Associations between elevated depressive symptoms and substance use, prescription opioid misuse, overdose history, pain, and general health among community pharmacy patients prescribed opioids.

Background: Individuals with pain prescribed opioids experience high rates of comorbid depression. The aim of this study was to characterize pain, substance use, and health status as a function of depressive symptom level in individuals filling an opioid prescription at a community pharmacy. Methods: Participants (N = 1268) filling an opioid prescription enrolled in a study validating a prescription drug monitoring metric completed an online survey assessing sociodemographics, depressive symptoms, substance use, prescription opioid misuse, overdose history, general health, and pain severity and interference. Results: Approximately one-fifth (19.3%) had a positive depression screen result. In covariate-adjusted logistic regression analyses, individuals with a positive depression screen result were more likely to have moderate/high substance use risk scores for prescription opioids (adjusted odds ratio [AOR] = 2.06; 95% confidence interval [CI], 1.51-2.79); street opioids (AOR = 7.18; 95% CI, 2.57-20.01); cannabis (AOR = 2.00; 95% CI, 1.34-3.00); cocaine (AOR = 3.46; 95% CI, 1.46-8.22); tobacco (AOR = 1.59; 95% CI, 1.18-2.15); methamphetamine (AOR = 7.59; 95% CI, 2.58-22.35); prescription stimulants (AOR = 2.95; 95% CI, 1.59-5.49); and sedatives (AOR = 3.41; 95% CI, 2.43-4.79). Individuals with a positive depression screen were more likely to misuse prescription opioids (AOR = 3.46; 95% CI, 2.33-5.15), experience a prior overdose (AOR = 2.69; 95% CI, 1.76-4.11), report poorer general health (AOR = 0.25, 95% CI, 0.18-0.35), and report moderate/severe pain severity (AOR = 4.36, 95% CI, 2.80-6.77) and interference (AOR = 6.47, 95% CI, 4.08-10.26). Conclusions: Individuals prescribed opioids with heightened depression were more likely to report other substance use, prescription opioid misuse, prior overdose, greater pain, and poorer health.

Attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation: A comparison of health care professionals in rural communities.

Background: Health care professionals (HCPs) play an important role in opioid misuse and opioid use disorder (OUD) screening/identification, mitigation, and referral to treatment. This study compared attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation among pregnancy and non-pregnancy HCPs in rural communities. Methods: We conducted a secondary analysis of cross-sectional, self-report survey data of HCPs in two rural counties in southern Utah. Pregnancy HCPs were identified by a question asking whether they provide care to pregnant patients. HCPs' attitudes toward their patients with opioid misuse/OUD were measured using the Survey of Attitudes and Perceptions questionnaire. Self-efficacy and practices related to opioid risk assessment and mitigation were captured with questions asking about assessment and screening of opioid use, advisement to change opioid use behavior, and referral to treatment for OUD. We used linear regression analyses to estimate associations between HCPs' attitudes toward patients with opioid misuse/OUD and their self-efficacy and use of opioid risk assessment and mitigation practices. Results: This sample included a total of 132 HCPs, including 82 pregnancy HCPs and 50 non-pregnancy HCPs. Attitudes domains were similar among pregnancy and non-pregnancy HCPs. Among pregnancy HCPs, role adequacy (ß = .48, 95% CI = .16-.80), role legitimacy (ß = .72, 95% CI = .21-1.22), motivation (ß = .68, 95% CI = .14-1.21), and positive task-specific self-esteem (ß = 1.52, 95% CI = .70-2.35) were positively associated with more frequent use of opioid risk assessment and mitigation practices, while attitudes were not associated with these practices among non-pregnancy HCPs. Conclusions: Training initiatives that lead to improved HCP attitudes could improve opioid care management among rural pregnancy HCPs. More research is needed to determine approaches to increase the use of opioid risk assessment and mitigation practices among rural non-pregnancy HCPs.

Pain Severity and Interference and Substance Use Among Community Pharmacy Patients Prescribed Opioids: A Secondary Analysis of the PHARMSCREEN Study.

This secondary analysis examined relationships between pain severity and interference and substance use among patients filling opioid prescriptions in Indiana and Ohio community pharmacies (n = 1,461). We likewise sought to explore the moderating role of gender in pain-substance use relations. We used patient-reported data from a cross-sectional health survey linked with controlled substance dispensing data from statewide prescription drug monitoring programs. Multivariable logistic regression estimated associations between pain severity and interference and various indices of risky prescription opioid use and non-opioid substance use. Exploratory analyses examined whether gender moderated associations. Increased pain severity was associated with increased odds of moderate- to high-risk opioid use (OR: 1.23; 95% CI: 1.16-1.31) and opioid-benzodiazepine co-use (OR: 1.20; 95% CI: 1.03-1.40). Increased pain interference was associated with greater odds of receiving opioids from multiple pharmacies or providers (OR: 1.15; 95% CI: 1.01-1.31). Increased pain severity and interference were associated with higher odds of any tobacco use (severity: OR: 1.13; 95% CI: 1.06-1.21; interference: OR: 1.07; 95% CI: 1.01-1.12) and weekly to daily sedative use (severity: OR: 1.13; 95% CI: 1.03-1.25; interference: OR: 1.13; 95% CI: 1.04-1.22). Increased pain severity was associated with decreased odds of any alcohol use (OR: 0.93; 95% CI: 0.88-0.99). Gender was a significant effect modifier in associations between pain and alcohol, tobacco, and cannabis use. The study was registered in the database of clinicaltrials.gov (register number NCT03936985). Perspective: This study suggests that pain severity and interference are associated with increased use of non-medical prescription opioids, sedatives, and tobacco and decreased use of alcohol, in ways that are different between women and men. Findings may guide the development of gender-sensitive evidence-based strategies to ameliorate or prevent substance misuse among patients living with pain.

Mindfulness and Savoring: A Commentary on Savoring Strategies and Their Implications for Addiction Treatment.

Background: A central facet of the popular understanding of mindfulness practice is the non-judgmental observation of all thoughts and feelings. Savoring is a cognitive practice developed out of economics and positive psychology, which involves the conscious mental engagement with positively-valenced interoceptive and exteroceptive stimuli, which in turn amplifies the derived pleasure experience. Results: When incorporated into mindfulness-based interventions (MBIs), savoring holds promise in improving outcomes related to reward processing, such as positive affect and well-being. The growing body of mindfulness literature also suggests that the inclusion of savoring in MBIs may be key in treating disorders of reward dysregulation, such as addiction. If savoring does indeed reduce craving, this phenomenon offers a point of union for divergent neurobiological theories of addiction. Conclusion: In this commentary, we explore the existing literature on savoring and mindfulness practices as it relates to addictive disorders, posit underlying neurocognitive mechanisms, and present future areas of research.

Validation and threshold identification of a prescription drug monitoring program clinical opioid risk metric with the WHO alcohol, smoking, and substance involvement screening test.

BACKGROUND: Prescription drug monitoring programs (PDMPs) are critical for pharmacists to identify risky opioid medication use. We performed an independent evaluation of the PDMP-based Narcotic Score (NS) metric. METHODS: This study was a one-time, cross-sectional health assessment within 19 pharmacies from a national chain among adults picking-up opioid medications. The NS metric is a 3-digit composite indicator. The WHO Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was the gold-standard to which the NS metric was compared. Machine learning determined optimal risk thresholds; Receiver Operating Characteristic curves and Spearman (P) and Kappa (K) coefficients analyzed concurrent validity. Regression analyses evaluated participant characteristics associated with misclassification. RESULTS: The NS metric showed fair concurrent validity (area under the curve≥0.70; K=0.35; P = 0.37, p < 0.001). The ASSIST and NS metric categorized 37% of participants as low-risk (i.e., not needing screening/intervention) and 32.3% as moderate/high-risk (i.e., needing screening/intervention). Further, 17.2% were categorized as low ASSIST risk but moderate/high NS metric risk, termed false positives. These reported disability (OR=3.12), poor general health (OR=0.66), and/or greater pain severity/interference (OR=1.12/1.09; all p < 0.05; i.e., needing unmanaged-pain screening/intervention). A total of 13.4% were categorized as moderate/high ASSIST risk but low NS metric risk, termed false negatives. These reported greater overdose history (OR=1.24) and/or substance use (OR=1.81-12.66; all p < 0.05). CONCLUSIONS: The NS metric could serve as a useful initial universal prescription opioid-risk screener given its: 1) low-burden (i.e., no direct assessment); 2) high accuracy (86.5%) of actionable data identifying low-risk patients and those needing opioid use/unmanaged pain screening/intervention; and 3) broad availability.

Concomitant Cannabis Misuse and Associations with Depression, Pain and Substance Misuse among Patients Prescribed Opioids.

BACKGROUND: Cannabis use is common among individuals with pain who are prescribed opioids, occurring in approximately 10% of this population. This study aims to explore the relationship between non-medical cannabis use and other health risks among individuals filling opioids at community pharmacies. METHODS: This study was an exploratory secondary data analysis of a National Drug Abuse Treatment Clinical Trials Network (CTN)-sponsored study, Validation of a Community Pharmacy-Based Prescription Drug Monitoring Program Risk Screening, examining the relationship between risky cannabis use and depressive symptoms, pain, overdose, and other substance misuse among individuals filling opioid prescriptions in community pharmacies (N = 1440). RESULTS: Participants reporting moderate- to high-risk compared to low-risk cannabis use were more likely to report depressive symptoms (adjusted OR = 1.67, 95% CI = 1.11-2.56), history of overdose (adjusted OR = 2.15, 95% CI = 1.34-3.44), and moderate- to high-risk use of alcohol (adjusted OR = 2.10, 95% CI = 1.28-3.45), opioids (adjusted OR = 2.50, 95% CI = 1.67-3.76), sedatives (adjusted OR = 2.58, 95% CI = 1.72-3.86), stimulants (adjusted OR = 4.79, 95% CI = 2.83-8.01), and tobacco (adjusted OR = 3.60, 95% CI = 2.47-5.24). CONCLUSIONS: Community pharmacies may be valuable sites for identifying, studying, and intervening with substance use problems.

Brief intervention medication therapy management: Establishment of an opioid misuse intervention model delivered in a community pharmacy.

PURPOSE: Medication expertise and close patient contact position community pharmacists to make significant contributions to combatting the opioid epidemic. This position facilitated the development and initial implementation of the Brief Intervention Medication Therapy Management (BIMTM) model to detect and address patient opioid misuse. BIMTM is an intervention consisting of 9 sessions. One medication management session is delivered by a pharmacist in a community pharmacy setting, and the remaining sessions are delivered telephonically by a patient navigator to follow up with goals established with the pharmacist and address concomitant health concerns that increase risk for misuse. METHODS: We employed the Consolidated Framework for Implementation Research (CFIR) to summarize and present key findings from 4 distinct studies. CFIR domains addressed were (1) intervention characteristics, (2) outer setting, (3) inner setting, (4) process, and (5) characteristics of individuals. The study results show sequential development of evidence for BIMTM. RESULTS: A multistate cross-sectional pharmacist survey (n = 739) demonstrated limited pharmacist training and/or resources to address misuse, suggesting the need for external intervention development. Our multistakeholder intervention planning project showed limitations of current evidence-based models of care and of intervention implementation, which resulted in construction of the BIMTM. A multisite cross-sectional screening survey of patients (n = 333) established an electronic misuse screening protocol within 4 community pharmacies and identified opioid misuse in 15% of screened patients; among those patients, 98% had concomitant health conditions that contribute to the risk of opioid misuse. Presentation of study results to pharmacy leaders produced commitment for intervention implementation and a partnership to develop a grant proposal supporting this action. Our small-scale randomized trial evinced success in recruitment and retention and BIMTM patient benefit. The small-scale randomized trial likewise showed high levels of satisfaction with BIMTM. CONCLUSION: The establishment of BIMTM supports community pharmacist identification and intervention with patients engaged in misuse. Continued use of this research-based strategy may further empower pharmacists to address the opioid epidemic.

Addressing opioid use disorder among rural pregnant and postpartum women: a study protocol.

BACKGROUND: Opioid use disorder (OUD) among women delivering at a hospital has increased 400% from 1999-2014 in the United States. From the years 2007 to 2016, opioid-related mortality during pregnancy increased over 200%, and drug-overdose deaths made up nearly 10% of all pregnancy-associated mortality in 2016 in the US. Disproportionately higher rates of neonatal opioid withdrawal syndrome (NOWS) have been reported in rural areas of the country, suggesting that perinatal OUD is a pressing issue among these communities. There is an urgent need for comprehensive, evidence-based treatment services for pregnant women experiencing OUD. The purpose of this article is to describe a study protocol aimed at developing and evaluating a perinatal OUD curriculum, enhancing evidence-based perinatal OUD treatment in a rural setting, and evaluating the implementation of such collaborative care for perinatal OUD. METHODS: This two-year study employed a one group, repeated measures, hybrid type-1 effectiveness-implementation design. This study delivered interventions at 2 levels, both targeting improvement of care for pregnant women with OUD. The first area of focus was at the community healthcare provider-level, which aimed to evaluate the acceptability and feasibility of perinatal OUD education across time and to improve provider education by increasing knowledge specific to: MOUD provision; screening, brief intervention, and referral to treatment (SBIRT) utilization; and NOWS treatment. The second area of intervention focus was at the patient-level, which assessed the preliminary effect of perinatal OUD provider education in promoting illicit opioid abstinence and treatment engagement among pregnant women with OUD. We adopted constructs from the Consolidated Framework for Implementation Research (CFIR) to assess contextual factors that may influence implementation, and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model to comprehensively evaluate implementation outcomes. DISCUSSION: This article presents the protocol of an implementation study that is employing the CFIR and RE-AIM frameworks to implement and evaluate a perinatal OUD education and service coordination program in two rural counties. This protocol could serve as a model for clinicians and researchers seeking to implement improvements in perinatal care for women with OUD in other rural communities. Trial registration NCT04448015 clinicaltrials.gov.

A pilot multisite study of patient navigation for pregnant women with opioid use disorder.

The opioid crisis continues to affect pregnant and postpartum women the United States, with the number of pregnant women diagnosed with opioid use disorder (OUD) quadrupling over the last decade. The associated increase in morbidity and mortality among mother and baby warrants prompt, targeted intervention efforts that improve engagement, linkage of care, and treatment retention. Patient navigation (PN) is a chronic care intervention that can directly address this need by helping women identify medical, behavioral, and psychosocial care goals. Moreover, PN can assist women in preparing for, engaging in, and maintaining patient participation in necessary services. Specifically, PN includes strengths-based case management, 1-1 clinical support, motivational interviewing, and addiction-relapse prevention programming. The objective of this article is to present the study protocol of a pilot multisite randomized clinical trial, entitled: Optimizing Pregnancy and Treatment Interventions for Moms 2.0 (OPTI-Mom 2.0; NCT03833245). In this study, we build upon a proof-of-concept study, employing evidence-informed frameworks for protocol and intervention expansion in order to construct a PN intervention tailored for pregnant women with OUD in central Utah and southwestern Pennsylvania. Our protocol provides an initial framework of a potentially impactful intervention and may guide development of future programs. Importantly, this study further establishes the evidence-base-with potential to ameliorate serious adverse opioid-related outcomes and improve health for women and their children.