Associations of Transactional Sex and Sexually Transmitted Infections Among Treatment-Seeking Individuals With Opioid Use Disorder.

INTRODUCTION: Coinciding with the rise in opioid use across the U.S., the rates of sexually transmitted infections have reached historically high levels, underscoring the need to understand multiple pathways of disease spread. Although prevention is often focused on injection-related behaviors, this study sought to identify the prevalence and associations of a little understood pathway, transactional sex, among individuals with opioid use disorder, including associations of transactional sex with the prevalence of sexually transmitted infection diagnoses. METHODS: Data were sourced from a nationwide opioid surveillance program of treatment-seeking individuals with opioid use disorder utilizing a serial, cross-sectional survey of 4,366 new entrants to 1 of 99 substance use treatment programs for opioid use disorder in 37 states from October 2018 to June 2021. RESULTS: A quarter of the sample (24.9%) self-reported a lifetime history of transactional sex for drugs, with rates highest for sexual (56.6%) and gender (53.8%) minority, female (33.4%), Latinx (30.4%), and Black (29.6%) subgroupings. Lifetime diagnoses of all specific sexually transmitted infections analyzed were significantly higher (p<0.001) among those reporting transactional sex, particularly syphilis (14.3% vs 4.4%) and HIV (4.0 vs 0.9%). Financial hardship, trauma, and psychiatric disorder were significantly associated with transactional sex engagement. CONCLUSIONS: Transactional sex is relatively common among patients with opioid use disorder, particularly among sexual/gender minorities, which was associated with a greater lifetime prevalence of all sexually transmitted infections assessed. Sexually transmitted infection testing remains at low levels within substance use treatment programs, occurring in just 26.3% of programs; sexual health screenings and sexually transmitted infection prevention/testing need to be prioritized and integrated into opioid use disorder patient care.

Differences in Self-identification of Opioid Overdose Risk and Naloxone Perceptions Between Therapeutic and Nontherapeutic Opioid Populations.

OBJECTIVES: Efforts to improve low naloxone uptake to mitigate the current opioid crisis have included coprescribing naloxone with opioid medications and, more recently, expansion through over-the-counter availability, the latter of which necessitates self-identification of overdose risk by consumers. This study sought to understand perceptions of opioid overdose risk and naloxone among distinct opioid populations at elevated risk for overdose. METHODS: A cross-sectional, online survey was provided to 2 opioid populations in June 2020. First, chronic pain opioid managed (CPOM; n = 190) individuals currently treated with an opioid prescription (either >50 daily morphine milligram equivalents [73.2%] or benzodiazepine co-use [52.6%]), restricted by confounders. Second, individuals with a history of opioid use disorder (OUD; n = 152) previously participating in a national opioid surveillance study of new entrants to substance use treatment centers. RESULTS: Risk perceptions significantly differed, with 60.0% (CPOM) versus 28.9% (OUD) reporting that they were "not at all concerned about overdosing," and 62.1% (CPOM) versus 19.1% (OUD) perceiving themselves as having "no risk" of overdose. Perceived need for naloxone was lower among CPOM versus OUD patients (48.3% and 71.8%, respectively), whereas 22.6% and 35.0%, respectively, indicated any likelihood of obtaining naloxone in the future. CONCLUSIONS: Results suggest that a significant proportion of both samples lacked the ability to self-identify their risk of overdose and self-select themselves as needing naloxone, with gaps being more prominent in the CPOM sample. A multi-intervention framework that addresses distinct pathways of behavioral change between unique opioid populations should be considered in conversations surrounding potential transitions to over-the-counter naloxone.

Association between recent overdose and chronic pain among individuals in treatment for opioid use disorder.

Chronic pain increases risk for opioid overdose among individuals with opioid use disorder. The purpose of this study is to evaluate the relationship between recent overdose and whether or not chronic pain is active. 3,577 individuals in treatment for opioid use disorder in 2017 or 2018 were surveyed regarding recent overdoses and chronic pain. Demographics from the 2017 Treatment Episode Data Set, which includes all U.S. facilities licensed or certified to provide substance use care, were used to evaluate the generalizability of the sample. χ2 tests and logistic regression models were used to compare associations between recent overdoses and chronic pain. Specifically, active chronic pain was associated with opioid overdose among people in treatment for opioid use disorder. Individuals with active chronic pain were more likely to have had a past month opioid overdose than those with no history chronic pain (adjusted OR = 1.55, 95% CI 1.16-2.08, p = 0.0003). In contrast, individuals with prior chronic pain, but no symptoms in the past 30 days, had a risk of past month opioid overdose similar to those with no history of chronic pain (adjusted OR = 0.88, 95% CI 0.66-1.17, p = 0.38). This suggests that the incorporation of treatment for chronic pain into treatment for opioid use disorder may reduce opioid overdoses.

Nonmedical use of gabapentin and opioid agonist medications in treatment-seeking individuals with opioid use disorder.

BACKGROUND: As prescriptions for gabapentin have increased in recent years, nonmedical use and risk of adverse outcomes (e.g., hospitalizations and overdose) have been identified, particularly in association with opioids, including opioid agonist medications (OAMs) buprenorphine and methadone. However, there is a lack of systematic, nationwide data assessing the relationship between the nonmedical use of gabapentin and OAMs. METHODS: Data were sourced from two nationwide opioid surveillance programs of treatment-seeking individuals with opioid use disorder (OUD). Both programs utilized an identical serial, cross sectional survey of 12,792 new entrants to one of 163 substance use treatment programs for OUD in 46 states and the District of Columbia from January 2019 to December 2020. RESULTS: Past month nonmedical use of gabapentin was endorsed by 9.3% of the sample. Of those using gabapentin nonmedically, 64.1% also endorsed nonmedical use of an OAM, including concomitant use of methadone (35.3%), and buprenorphine (49.0%). Concomitant nonmedical use of gabapentin and OAMs was more prevalent (versus nonmedical use of gabapentin alone) in the Southern region, among those living in a street dwelling, those with chronic pain and healthcare professionals. CONCLUSIONS: Nonmedical use of gabapentin in people with OUD appears to frequently coincide with nonmedical use of OAMs. As prescriptions and off-label use of gabapentin increase, provider education should include the risks of concomitant gabapentin and OAM use, particularly amongst buprenorphine prescribers. Future research should investigate motivations (e.g., OUD self-management) for nonmedical use of gabapentin and OAMs within the context of OUD treatment access and retention.

Opioid Dosage Levels, Concurrent Risk Factors and Self-Perceptions among Chronic Pain, Opioid-Managed Individuals at Elevated Risk for Opioid Overdose.

While current opioid prescribing guidelines highlight a dose-response relationship between therapeutic management and overdose risk, other concurrent risk factors have also been identified. However, there is little data in assessing the relationship between risk factor prevalence, associated provider communication, and subsequent perceptions of overdose risk among chronic pain, opioid-managed (CPOM) patients. An online questionnaire was distributed in June 2020 to a sample of CPOM individuals (n = 190) treated with an opioid prescription at or above 50 daily MME, or any dosage alongside benzodiazepines. CPOM individuals reported a mean daily MME of 470, with half (52.6%) receiving a concurrent benzodiazepine prescription. All patients reported past month alcohol use, and 67.4% indicated a risk-elevating diagnosed medical condition. In assessing provider communication, 41.6% reported no discussion focusing on the risks of one's opioid therapy. Subsequently, 62.1% perceived themselves as having "no risk", and 60.0% were "not at all concerned" (60.0%) about experiencing an opioid overdose. Organizational policies should focus on implementing consistent methods of patient education regarding overdose risk, as well as assessments of behaviors or characteristics that my increase an individual's risk of opioid overdose. These policies should also include other forms of evidence-based overdose risk prevention such as co-prescriptions of naloxone.

Polysubstance use trends and variability among individuals with opioid use disorder in rural versus urban settings.

Rural areas of the United States have been disproportionately impacted by the opioid epidemic, exacerbated by COVID-19-related economic upheavals. While polysubstance use is an important determinant of overdose risk, variability in polysubstance use as a result of numerous factors (e.g., access, preference) has yet to be described, particularly among rural persons with opioid use disorder (PWOUD). Survey data on past-month use of prescription and illicit opioids and 12 non-opioid psychoactive drug classes were analyzed from a national sample of rural (n = 3872) and urban (n = 8153) residents entering treatment for OUD from 2012 to 2019. Trend analyses for opioid and stimulant use were compared between rural and urban PWOUD. Latent class analyses assessed substance use trends through identified typologies of rural/urban PWOUD, which then underwent comparative analyses. By 2019, prescription opioid use remained greater in rural versus urban PWOUD, and methamphetamine use showed greater growth in rural, compared to urban areas. Latent class analyses identified variability in polysubstance use, with five identical subgroups in rural/urban PWOD: high polysubstance, polyprescription, prescription opioid-focused, prescription opioid-focused with polysubstance use, and illicit opioid-focused. Polyprescription was highest in rural areas, with illicit opioid-focused use highest in urban areas. Demographic characteristics, co-morbid conditions and healthcare coverage were all associated with between-group differences. There is significant variability in polysubstance use that may identify specific prevention and treatment needs for subpopulations of OUD patients: interventions focused on reducing opioid prescriptions, early engagement with mental health resources, wider distribution of naloxone, and screening/treatment plans that take into account the use of multiple substances.

Shifting Pathways of Stimulant Use Among Individuals With Opioid Use Disorder: A Retrospective Analysis of the Last Thirty Years.

Background: Stimulant use among individuals with opioid use disorder has recently increased, driven by changes in drug distribution channels. However, our understanding of polysubstance use is often limited by a need to provide targeted treatment to a primary drug of addiction. Yet there is a crucial need to better understand pathways to addiction, and how the use of multiple substances may differ between populations, as well as time periods. Methods: Using a national opioid surveillance system, we analyzed survey data from new entrants to 124 opioid use disorder treatment centers from 2017 to 2020. Age of first use was collected for prescription opioids, illicit opioids, prescription stimulants, crack/cocaine, and methamphetamines. Year of initial use of an opioid or stimulant was calculated and grouped by 5 year blocs, inclusive of initial use starting from 1991 and ending in 2020 (n = 6,048). Results: Lifetime exposure to stimulants was 82.5% among individuals with opioid use disorder. Mean age of initiation increased for all drugs in 2016-2020, in particular prescription opioids (22.3 to 31.8). Stimulants were initiating drugs for a substantial proportion of individuals with opioid use throughout the analyzed time period. Those initiating opioid/stimulant use from 1991 to 1995 had a mean average of 6.8 years between first and second drug exposure, which steadily decreased to 1.5 years between exposures in 2016-2020. Sankey plots depict significantly more drug transitions in those initiating use from 1991 to 2000 (65.1% had at least two drug transitions) compared to 2010-2020 (16.0%). Opioid-stimulant use increased over time among racial/ethnic minorities, sexual minorities, and those with an educational attainment of high school or less. Conclusion: These data highlight not only the substantial prevalence of stimulant use among individuals who develop opioid use disorder, but also the variability through which pathways of use occur. Prevention and intervention efforts need to take into account increasing ages of initial drug exposures, demographic shifts in stimulant-using populations, and more rapid drug transitions between opioid and stimulants. But at a broader level, prevention, harm reduction ideology, and addiction medicine needs to take into account the ubiquity of polysubstance use among individuals with substance use disorders.

Assessment of Chronic Pain Management in the Treatment of Opioid Use Disorder: Gaps in Care and Implications for Treatment Outcomes.

Chronic pain is a significant comorbid condition among individuals with opioid use disorder (OUD). However, due to conflicting perceptions of responsibility, structural barriers, and a lack of widely applied standards of care, it is unclear what the landscape of chronic pain management looks like in addiction medicine. Using a national opioid surveillance system, we analyzed survey data from new entrants (n = 14,449) to 225 OUD treatment centers from 2013 to 2018, as well as an online survey among a subset of respondents (n = 309). While chronic pain was reported by 33.4% of the sample, two-thirds of the chronic pain group (66.0%) reported their pain was not managed through their OUD treatment program, with 47% reporting worsening pain. Pain that was managed was primarily done so through pharmaceuticals (75.2%), notably as a secondary effect of medication-assisted treatment. In addition, 43.2% reported chronic pain as a primary factor in their opioid relapse. These data suggest that chronic pain is commonly reported, yet not managed by many OUD treatment programs, increasing the likelihood of opioid relapse. In order to improve poor outcomes among OUD patients, interdisciplinary collaboration/care, along with evidence-based policies or processes for quality pain management in addiction care need to be prioritized. PERSPECTIVE: This article suggests chronic pain is commonly reported, yet not managed by many OUD treatment programs, increasing the likelihood of opioid relapse. In order to improve low retention and success rates among OUD patients, interdisciplinary collaboration, evidence-based policies or processes (eg, referral) for quality pain management in addiction care need to be prioritized.

The impact of opioid use disorder on levels of educational attainment: Perceived benefits and consequences.

BACKGROUND/AIMS: Adolescents and young adults have the highest rates of opioid use, and despite shared risk-factors such as mental health and social pressures, there is little information on the relationship between education and opioid use disorder. In this study, we sought to assess differences in educational attainment between opioid users and the general population, and the impact of opioid use on one's education. METHODS: Patients (N = 14,349) entering opioid treatment programs across the United States were surveyed on educational attainment from 2010 to 2018. Data were compared to estimates from an annual survey administered by the US Census. A follow-up sub-set of opioid users (N = 240) was interviewed to add context and expand on the structured survey. RESULTS: Nearly one-third (32.2%) of the US population is estimated to have earned a bachelor's/advanced degree, compared to just 7.8% of treatment-seeking opioid users. Over half of follow-up respondents (57.5%) reported initiating regular opioid use while attending an educational institution. The majority (68.0%) also indicated opioids negatively impacted their education, with drug-seeking behavior prioritized over attendance and academic performance. Perceived benefits included cognitive enhancement and therapeutic value for anxiety/depression. CONCLUSIONS: Our data suggest that opioid users achieve lower levels of education, which may result in both individual and economic costs. Prevention programs need to not only include education-specific risk factors (e.g., social norms), but underlying precipitators such as mental health, stigma, and the myth of risk-free cognitive enhancement. Opioid specific services should be available and disseminated to student populations, including certification of campus physicians to provide buprenorphine maintenance.

Polysubstance Use: A Broader Understanding of Substance Use During the Opioid Crisis.

Objectives. To understand important changes in co-occurring opioid and nonopioid drug use (i.e., polysubstance use) within the opioid epidemic in the United States.Methods. We analyzed survey data on the past month co-use of prescription and illicit opioids and 12 nonopioid psychoactive drug classes from a national sample of 15 741 persons entering treatment of opioid use disorder.Results. Past-month illicit opioid use increased from 44.8% in 2011 to 70.1% in 2018, while the use of prescription opioids alone dropped from 55.2% to 29.9%, yet overall remained high (94.5% to 85.2%). Past-month use of at least 1 nonopioid drug occurred in nearly all participants (> 90%), with significant increases in methamphetamine (+85%) and decreases across nonopioid prescription drug classes (range: -40% to -68%).Conclusions. Viewing opioid trends in a "silo" ignores the fact not only that polysubstance use is ubiquitous among those with opioid use disorder but also that significant changes in polysubstance use should be monitored alongside opioid trends.Public Health Implications. Treatment, prevention, and policymaking must address not only the supply and demand of a singular drug class but also the global nature of substance use overall.

Twin epidemics: The surging rise of methamphetamine use in chronic opioid users.

BACKGROUND/AIMS: Recent supply-side efforts enacted to curb the opioid epidemic have had both positive (i.e., prescription opioid abuse is on the decline) and negative outcomes (i.e., shifts to other drugs). Given methamphetamine is notably increasing in use across the United States, we sought to understand whether use of methamphetamine has increased among opioid users and whether there is an association between these two epidemics. METHODS: Patients (N = 13,521) entering drug treatment programs across the United States completed an anonymous survey of drug use patterns from 2011 to 2017. A subset of these patients (N = 300) was also interviewed to add context and expand on the structured survey. RESULTS: Past month use of methamphetamine significantly increased among treatment-seeking opioid users (+82.6%, p < .001), from 18.8% in 2011 to 34.2% in 2017. The Western region had the greatest increase in past month methamphetamine use (+202.4%, p < 0.001) and the highest prevalence rate in 2017 (63.0%). Significant increases (p < .001) in methamphetamine use were seen among males (+81.8%), females (+97.8%), whites (+100.6%), urban residents (+123.0%) and rural residents (+93.7%). CONCLUSIONS: Our studies show that there has been a marked increase in the past month use of methamphetamine in individuals with a primary indication of opioid use disorder. Qualitative data indicated that methamphetamine served as an opioid substitute, provided a synergistic high, and balanced out the effects of opioids so one could function "normally". Our data suggest that, at least to some extent, efforts limiting access to prescription opioids may be associated with an increase in the use of methamphetamine.

Increased use of heroin as an initiating opioid of abuse: Further considerations and policy implications.

INTRODUCTION: Previously, we reported a marked increase in the use of heroin as an initiating opioid in non-tolerant, first time opioid users. In the current paper, we sought to update and expand upon these results, with a discussion of the policy implications on the overall opioid epidemic. METHODS: Opioid initiation data from the original study were updated to include surveys completed through 2017 (N = 8382) from a national sample of treatment-seeking opioid users. In addition, past month abuse of heroin and prescription were analyzed as raw numbers of treatment program entrant in the last five years (2013-2017), drawing from only those treatment centers that participated every year in that time frame. RESULTS: The updated data confirm and extend the results of our original study: the use of heroin as an initiating opioid increased from 8.7% in 2005 to 31.6% in 2015, with increases in overall Ns per initiation year reflecting a narrowing of the "treatment gap", the time lag between opioid initiation from 2005 to 2015 and later treatment admission (up to 2017). Slight decreases were observed in treatment admissions, but this decline was totally confined to prescription opioid use, with heroin use continuing to increase in absolute numbers. CONCLUSIONS: Given that opioid novices have limited tolerance, the risk of fatal overdose for heroin initiates is elevated compared to prescription opioids, particularly given non-oral administration and often unknown purity/adulterants (i.e., fentanyl). Imprecision of titrating dose among opioid novices may explain observed increases opioid overdoses. Future policy decisions should note that prescription opioid-specific interventions may have little impact on a growing heroin epidemic.

Increased use of heroin as an initiating opioid of abuse.

INTRODUCTION: Given the relatively recent growth in access to heroin and a more permissive atmosphere surrounding its use, we hypothesized that an increasing number of persons with limited experience and tolerance to opioids would experiment with heroin as their first opioid rather than more common prescription opioid analgesics. METHODS: Individuals entering substance abuse treatment for an opioid use disorder in the period 2010-2016 (N=5885) were asked about the specific opioid they first regularly used to get high. To limit long-term recall and survival bias, analyses was restricted to opioid initiation that occurred in the past ten years (2005-2015). RESULTS: In 2005, only 8.7% of opioid initiators started with heroin, but this sharply increased to 33.3% (p<0.001) in 2015, with no evidence of stabilization. The use of commonly prescribed opioids, oxycodone and hydrocodone, dropped from 42.4% and 42.3% of opioid initiators, respectively, to 24.1% and 27.8% in 2015, such that heroin as an initiating opioid was now more frequently endorsed than prescription opioid analgesics. CONCLUSIONS: Our data document that, as the most commonly prescribed opioids - hydrocodone and oxycodone - became less accessible due to supply-side interventions, the use of heroin as an initiating opioid has grown at an alarming rate. Given that opioid novices have limited tolerance to opioids, a slight imprecision in dosing inherent in heroin use is likely to be an important factor contributing to the growth in heroin-related over dose fatalities in recent years.

Increases in self-reported fentanyl use among a population entering drug treatment: The need for systematic surveillance of illicitly manufactured opioids.

BACKGROUND/PURPOSE: Recent reports indicate a sharp increase in fentanyl-related overdose deaths across the United States, much of which is likely related to the introduction of cheap, illicitly manufactured fentanyl derivatives. In this study, we sought to estimate the magnitude of illicit fentanyl use from 2012 to 2016 using a national opioid abuse surveillance system. METHODS: The study program surveyed 10,900 individuals entering substance abuse treatment for opioid use disorder, with participants asked to endorse past month 'use to get high' of fentanyl drugs, stratified by identifiable (i.e., branded) fentanyl formulations or a 'type unknown' drug alleged to contain fentanyl. MAIN FINDINGS: Total past-month fentanyl-use rose modestly from 2012 to 2016. While use of known fentanyl products remained relatively stable (mean=10.9%; P=0.25), endorsements of 'unknown' fentanyl products nearly doubled from 9% in 2013 to 15.1% by 2016 (P<0.001). Data show no discernable indication that this increase is diminishing or stabilizing. CONCLUSIONS: This first attempt to assess the prevalence of illicit fentanyl use shows that recent increases in fentanyl use seem to be due almost entirely to 'unknown' fentanyl presumed to be illicitly manufactured. Given that it is difficult to assess the extent to which fentanyl may have been substituted for another drug (i.e., oxycodone, alprazolam, etc.) or was used as a heroin admixture, our data likely represent an underestimation of the full magnitude of illicit fentanyl abuse. As such, this growing public health problem requires immediate attention and more systematic efforts to identify and track its abuse.

Psychoactive substance use prior to the development of iatrogenic opioid abuse: A descriptive analysis of treatment-seeking opioid abusers.

Physicians are frequently thought to be a major source of opioids diverted for non-therapeutic purposes, largely because it is so difficult for them to discern which patients might abuse them. In this study we sought to determine whether those who were first exposed to an opioid through a physician's prescription, and subsequently developed a substance use disorder, had a history of using psychoactive drugs prior to abusing opioids. Patients entering one of 125 drug treatment programs across the country for opioid abuse were asked to provide detailed histories of psychoactive drug use prior to their initial opioid exposure. Nearly half (47.1%, N=4493) indicated they were first exposed to opioids through a prescription from their physician to treat pain. Of these, 94.6% indicated experience with at least one other psychoactive substance (mean=4.55±0.05) prior to, or coincident with, their first exposure to an opioid from a physician. Alcohol (92.9%), nicotine and/or tobacco (89.5%), and marijuana (87.4%) were used by nearly all patients prior to, or coincident with, their first opioid prescription. If one excludes these drugs, 70.1% (N=2913) still reported some psychoactive drug use of licit or illicit stimulants (77.8%), benzodiazepines (59.8%) or hallucinogens (55.2%). Our results indicate that pain patients who developed a substance use disorder were rarely drug naïve prior to receiving their first opioid prescription. Rather, most have an extensive history of psychoactive drug use. As such, physicians should routinely ascertain complete licit and illicit drug histories in patients for whom they prescribe opioids.

Relative preferences in the abuse of immediate-release versus extended-release opioids in a sample of treatment-seeking opioid abusers.

PURPOSE: Although differences in the pharmacological properties of immediate-release (IR) and extended-release (ER) opioid formulations have been reported, there are few studies comparing the real world abuse and relative preferences for these formulations. METHODS: To examine drug preferences, we used a structured survey of 8304 individuals entering treatment (2011-2014) for opioid use disorder followed by a more focused online survey (2014-2015) with a subset of these patients (N = 301). RESULTS: Our results demonstrated that both ER and IR opioids were frequently abused by those with an opioid use disorder in terms of lifetime (91.0% vs. 98.7%, respectively) or past month (46.1% vs. 67.4%, respectively) abuse, but given the choice, only 4% of the sample selected ER compounds as their preferred formulation. The remainder had no preference (29.9%) or a distinct preference for IR formulations (66.1%), regardless of route of administration-oral or non-oral (smoking/snorting or injecting). This preference for IR formulations seems to be related to: (i) the perceived immediacy and quality of the high (73.0%) from IR products; and (ii) they were easier to use, particularly when manipulated for non-oral abuse, than ER products (31.2%). CONCLUSIONS: Based on these results, while most abusers have experience with both formulations, there is a greater preference for IR formulations, compared to ER, regardless of route of administration. As a result, it may not be unreasonable to suggest that supply-side initiatives to restrict the diversion and abuse of prescription opioids may be just as important for both IR and ER opioids. Copyright © 2016 John Wiley & Sons, Ltd.

Changes in Body Mass Index and the Trajectory of Depressive Symptoms Among Rural Men and Women.

PURPOSE: This study examined the association between body mass index (BMI) changes over time and the risk of elevated depressive symptoms in a cohort of Midwestern rural adults. METHODS: The longitudinal study used data from a telephone survey in 2005 including 1,475 men and women enrolled in the Walk the Ozarks to Wellness Project from 12 rural communities in Missouri, Arkansas, and Tennessee. Multilevel random intercept mixed models were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the association between BMI calculated from self-reported height and body weight and elevated depressive symptoms, adjusting for sociodemographic, behavioral, and medical variables. FINDINGS: Elevated depressive symptoms were common in this rural population (17%-19%) and the mean BMI was 28 kg/m2 . For each unit increase in BMI over time, representing an average increase of about 5.8 pounds from baseline weight, there was a 6% increased odds of elevated depressive symptoms (aOR: 1.06, 95% CI: 1.02-1.12). CONCLUSIONS: Our findings hold important public health implications given the increasing rates of overweight and obesity over the past couple of decades, particularly among rural adults.

A tale of 2 ADFs: differences in the effectiveness of abuse-deterrent formulations of oxymorphone and oxycodone extended-release drugs.

The introduction of extended-release opioid analgesics helped initiate an epidemic of prescription opioid abuse in the United States. To make access to the drug by crushing or dissolution more difficult, abuse-deterrent formulations (ADFs) of OxyContin (Purdue Pharma, Stamford, CT) and Opana ER (Endo Pharmaceuticals Inc., Malvern, PA), which use the same foundation technology (Intac, Grunenthal, Aachen, Germany), were introduced in 2010 and 2012, respectively. To examine their relative effectiveness, we used a structured survey of 12,124 individuals entering treatment for opioid use disorder followed by a more focused online survey with a subset of these patients (N = 129) using both structured and open-ended questions. Data showed that the OxyContin ADF was highly effective in reducing nonoral abuse (91.4% before the ADF, 47.9% afterwards), particularly with insufflation (78%-28.8%) and intravenous injection of the active drug (42.7%-21.4%). However, although the Opana ER ADF was effective in reducing insufflation (80%-37.1%), injection (60.0%-51.4%), and overall nonoral abuse (94.3%-77.1%), it showed no significant decrease over time. Bearing in mind that the Opana ER sample was smaller in size than that for OxyContin, our results nonetheless suggest disparate outcomes resulting from the introduction of the ADFs, which could indicate that an ADF's effectiveness may be drug-specific. Given the public health impact of prescription opioids and the considerable effort being expended to develop ADFs as a partial solution to the problem, our preliminary studies suggest that each ADF must be evaluated on its own merits even if the same proprietary technology is used.