studies are required to focus on these mechanisms and reveal how molecular changes during brain development can result in differential responses to drugs at the behavioral level.

Sex differences in opioid response: a role for the gut microbiome?

Opioid drugs have been long known to induce different responses in males compared to females, however, the molecular mechanisms underlying these effects are yet to be fully characterized. Recent studies have established a link between the gut microbiome and behavioral responses to opioids. Chronic opioid use is associated with gut dysbiosis, or microbiome disruptions, which is thought to contribute to altered opioid analgesia and reward processing. Gut microbiome composition and functioning have also been demonstrated to be influenced by sex hormones. Despite this, there is currently very little work investigating whether sex differences in the gut microbiome mediate sex-dependent responses to opioids, highlighting a critical gap in the literature. Here, we briefly review the supporting evidence implicating a potential role for the gut microbiome in regulating sexually dimorphic opioid response and identify areas for future research.

[Pain relief after abdominal oncologic surgery. Evaluation of the effectiveness and safety of a fixed combination of diclofenac and orphenadrine]. / Obezbolivanie posle abdominal'nykh onkokhirurgicheskikh vmeshatel'stv. Otsenka effektivnosti i perenosimosti fiksirovannoi kombinatsii diklofenaka i orfenadrina.

OBJECTIVE: Evaluation of the analgesic, opioid-sparing, anti-inflammatory and adverse effects of the diclofenac and orphenadrine (Neodolpasse) fixed combination for analgesia in the postoperative period of surgical cancer patients. MATERIAL AND METHODS: A randomized, single-center, prospective, comparative study evaluated two analgesic regimens in 40 cancer patients undergoing various open cavity surgeries, including extensive combined interventions associated with the resection of 3 or more organs. The study was conducted following the transfer from the ICU to the surgical department during the early activation period, within the first two postoperative days. In the first group N (n=20), "Neodolpasse" (a fixed combination of 75 mg Diclofenac and 30 mg Orphenadrine) was administered as an infusion, twice daily. In the second group K (n=20) analgesia was performed with ketoprofen as an intravenous infusion at a daily dose of 200 mg. Patients in both groups received scheduled prolonged epidural analgesia with 0.2% ropivacaine, and when the severity of pain in a visual analogue scale (VAS) increased to more than 40 mm, so an additional dose of 100 mg tramadol was administered intramuscularly. Daily measurments of blood creatinine level and C-reactive protein were taken, postoperative blood loss was accounted for, as well as postoperative complications according to the Clavien-Dindo classification. RESULTS: The comparative analysis of the indicators of pain syndrome severity showed that the patients in group N exhibited a more pronounced analgesic effect, so on the second postoperative day 30% of patients reported moderate pain (from 50 to 60 mm on the pain scale), on the third day - 15%, and by the fourth day - all 100% of patients experienced pain of low intensity. The additional analgesia with tramadol in group N was required twice less than in the comparison group, and such adverse effects as nausea, drowsiness, and weakness were significantly more common in the ketoprofen group. In both groups, the average blood creatinine level did not exceed permissible values, and the C-reactive protein was elevated at all stages of the study but tended to decrease by the fourth day. The analysis of postoperative complications according to the Clavien-Dindo scale at the time of discharge did not reveal a direct correlation between the occurred complications and the use of NSAIDs. Adverse effects such as anastomotic failure, gastrointestinal complications, or other hemorrhagic manifestations were not recorded. CONCLUSION: The inclusion of Neodolpasse into multimodal analgesic regimens resulted in the most pronounced analgesic and opioid-sparing effects in surgical cancer patients using laparotomy access. Additionally, the application of short courses of nonsteroidal anti-inflammatory drugs (NSAIDs) was associated with a favorable safety profile.

Pain Management in Animals with Oncological Disease: Opioids as Influencers of Immune and Tumor Cellular Balance.

Advancements in understanding pain physiopathology have historically challenged animals' absence of pain senses. Studies have demonstrated that animals have comparable neural pain pathways, suggesting that cats and dogs likely experience pain similarly to humans. Understanding brain circuits for effective pain control has been crucial to adjusting pain management to the patient's individual responses and current condition. The refinement of analgesic strategies is necessary to better cater to the patient's demands. Cancer pain management searches to ascertain analgesic protocols that enhance patient well-being by minimizing or abolishing pain and reducing its impact on the immune system and cancer cells. Due to their ability to reduce nerve sensitivity, opioids are the mainstay for managing moderate and severe acute pain; however, despite their association with tumor progression, specific opioid agents have immune-protective properties and are considered safe alternatives to analgesia for cancer patients.

High-risk use of prescription opioids among patients treated for alcohol problems in New York State. A repeated cross-sectional study, 2005-2018.

Background: Patients with alcohol use disorder (AUD) and high-risk opioid use are at risk of serious complications. The purpose of this study was to estimate the prevalence of and factors associated with high-risk opioid use in patients with an alcohol use problem from 2005 to 2018. Methods: This repeated cross-sectional study analyzed data from first admissions for alcohol treatment (2005-2018) to the NYS Office of Addiction Services and Supports merged with Medicaid Claims Data. High-risk opioid use was defined as opioid dose ≥50 morphine mg equivalents (MME) per day; opioid prescriptions overlapping ≥7 days; opioids for chronic pain >90 days or opioids for acute pain >7 days. Results: Patients receiving ≥50 MME increased from 690 to 3226 from 2005 to 2010; then decreased to 2330 in 2018. From 2005-2011, patients with opioid prescriptions overlapping ≥7 days increased from 226 to 1594 then decreased to 892 in 2018. From 2005-2010, opioid use >7 days for acute pain increased from 133 to 970 and plateaued after 2010. From 2005-2018, patients who received opioids >90 days for chronic pain trended from 186 to 1655. White patients, females, age 36-55, patients with chronic and acute pain diagnoses had the highest rates of high-risk use. Conclusions: The prevalence of high-risk opioid use in patients with alcohol use problems increased from 2005 to 2011, and generally decreased after 2010. However, prevalence of opioids >90 days for chronic pain trended up from 2005 to 2018. High-risk opioid use among patients with AUD emphasizes the need to develop interventional strategies to improve patient care.

Peer Intervention to Link Overdose Survivors to Treatment (PILOT): Protocol for a Multisite, Randomized Controlled Trial Conducted Within the National Institute on Drug Abuse Clinical Trials Network.

BACKGROUND: The increase in opioid-related overdoses has caused a decrease in average life expectancy, highlighting the need for effective interventions to reduce overdose risk and prevent subsequent overdoses. Peer support specialists (PSSs) offer an appealing strategy to engage overdose survivors and reduce overdose risk, but randomized controlled trials are needed to formalize peer-led interventions and evaluate their effectiveness. OBJECTIVE: This National Institute on Drug Abuse Clinical Trials Network (CTN) study is a multisite, prospective, pilot randomized (1:1) controlled trial (CTN protocol 0107) that aims to evaluate the effectiveness of an emergency department (ED)-initiated, peer-delivered intervention tailored for opioid overdose survivors (Peer Intervention to Link Overdose survivors to Treatment [PILOT]), compared with treatment as usual (TAU). METHODS: This study evaluates the effectiveness of the 6-month, PSS-led PILOT intervention compared with TAU on the primary outcome of reducing overdose risk behavior 6 months after enrollment. Adults (aged ≥18 years; N=150) with a recent opioid-related overdose were identified and approached in the ED. Participants were screened and enrolled, either in the ED or within 7 days of ED discharge at research offices or in the community and then asked to complete study visits at months 1, 3, 6 (end of intervention), and 7 (follow-up). Participants were enrolled at 3 study sites in the United States: Greenville, South Carolina; Youngstown, Ohio; and Everett, Washington. Participants randomized to the PILOT intervention received a 6-month, PSS-led intervention tailored to each participant's goals to reduce their overdose risk behavior (eg, overdose harm reduction, housing, medical, and substance use treatment or recovery goals). Participants randomized to TAU received standard-of-care overdose materials, education, and services provided through the participating EDs. This paper describes the study protocol and procedures, explains the design and inclusion and exclusion decisions, and provides details of the peer-led PILOT intervention and supervision of PILOT PSSs. RESULTS: Study enrollment opened in December 2021 and was closed in July 2023. A total of 150 participants across 3 sites were enrolled in the study, meeting the proposed sample size for the trial. Primary and secondary analyses are underway and expected to be published in early 2025. CONCLUSIONS: There is an urgent need to better understand the characteristics of overdose survivors presenting to the ED and for rigorous trials evaluating the effectiveness of PSS-led interventions on engaging overdose survivors and reducing overdose risk. Results from this pilot randomized controlled trial will provide a description of the characteristics of overdose survivors presenting to the ED; outline the implementation of PSS services research in ED settings, including PSS implementation of PSS supervision and activity tracking; and inform ED-initiated PSS-led overdose risk reduction interventions and future research to better understand the implementation and efficacy of these interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT05123027; https://clinicaltrials.gov/study/NCT05123027. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/60277.

Synthetic opioids in Poland-A cause for concern or a media distraction?

BACKGROUND: The North American continent has been battling a major health crisis defined by opioids like OxyContin and fentanyl for over two decades now. In that time, it seemed that Europe is rather resilient to a similar problem, and heroin retained its position as a the most problematic opioid. This does seem to be changing and European media, including in Poland, is starting to report on growing popularity of synthetic opioids like fentanyl. METHODS: We use official data showing the number of prescriptions for synthetic opioids; data showing the percentage of people entering treatment due to different opioids; police data on drug interceptions as well as lab closures, and data on opioid related poisonings. RESULTS: The data demonstrates that although Polish physicians are increasingly more likely to prescribe synthetic opioids like OxyContin or Fentanyl, their problematic use remains low. CONCLUSION: Poland currently does not seem to be in a position that resembles an early stage of an opioid crisis. With this article we want to calm a heated public debate that is currently taking place in Poland, and redirect attention to a much more substantial problem of synthetic cathinones.

Postoperative pain management in children: guidance from the Pain Committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative) Part II.

The ESPA Pain Management Ladder Initiative is a clinical practice advisory based upon expert consensus supported by the current literature to help ensure a basic standard of perioperative pain management for all children. In 2018 the perioperative pain management of six common pediatric surgical procedures was summarised. The current Pain Management Ladder recommendations focus on five more complex pediatric surgical procedures and suggest basic, intermediate, and advanced pain management methods. The aim of this paper is to encourage best possible pain management practice and to support institutions to create their own pain management concepts according to their financial and human resources due to the diversity of clinical settings in Europe. Furthermore, the authors underline that these recommendations are intended for inpatients only.

Renal Auto-Transplant as a Definitive Treatment for Nutcracker Syndrome: A Multi-Center Retrospective Study.

OBJECTIVE: Nutcracker Syndrome is a rare condition that involves mechanical compression of the left renal vein leading to chronic and debilitating left flank pain. The etiology of the pain is frequently misdiagnosed, and patients usually require long-term opioid use to manage their pain. Multiple therapeutic options for Nutcracker Syndrome have been described in the literature but the reports are limited by small numbers of patients, and the lack of convincing data demonstrating consistently improved outcomes. Here we report the largest series to date of patients undergoing renal auto-transplantation for the treatment of Nutcracker Syndrome. METHODS: We performed a multi-center retrospective cohort review of patients 105 patients with Nutcracker Syndrome who underwent renal auto-transplantation as a primary or salvage therapy. RESULTS: During the overall study period, 93.1% of patients treated with auto-transplantation had durable, complete flank pain relief at 12 months with both open and robotic surgical approach. Following auto-transplantation, a statistically significant reduction in percentage of patients using opioids from 48.6 to 17.0% was demonstrated at 12 months. In those patients using opioids prior to auto-transplantation, a statistically significant decrease in Morphine Milligram Equivalents (MME) was demonstrated from an alarming 68.9±15.0 per day to 25.0±11.02 MME per day. CONCLUSIONS: Our findings suggest renal auto-transplantation, as a primary treatment or salvage treatment, in patients with Nutcracker Syndrome provides durable pain relief and a marked decrease in chronic opioid use regardless of surgical approach.

Reliability and validity of the pressure algometer in predicting gynecological surgery pain.

OBJECTIVE: The purpose of this study was to determine the reliability and validity of the pressure algometer in predicting gynecological surgery pain. We looked into the predictive value of preoperative pain sensitivity to gynecological pain and the relationship between preoperative pressure pain threshold (PPT), pressure pain tolerance (PTO), and postoperative pain outcomes. METHODS: Reliability test: We recruited 60 volunteers at Nantong University. For three consecutive days, two examiners measured the pain sensitivity of each participant using a pressure algometer. Its test-retest and intra-rater reliability were assessed using the intraclass correlation coefficient (ICC). Validity test: We selected patients who underwent gynecological surgery in a hospital for the validity test. Before surgery, we assessed the patient's pain sensitivity to various stimuli. To determine the relationship between preoperative pain sensitivity and postoperative pain, we collected postoperative Numerical Rating Scale (NRS) and sufentanil consumption data. RESULTS: The algometer revealed a high test-retest and intra-rater reliability. According to the calculation of Youden's index, there was a 73.1% chance of patients with moderate to severe postoperative pain having a PTO <6.22 N, and patients with PTO <6.22 N had an 87.5% probability of moderate to severe postoperative pain. CONCLUSIONS: The pressure algometer has a high degree of accuracy in measuring the PPT and PTO of normal healthy individuals, making it a reliable tool for quantifying pain sensitivity. PTO can be used to predict the occurrence of moderate to severe postoperative pain.

Morphine-induced fever: a case report and review of the literature.

BACKGROUND: Morphine is widely used to treat moderate-to-severe cancer pain. However, it causes various adverse effects, with morphine-induced fever being an extremely rare and poorly understood symptom. CASE PRESENTATION: We report the case of a 58-year-old Chinese woman with advanced lung cancer. Due to the ineffectiveness of tramadol for pain relief, her treatment regimen was switched to morphine. Following the change, she developed nausea, vomiting, dizziness, and elevated body temperature. A similar episode occurred subsequently. After a drug review, the pharmacist speculated that morphine was the most likely causative agent. Upon discontinuation of morphine, her body temperature returned to baseline levels. CONCLUSIONS: This case highlights the need for healthcare providers to consider morphine as a potential cause of unexplained fever in patients. The fever may be caused by a hypersensitive response, as there was a significant increase in eosinophils during the fever episodes.

Identifying Provider Barriers to the Implementation of Opioid Harm Reduction Methods: An Initial Narrative Review.

According to the Centers for Disease Control and Prevention, the opioid epidemic remains a major issue in the United States, with over 80,000 deaths attributed to opioids in 2021. This public health crisis continues to impact communities across the country, highlighting the need for intervention and reflecting the nation's failed attempts at prohibition through criminalization to reduce opioid use. Harm reduction methodshave proven to be effective in preventing adverse health outcomes and promoting the overall well-being of individuals with opioid use disorders. However, significant gaps remain in the universal implementation by healthcare providers. This review evaluated the PICOT question: What barriers exist among providers in implementing evidence-based harm reduction methods for adults aged 18 years and older, with and without opioid use disorders? A literature search was conducted across databases using key words which included: "Health care provider," "Physician," "Pharmacist," "Harm reduction," "Harm reduction programs," "Naloxone," "Buprenorphine-naloxone induction," "Methadone," "Naloxone take home kits," "Stigma," "Barriers," "Negative perception," "Refusal." The inclusion criteria focused on identifying provider barriers, specifically regarding opioid use. . The review revealed 3 major barriers that exist among providers to prevent harm reduction: stigma, lack of education and knowledge, and lack of access to resources for long-term management. Recognizing these barriers among providers can help organizations develop targeted interventions to overcome them, leading to widespread adoption of opioid harm reduction methods. The results provide an initial narrative review of the current evidence at the time of the authors search to inform practice, policy, and future research.

A cross-sectional survey exploring organizational readiness to implement community pharmacy-based opioid counseling and naloxone services in rural versus urban settings in Alabama.

Background: Rural US regions experience lower naloxone dispensing rates compared to urban counterparts, particularly in Alabama. In light of this, strategies to enhance opioid counseling and naloxone services (OCN) in rural community pharmacies are critical. However, organizational readiness to implement OCN in rural versus urban contexts where resource networks may differ is not well understood. Objectives: The purpose of this study was to explore organizational readiness and identify factors associated with implementation of OCN in rural versus urban Alabama community pharmacies. Methods: Alabama community pharmacists and technicians were recruited to participate in an anonymous online cross-sectional survey via email. The survey instrument was adapted from the Organizational Readiness to Change Assessment (ORCA). Primary outcome measures included 3 overarching ORCA domains (Evidence, Context, and Facilitation) with 19 subscales regarding OCN implementation readiness, measured via 5-point Likert-type scales (1 = strongly disagree, 5 = strongly agree). Secondarily, pharmacy OCN implementation status (implementer, non-implementer, or in-development) was measured via multiple-choice (1-item). Differences in mean domain and subscale scores between rural and urban pharmacies were evaluated using Mann-Whitney U tests and influential factors affecting OCN implementation status were assessed via logistic regression (alpha = 0.05). Results: Of 171 respondents, the majority were pharmacists (78.6 %) in urban locations (57.1 %). Mean[SD] clinical experience evidence (Evidence) (3.98[0.69] vs 3.74[0.71]; p = 0.029), staff culture (Context) (4.04[0.66] vs 3.85[0.76]; p = 0.047), service measurement goals (Context) (3.92[0.77] vs 3.66[0.79]; p = 0.034), and senior management characteristics (Facilitation) (3.87[0.72] vs 3.71[0.66]; p = 0.045) subscales were higher in urban versus rural pharmacies. Notably, 66.7 % of pharmacies were current OCN implementers, and pharmacies with higher ORCA context domain scores had 3.230 greater odds of implementing or being in the process of developing OCN (95 % CI = 1.116-9.350; p = 0.031). Conclusion: Organizational readiness to implement OCN was higher among urban versus rural pharmacies in terms of perceived strength of clinical evidence, staff culture, service measurement goals, and senior management characteristics. Future research may leverage key contextual factors to enhance OCN implementation.

Is general practitioner involvement in the initiation of opioids for chronic non-cancer pain associated with opioid dose and concurrent drug use?

Objective Is the involvement of the regular general practitioner (GP) in the decision to initiate opioid treatment for chronic non-cancer pain (CNCP) associated with two main risk factors for serious adverse events: increased opioid dose and the concomitant use of prescribed benzodiazepines or benzodiazepine-related medications? Design and setting An anonymous web-based survey was conducted in the county of Rogaland, Norway, during the spring of 2021. Subjects GPs who self-reported applying at least once for reimbursement of opioids prescribed to treat CNCP. They were asked to answer the survey based on the last patient for whom they recalled submitting a reimbursement application. Main outcome measures 1) Total opioid dose in daily oral morphine equivalents (OMEQ). 2) Concurrent use of benzodiazepines and/or benzodiazepine-related drugs. Results The daily opioid dose was lower when the surveyed GPs initiated the opioid treatment (36 OMEQ, n = 25), than when others had initiated the treatment (108 OMEQ, n = 31, p = 0.001). For concurrent use of benzodiazepine or benzodiazepine-related drugs, no significant difference was found (33%, n = 9 with GP involvement vs. 47%, n = 16, p = 0.279 with no GP involvement). Conclusions GP involvement in the initiation of opioid medication for CNCP was associated with a lower opioid dose being prescribed. Implications GP involvement in the initiation of opioid prescriptions may facilitate safer prescribing.

Opioid treatment against chronic non-cancer pain (CNCP) can be reimbursed in Norway. High opioid doses and the concomitant use of other medications with addictive properties, particularly benzodiazepines, increase the risk of serious adverse events. When the general practitioner (GP) in the survey had initiated the opioid treatment, this was associated with a lower opioid dose, but not with less concomitant use of benzodiazepines.

Treatment of insomnia associated with alcohol and opioid use: a narrative review.

Substance use disorders (SUDs) are associated with profound sleep disturbances, including insomnia, sleep fragmentation, and circadian rhythm dysfunction resulting in serious mental and physical consequences. This minireview presents an overview of the neurocircuitry underlying sleep disturbances in SUDs and elaborates on treatment options with emphasis on alcohol use disorder (AUD) and opioid use disorder (OUD). A PubMed, Embase, CINAHL Plus, Cochrane, and Scopus search were conducted using sleep- and AUD/OUD related keywords from January 1st, 2000, to January 31st, 2023, with preferences for recent publications and randomized-controlled trials. A bidirectional relationship exists between insomnia and addiction with the status of each condition impacting the other in dictating clinical outcome. Existing evidence points to a resurgence of insomnia during detoxification, and unless treated satisfactorily, insomnia may lead to relapse. The discussion summarizes the strengths and limitations of cognitive behavioral therapy and pharmacological treatment for insomnia in SUDs covering evidence from both animal and clinical studies. The assumption of reestablishing normal sleep patterns by attaining and maintaining sobriety is misguided. Comorbid insomnia in patients with SUDs should be approached as an independent condition that requires its own treatment. Future clinical trials are needed with the aim of providing a resource for guiding clinical management of the many patients with insomnia and SUD.

Trends in fatal poisoning among medical users of analgesics in France from 2013 to 2022: an analysis of the DTA register.

OBJECTIVE: To describe analgesic-related deaths in France and report trends over a 10-year period. STUDY DESIGN: The DTA ("Décès Toxiques par Antalgiques") register is a French database of analgesic-related deaths among people without a history of drug abuse, reported by forensic toxicology experts. METHODS: We included analgesic-related deaths occurring from January 2013 to December 2022 in France. Subject demographic characteristics and medical history, forensic autopsy findings, and toxicology reports were evaluated. RESULTS: Among the 1036 deceased individuals (mean [SD] age, 48.3 [15.6] years), there were slightly more women than men (M:F sex ratio, 0.89:1). Over the entire study period, tramadol was the leading cause of death, ahead of morphine. A relative increase in oxycodone-related mortality was observed (from 6.8% in 2013 to 21.1% in 2022) compared to a progressive decrease in tramadol, morphine, and codeine-related deaths (from 43.2%, 31.1% and 24.3% in 2013 to 37.5%, 26.6% and 20.3% in 2022, respectively). However, no statistically significant variations were found (Chi-squared tests of homogeneity). Other analgesics (buprenorphine, dihydrocodeine, fentanyl, gabapentin, ketamine, methadone, nefopam, and pregabalin) were also implicated in deaths, but with low and stable rates over the period studied. CONCLUSIONS: In France, no increase in fentanyl-related deaths and only a non-significant increase in oxycodone-related deaths were observed over the period 2013-2022. Tramadol was the leading cause of analgesic-related deaths throughout this period. Although close monitoring is still required, particularly for oxycodone, our data do not support the hypothesis of an opioid crisis in France.

Joint effects of prescription opioid use and physical activity on depressive symptoms.

OBJECTIVES: The possible interaction of prescription opioid use and physical activity with regard to depressive symptoms has not been well studied. This study aimed to investigate the joint effects of prescription opioid use and physical activity on depressive symptoms. STUDY DESIGN: Cross-sectional study. METHODS: This cross-sectional study included 29,542 participants from the National Health and Nutrition Examination Survey (2007 to March 2020). Depressive symptoms were evaluated using the Patient Health Questionnaire-9. Multivariable logistic regression models were used to examine the association. RESULTS: Of the 29,542 adults, 2598 had depressive symptoms (weighted, 7.7%), 1845 used prescription opioids (weighted, 6.0%), and 18,373 (weighted 67.0%) achieved the recommended physical activity. After multivariable adjustment, the odds ratio (OR) of depressive symptoms was 4.06 (95% confidence interval [CI]: 3.28, 5.02) for both prescription opioid use and inactive physical activity compared to those without either condition. No multiplicative interaction was observed for prescription opioid use and inactive physical activity on depressive symptoms (OR = 1.26 [95% CI: 0.87, 1.81]). However, additive interaction was statistically significant between the 2 exposures (relative excess risk due to interaction = 1.34 [95% CI: 0.31, 2.36]; attributable proportion due to interaction = 0.33 [95% CI: 0.12, 0.54]; synergy index = 1.78 [95% CI: 1.12, 2.83]). CONCLUSIONS: Prescription opioid use and inactive physical activity interacted synergistically to affect depressive symptoms.