The Opioid Epidemic: a Crisis Disproportionately Impacting Black Americans and Urban Communities.

The heroin epidemic has existed for decades, but a sharp rise in opioid overdose deaths (OODs) jolted the nation in the mid-twenty-teens and continues as a major health crisis to this day. Although the new wave of OODs was initially approached as a rural problem impacting a White/Caucasian demographic, surveillance records suggest severe impacts on African Americans and urban-dwelling individuals, which have been largely underreported. The focus of this report is on specific trends in OOD rates in Black and White residents in states with a significant Black urban population and declared as hotspots for OOD: (Maryland (MD), Illinois (IL), Michigan (MI), and Pennsylvania (PA)), and Washington District of Columbia (DC). We compare OODs by type of opioid, across ethnicities, across city/rural demographics, and to homicide rates using 2013-2020 data acquired from official Chief Medical Examiners' or Departments of Health (DOH) reports. With 2013 or 2014 as baseline, the OOD rate in major cities (Baltimore, Chicago, Detroit, Philadelphia) were elevated two-fold over all other regions of their respective state. In DC, Wards 7 and 8 OODs were consistently greater than other jurisdictions, until 2020 when the rate of change of OODs increased for the entire city. Ethnicity-wise, Black OOD rates exceeded White rates by four- to six-fold, with fentanyl and heroin having a disproportionate impact on Black opioid deaths. This disparity was aggravated by its intersection with the COVID-19 pandemic in 2020. African Americans and America's urban dwellers are vulnerable populations in need of social and political resources to address the ongoing opioid epidemic in under-resourced communities.

Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management.

While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.

Suicide and the opioid overdose crisis among American Indian and Alaska Natives: a storm on two fronts demanding swift action.

The opioid crisis in the United States has received national attention and critical resources in the past decade. However, what has been overlooked is the effect the opioid crisis may be having on a three-decade suicide crisis among American Indian and Alaska Native (AIAN) communities that already have too few resources to address behavioral and mental health issues. This paper describes recent epidemiological trends associated with both opioid overdose and suicide at a national level for AIANs and the rest of the United States. We used data reported by the Centers for Disease Control and Prevention to report historical trends of opioid overdose and suicide for AIAN and non-AIAN populations. We found alarming and potentially correlated trends of opioid use and suicidality among AIAN populations. We highlight both current and future research that will be essential to understanding and addressing the unique intersection between opioid and suicide risk and protective factors to inform dual prevention and intervention efforts among AIAN populations with potential relevance to public health response among other at-risk populations.

Trends in opioid prescribing practices in South Korea, 2009-2019: Are we safe from an opioid epidemic?

Opioid prescribing data can guide regulation policy by informing trends and types of opioids prescribed and geographic variations. In South Korea, the nationwide data on prescribing opioids remain unclear. We aimed to evaluate an 11-year trend of opioid prescription in South Korea, both nationally and by administrative districts. A population-based cross-sectional analysis of opioid prescriptions dispensed nationwide in outpatient departments between January 1, 2009, and December 31, 2019, was conducted for this study. Data were obtained from the Health Insurance Review & Assessment Service. The types of opioids prescribed were categorized into total, strong, and extended-release and long-acting formulation. Trends in the prescription rate per 1000 persons were examined over time nationally and across administrative districts. There are significant increasing trends for total, strong, and extended-release and long-acting opioid prescriptions (rate per 1000 persons in 2009 and 2019: total opioids, 347.5 and 531.3; strong opioids, 0.6 and 15.2; extended-release and long-acting opioids, 6.8 and 82.0). The pattern of dispensing opioids increased from 2009 to 2013 and slowed down from 2013 to 2019. The rate of opioid prescriptions issued between administrative districts nearly doubled for all types of opioids. Prescription opioid dispensing increased substantially over the study period. The increase in the prescription of total opioids was largely attributed to an increase in the prescription of weak opioids. However, the increase in prescriptions of extended-release and long-acting opioids could be a future concern. These data may inform government organizations to create regulations and interventions for prescribing opioids.

Naloxone's role in the national opioid crisis-past struggles, current efforts, and future opportunities.

Over the past 25 years, naloxone has emerged as a critical lifesaving overdose antidote. Public health advocates and community activists established early methods for naloxone distribution to people who inject drugs, but a legacy of stigmatization and opposition to universal naloxone access continues to limit the drug's full potential to reduce opioid-related mortality. The establishment of naloxone distribution programs under the umbrella of syringe exchange programs faces the same practical, ideological and financial barriers to expansion similar to those faced by syringe exchange programs themselves. The expansion of naloxone from the confines of a few syringe exchange programs to what we see today represents an enormous triumph for the grass-roots activists, service providers, and public health professionals who have fought to guarantee lay access to naloxone. Despite the extensive efforts to expand access to naloxone, naloxone continues to remains a scarce resource in many US localities. Considerable naloxone "deserts" remain and even where there is naloxone access, it does not always reach those at risk. Promising areas for expansion include the development of more robust telehealth methods for naloxone distribution, including subsidized mail delivery programs; lowering barriers to pharmacy access; working with hospitals, ambulances, and law enforcement to expand naloxone "leave behind" programs; providing naloxone co-prescription with medications for opioid use disorder; and working with prisons, shelters, and networks of people who use drugs to increase access to the lifesaving medication. Efforts to ensure over-the-counter and low- or no-cost naloxone are ongoing and stand alongside medication-assisted treatments as efficacious, readily-actionable, and cost-efficient population-level interventions available for combatting opioid-related overdose in the United States.

Opioid Prescribing Patterns Among Facial Plastic and Reconstructive Surgeons in the Medicare Population.

Objective: To evaluate opioid prescribing patterns among American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) members in the Medicare population. Methods: Retrospective cohort study of AAFPRS members in the Medicare Part D Prescriber dataset. Results: From 2014 to 2016, there was a significant decrease in the number of days of opioids supplied per beneficiary (5.9 vs. 4.9 days, p < 0.005), as well as the opioid prescription cost per beneficiary ($14.52 vs. $11.79, p = 0.005). The highest prescription rate was found in the Midwest (20.5%) and lowest in the Northeast (14.0%), however, the difference between geographic regions was not significant (p = 0.11). There was a significant decrease in the number of total opioid days supplied per beneficiary in the South (p = 0.001), Midwest (p = 0.05), and West regions (p < 0.001). There was no significant difference in opioid prescription rate (p = 0.89) or total opioid days supplied per beneficiary (p = 0.26) when states were stratified by age-adjusted opioid-specific death rate. Conclusion: This study demonstrates a national trend toward fewer opioid days supplied and less opioid cost per Medicare beneficiary among AAFPRS members between 2014 and 2016.

Modeling Mitigation Strategies to Reduce Opioid-Related Morbidity and Mortality in the US.

Importance: The US opioid epidemic is complex and dynamic, yet relatively little is known regarding its likely future impact and the potential mitigating impact of interventions to address it. Objective: To estimate the future burden of the opioid epidemic and the potential of interventions to address the burden. Design, Setting, and Participants: A decision analytic dynamic Markov model was calibrated using 2010-2018 data from the National Survey on Drug Use and Health, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey, the US Census, and National Epidemiologic Survey on Alcohol and Related Conditions-III. Data on individuals 12 years or older from the US general population or with prescription opioid medical use; prescription opioid nonmedical use; heroin use; prescription, heroin, or combined prescription and heroin opioid use disorder (OUD); 1 of 7 treatment categories; or nonfatal or fatal overdose were examined. The model was designed to project fatal opioid overdoses between 2020 and 2029. Exposures: The model projected prescribing reductions (5% annually), naloxone distribution (assumed 5% reduction in case-fatality), and treatment expansion (assumed 35% increase in uptake annually for 4 years and 50% relapse reduction), with each compared vs status quo. Main Outcomes and Measures: Projected 10-year overdose deaths and prevalence of OUD. Results: Under status quo, 484 429 (95% confidence band, 390 543-576 631) individuals were projected to experience fatal opioid overdose between 2020 and 2029. Projected decreases in deaths were 0.3% with prescribing reductions, 15.4% with naloxone distribution, and 25.3% with treatment expansion; when combined, these interventions were associated with 179 151 fewer overdose deaths (37.0%) over 10 years. Interventions had a smaller association with the prevalence of OUD; for example, the combined intervention was estimated to reduce OUD prevalence by 27.5%, from 2.47 million in 2019 to 1.79 million in 2029. Model projections were most sensitive to assumptions regarding future rates of fatal and nonfatal overdose. Conclusions and Relevance: The findings of this study suggest that the opioid epidemic is likely to continue to cause tens of thousands of deaths annually over the next decade. Aggressive deployment of evidence-based interventions may reduce deaths by at least a third but will likely have less impact for the number of people with OUD.

Tracking Trends in the Opioid Epidemic in North Carolina : Early Results from the Opioid Action Plan Metrics.

BACKGROUND Deaths from unintentional opioid overdose have increased markedly over the last decade in North Carolina. In 2017 the state created a North Carolina Opioid Action Plan, which laid out a multisectoral response to the crisis that included the medical community, law enforcement, emergency medical services, and treatment professionals. It also created a website providing county-level data associated with the crisis. Using this publicly available data, we examine trends and associations between opioid-related mortality and strategies to reduce opioid prescriptions, reduce fatality of overdose, and improve treatment and recovery.METHOD We examine yearly trends from 2010-2017 for statewide unintentional opioid-related death rates, prescription of opioid pills, buprenorphine prescription rates, naloxone administrations, and number of Certified Peer Support Specialists. We compare recent opioid-related death rates for 2015-2017 with an earlier period (2010-2012) at the county level, and examine the association between death rates and rates of the supply, treatment, and recovery metrics.RESULTS Trends for all metrics increased from 2010-2017, although the number of opioid pills per capita has declined since 2015. Between 2010 and 2017, 84 of the state's 100 counties experienced an increase in opioid-related mortality. County-level mortality was positively associated with opioid prescription rate (r = +0.12, P = 0.24) and with naloxone administrations (r = +0.20, P = 0.05). Prescription of buprenorphine was associated with a reduction in opioid mortality (r = -0.27, P = 0.01). The effect of Certified Peer Support Specialists was not discernable.LIMITATIONS Data are available for only eight years and aggregated at the county level. Mortality data are based on death certificates using ICD-10 codes from the North Carolina State Center for Health Statistics, Vital Statistics, which may not capture all opioid-related fatalities. Drug-related deaths may involve multiple non-opioid substances; in addition, determining the intent of the deceased individual may be difficult (suicide versus unintentional). Naloxone administration data only includes data from emergency medical services, not community-administered naloxone, because that data was only available for 2013 and later and is based only on self-reports.CONCLUSIONS The potential efficacy of buprenorphine is promising and should be further explored. All interventions should be monitored.

Review of the Transitional Pain Service as a method of postoperative opioid weaning and a service aimed at minimizing the risk of chronic post-surgical pain.

Opioid use and prescribing have become a subject of increasing focus and scrutiny. The ongoing "opioid epidemic" in North America has further increased interest in this area. In patients presenting for surgery, the prescribing of opioids during and following admission to hospital is commonplace and has been identified as a potential contributor to the growing opioid problem in North America. This review aims to present the timeline of the "opioid epidemic" as well as to introduce the concept of a "Transitional Pain Service". The Transitional Pain Service is a multidisciplinary service originating at Toronto General Hospital that employs a multi-faceted approach to monitoring opioid use after discharge from surgery, and aims to safely wean patients from opioids while maintaining effective pain management. This approach and its results will be discussed in this review.

Discovery and validation of biomarkers to aid the development of safe and effective pain therapeutics: challenges and opportunities.

Pain medication plays an important role in the treatment of acute and chronic pain conditions, but some drugs, opioids in particular, have been overprescribed or prescribed without adequate safeguards, leading to an alarming rise in medication-related overdose deaths. The NIH Helping to End Addiction Long-term (HEAL) Initiative is a trans-agency effort to provide scientific solutions to stem the opioid crisis. One component of the initiative is to support biomarker discovery and rigorous validation in collaboration with industry leaders to accelerate high-quality clinical research into neurotherapeutics and pain. The use of objective biomarkers and clinical trial end points throughout the drug discovery and development process is crucial to help define pathophysiological subsets of pain, evaluate target engagement of new drugs and predict the analgesic efficacy of new drugs. In 2018, the NIH-led Discovery and Validation of Biomarkers to Develop Non-Addictive Therapeutics for Pain workshop convened scientific leaders from academia, industry, government and patient advocacy groups to discuss progress, challenges, gaps and ideas to facilitate the development of biomarkers and end points for pain. The outcomes of this workshop are outlined in this Consensus Statement.