Prescription Opioid Diversion Sources Among African Americans: Implications for Overdose Prevention.

Recent data show that African Americans (AAs) experienced a greater increase in overdose deaths involving prescription opioids relative to other racial/ethnic groups. One possible mechanism through which elevated risk for overdose is conferred to AAs could be due to greater exposure to contaminated counterfeit pills. Unfortunately, prescription opioid diversion is understudied among AAs and less is known regarding which sources AAs use to access pharmaceutical opioids. The objective of this study, therefore, was to identify and describe the most commonly used diversion sources for prescription opioids among AAs. Qualitative interview data are also presented to contextualize the most prevalent sources. This study used data from the Florida Minority Health Study, a mixed-methods project that included online surveys (n = 303) and qualitative in-depth interviews (n = 30) of AAs. Data collection was conducted from August 2021 to February 2022 throughout Southwest Florida. Analyses revealed that the most widely used sources for prescription opioids were dealers (33.0%) and friends/relatives (34.7%). Additionally, interview data indicated that dealers are the access point where larger volume acquisitions are made and high potency formulations are accessed. These findings suggest that AAs may utilize nonhealthcare related sources at higher rates than healthcare related sources to acquire prescription opioids. This is concerning because opioid pills acquired through nonhealthcare related sources are especially susceptible to fentanyl adulteration. These findings invite further study using nationally representative data to determine if AAs disproportionately use nonhealthcare related sources compared to persons from other racial/ethnic groups.

Chronic Pain and Opioid Prescribing: Three Ways for Navigating Complexity at the Clinical‒Population Health Interface.

Clinically focused interventions for people living with pain, such as health professional education, clinical decision support systems, prescription drug monitoring programs, and multidisciplinary care to support opioid tapering, have all been promoted as important solutions to the North American opioid crisis. Yet none have so far delivered substantive beneficial opioid-related population health outcomes. In fact, while total opioid prescribing has leveled off or reduced in many jurisdictions, population-level harms from opioids have continued to increase dramatically. We attribute this failure partly to a poor recognition of the epistemic and ethical complexities at the interface of clinical and population health. We draw on a framework of knowledge networks in wicked problems to identify 3 strategies to help navigate these complexities: (1) designing and evaluating clinically focused interventions as complex interventions, (2) reformulating evidence to make population health dynamics apparent, and (3) appealing to the inseparability of facts and values to support decision-making in uncertainty. We advocate that applying these strategies will better equip clinically focused interventions as complements to structural and public health interventions to achieve the desired beneficial population health effects. (Am J Public Health. 2022;112(S1):S56-S65. https://doi.org/10.2105/AJPH.2021.306500).

Trajectories of Prescription Drug Misuse Among US Adults From Ages 18 to 50 Years.

Importance: US adults born from 1965 to 1996 had high exposure to controlled medications, yet little is known about how this exposure has affected them over time. Prescription drug misuse (PDM) has increased among adults in the past 2 decades, with related increases in emergency department visits, overdoses, and deaths. Objectives: To identify 32-year PDM trajectories involving opioids, stimulants, and sedatives or tranquilizers and to examine associations between these PDM trajectories and substance use disorder (SUD) symptoms in adulthood as well as between baseline characteristics and PDM trajectories. Design, Setting, and Participants: This cohort study included 11 cohorts of adolescents who were followed up longitudinally from age 18 years (study start, 1976-1986) to age 50 years (2008-2018) in the Monitoring the Future (MTF) study, which included a national multistage random sample of US 12th grade students. Baseline surveys (modal age 18) were self-administered in classrooms. Ten follow-ups were conducted by mail. Data analysis was conducted from December 2020 to October 2021. Main Outcomes and Measures: Sociodemographic variables were measured at baseline. PDM and SUD symptoms were measured at baseline and every follow-up. Latent profile analysis (LPA) was used to create PDM trajectory profiles. Associations between these PDM trajectories, SUD symptoms, and baseline sociodemographic characteristics were examined. Results: The sample of 26 575 individuals was 50.8% (95% CI, 50.2%-51.4%) female and 79.3% (95% CI, 78.8%-79.8%) White. The baseline response rate ranged from 77% to 84%, and the 32-year retention rate was 53%. In adjusting for attrition, 45.7% (95% CI, 44.9%-46.4%) of the respondents reported past-year PDM at least once during the 32-year reporting period. Among those who reported PDM, the prevalence of poly-PDM was 40.3% (95% CI, 39.3%-41.3%). Based on LPA, the number of class-specific PDM trajectories ranged from 4 (prescription opioids) to 6 (prescription stimulants). For the class-combined analyses, we identified 8 PDM trajectories consisting of early peak trajectories (eg, age 18 years), later peak trajectories (eg, age 40 years), and a high-risk trajectory (eg, high frequency PDM at multiple ages). All PDM trajectories were associated with increased odds of developing SUD symptoms in middle adulthood, especially the later peak and high-risk trajectories compared with early peak trajectories (eg, peak at age 40 years: adjusted odds ratio [aOR], 5.17; 95% CI, 3.97-6.73; high-risk: aOR, 12.41; 95% CI, 8.47-18.24). Baseline characteristics associated with a high-risk trajectory were binge drinking (aOR, 1.69; 95% CI, 1.13-2.54), cigarette smoking (aOR, 2.30; 95% CI, 1.60-3.29), and marijuana use (aOR, 3.78; 95% CI, 2.38-6.01). More recent cohorts (eg, 1985-1986) had a higher risk of belonging to later peak PDM trajectories (ages 40 and 45 years) than the 1976-1978 cohort (age 40 years peak: aOR, 2.49; 95% CI, 1.69-3.68). Conclusions and Relevance: In this cohort study, adults with later peak PDM trajectories were at increased risk of SUD symptoms in middle adulthood. These findings suggest the need to screen for PDM and SUD from adolescence through middle adulthood.

Trends in Opioid Use Among Cancer Patients in the United States: 2013-2018.

Background: In response to the US opioid epidemic, the Centers for Disease Control and Prevention updated their guideline on prescription opioids for chronic pain management in March 2016. The aim of this study was to provide detailed analysis of trends in opioid claims among cancer patients in the United States during 2013-2018. Methods: We analyzed pharmaceutical dispensing data from Symphony Health's Integrated Dataverse database, which covers approximately 80% of the US population. We examined annual trends in dispensed opioids in cancer patients during 2013-2018. We examined quarterly trends of the prevalence, mean number of days, and dose (stated as morphine milligram equivalents) of opioid dispensing in cancer patients. Results: Dispensing records of an average of over 3.7 million cancer patients contributed to the study annually in 2013-2018. The annual prevalence of opioid dispensing claims declined from 40.2% in 2013 to 34.5% in 2018. Annual declines occurred across cancer sites, and particularly among patients with metastatic cancer (decline of 19.8%), breast cancer (18.2%), and lung cancer (13.8%). By quarter, the prevalence of opioid claims declined statistically significantly from 26.6% in Q1 2013 to 21.2% in Q4 2018; this decline was more pronounced after Q3 2016 (2-sided P = .004). Both quarterly trends in mean days and morphine milligram equivalents of opioids supplied showed a gradual decline from 2013 to 2018, with a slightly larger decline after 2016. Conclusions: We observed a decline in opioid use among cancer patients, particularly after 2016, coinciding with the publication of the Centers for Disease Control and Prevention's guideline on prescription opioids for chronic pain management.

Rapid Diagnostic Tests to Guide Case Management of and Improve Antibiotic Stewardship for Pediatric Acute Respiratory Illnesses in Resource-Constrained Settings: a Prospective Cohort Study in Southwestern Uganda.

Pediatric acute respiratory illness (ARI) is one of the most common reasons for evaluation at peripheral health centers in sub-Saharan Africa and is frequently managed based on clinical syndrome alone. Although most ARI episodes are likely caused by self-limited viral infections, the majority are treated with antibiotics. This overuse contributes to the development of antimicrobial resistance. To evaluate the preliminary feasibility and potential impact of adding pathogen-specific and clinical biomarker diagnostic testing to existing clinical management algorithms, we conducted a prospective, observational cohort study of 225 children presenting with malaria-negative, febrile ARI to the outpatient department of a semi-urban peripheral health facility in southwestern Uganda from October 2019 to January 2020. In addition to routine clinical evaluation, we performed influenza and Streptococcus pneumoniae antigen testing and measured levels of C-reactive protein, procalcitonin, and lactate in the clinic's laboratory, and conducted a follow-up assessment by phone 7 days later. Almost one-fifth of participants (40/225) tested positive for influenza. Clinical biomarker measurements were low with C-reactive protein of >40 mg/L in only 11% (13/222) of participants and procalcitonin >0.25 ng/mL in only 13% (16/125). All but two children received antibiotic treatment; only 3% (7/225) were admitted. At follow-up, 59% (118/201) of caregivers reported at least one persistent symptom, but fever had resolved for all children. Positive influenza testing was associated with persistent symptoms. In summary, we demonstrate that simple, rapid pathogen-specific testing and biomarker measurement are possible in resource-limited settings and could improve syndromic management and, in turn, antibiotic stewardship. IMPORTANCE Globally, respiratory illness is one of the most common reasons that children seek care. It is often treated inappropriately with antibiotics, which can drive the development of antibiotic resistance. In resource-rich settings, testing for specific pathogens or measurement of clinical biomarkers, such as procalcitonin and C-reactive protein, is often employed to help determine which children should receive antibiotics. However, there are limited data on the use of these tests in resource-constrained, outpatient contexts in sub-Saharan Africa. We enrolled children with respiratory illness presenting to a clinic in southwestern Uganda and performed testing for influenza, Streptococcus pneumoniae, C-reactive protein, and procalcitonin on-site. Almost all children received antibiotics. We demonstrate that employing clinical algorithms that include influenza and clinical biomarker testing could significantly decrease antibiotic prescriptions. Our study therefore provides preliminary data to support the feasibility and potential utility of diagnostics to improve management of respiratory illness in resource-constrained settings.

An Emergency Preparedness Response to Opioid-Prescribing Enforcement Actions in Maryland, 2018-2019.

Federal and state enforcement authorities have increasingly intervened on the criminal overprescribing of opioids. However, little is known about the health effects these enforcement actions have on patients experiencing disrupted access to prescription opioids or medication-assisted treatment/medication for opioid use disorder. Simultaneously, opioid death rates have increased. In response, the Maryland Department of Health (MDH) has worked to coordinate mitigation strategies with enforcement partners (defined as any federal, state, or local enforcement authority or other governmental investigative authority). One strategy is a standardized protocol to implement emergency response functions, including rapidly identifying health hazards with real-time data access, deploying resources locally, and providing credible messages to partners and the public. From January 2018 through October 2019, MDH used the protocol in response to 12 enforcement actions targeting 34 medical professionals. A total of 9624 patients received Schedule II-V controlled substance prescriptions from affected prescribers under investigation in the 6 months before the respective enforcement action; 9270 (96%) patients were residents of Maryland. Preliminary data indicate fatal overdose events and potential loss of follow-up care among the patient population experiencing disrupted health care as a result of an enforcement action. The success of the strategy hinged on endorsement by leadership; the establishment of federal, state, and local roles and responsibilities; and data sharing. MDH's approach, data sources, and lessons learned may support health departments across the country that are interested in conducting similar activities on the front lines of the opioid crisis.

Urban scaling of opioid analgesic sales in the United States.

Opioid misuse is a public health crisis in the United States. The origin of this crisis is associated with a sharp increase in opioid analgesic prescribing. We used the urban scaling framework to analyze opioid prescribing patterns in US commuting zones (CZs), i.e., groups of counties based on commuting patterns. The urban scaling framework postulates that a set of scaling relations can be used to predict health outcomes and behaviors in cities. We used data from the Drug Enforcement Administration's Automated Reports and Consolidated Ordering System (ARCOS) to calculate counts of oxycodone/hydrocodone pills distributed to 607 CZs in the continental US from 2006 to 2014. We estimated the scaling coefficient of opioid pill counts by regressing log(pills) on log(population) using a piecewise linear spline with a single knot at 82,363. Our results show that CZs with populations below the knot scaled superlinearly (ß = 1.36), i.e., larger CZs had disproportionally larger pill counts compared to smaller CZs. On the other hand, CZs with populations above the knot scaled sublinearly (ß = 0.92), i.e., larger CZs had disproportionally smaller pill counts compared to smaller CZs. This dual scaling pattern was consistent across US census regions. For CZs with population below the knot, the superlinear scaling of pills is consistent with the explanation that an increased number of successful matches between prescribers and users will lead to higher prescribing rates. The non-linear scaling behavior observed could be the result of a combination of factors, including stronger health care systems and prescribing regulation in largely populated commuting zones, as well as high availability of other opioids such as heroin in these commuting zones. Future research should explore potential mechanisms for the non-linearity of prescription opioid pills.

Effect of COVID-19 disruptions on young adults' affect and substance use in daily life.

OBJECTIVE: Guided by accounts of adjustment in daily life as a key indicator of health, the current study examined prospective changes in young adults' emotions and substance behaviors assessed during a normative baseline period and during the acute COVID-19 disruption period in late March/early April 2020. The COVID-19 assessment also collected psychosocial risk factors expected to moderate changes in adjustment across time. METHOD: Participants included 295 young adults (70.8% female; ages 18-21 at baseline), drawn from an ongoing study of daily behaviors and health in college life that oversampled for recent substance behaviors, who completed both the baseline and COVID-19 assessments. Hypotheses were tested using analyses of repeated-measures data that included covariates of length of time between assessments and sampling group status. RESULTS: Direct tests in support of hypotheses indicated an increase in negative affect (d = .67, p < .001), and greater alcohol use (d = .75, p < .001) and marijuana use (d = .58, p < .001), in daily life across time. Levels of positive affect (d = .08, p > .05), nicotine use (d = .01, p > .05), and prescription drug misuse (d = .003, p > .05) did not reliably change in tests of direct models. Moderation tests indicated several risk factors for experiencing steeper increases in negative affect, and increased likelihood of marijuana and nicotine use, in daily life across time. CONCLUSIONS: Findings offer implications for future research and clinical efforts to improve young adult adjustment in response to the pandemic. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

COBRE on Opioid and Overdose: A Collaborative Research-Based Center Addressing the Crises in Rhode Island and Beyond.

Overdose deaths across the country have spiked since the onset of the COVID-19 pandemic. It is crucial now, more than ever, to address the continuing and worsening, complex and dynamic opioid and overdose epidemics. In 2018, The Center of Biomedical Research Excellence (COBRE) on Opioids and Overdose, based at Rhode Island Hospital, launched with three major goals: 1) establish a center of scientific excellence on opioids and overdose; 2) train the next generation of scientists to become independent investigators and address the opioid and overdose crises; and 3) contribute to the scientific progress and solutions to combat these epidemics. To date, we have made substantial progress. While the opioid and overdose crises continue to evolve, the COBRE on Opioid and Overdose and its team of investigators are well poised to address the daunting task of understanding and meaningfully addressing these deadly epidemics, with the ultimate goal of saving lives.

Perspectives of US Adolescents on Diverted Stimulant Use.

OBJECTIVE: To evaluate perspectives of youth regarding diverted stimulant use among a contemporary sample of adolescents and young adults. STUDY DESIGN: This study used MyVoice, a longitudinal national text message survey of American youth. In February 2019, 1228 MyVoice youth were asked 4 open-ended questions to elicit their perspectives on diverted stimulant use. Responses were assessed using thematic analysis, and quantitative results were summarized using descriptive statistics. RESULTS: Of 1228 youth, 906 responded to at least one survey question (relative risk, 74%). Respondents' ages ranged from 14 to 24 years with a mean age of 18.8 ± 2.9 years, 57% were female, and 66% identified as White. Peer pressure and coping were commonly perceived reasons for diversion, and respondents believed that many youth misuse stimulants. Many were aware of health risks of misuse, but few mentioned potential legal consequences. Youth thought stimulants could be obtained from peers, people with a prescription, dealers, and family, and some mentioned access through unnecessary prescriptions. CONCLUSIONS: The perspectives of a national sample of youth suggest that stimulant diversion continues to be a significant problem among American youth, with many noting that diverted stimulants are easy to obtain and are used to self-treat mental health issues. Standardized interventions at schools and in healthcare settings, as well as universal screening for diversion and mental health conditions, may combat this public health concern.

NarxCare Scores Greater Than 300 Are Associated with Adverse Outcomes After Primary THA.

BACKGROUND: The association between preoperative prescription drug use (narcotics, sedatives, and stimulants) and complications and/or greater healthcare utilization (length of stay, discharge disposition, readmission, emergency department visits, and reoperation) after total joint arthroplasty has been established but not well quantified. The NarxCare score (NCS) is a weighted scalar measure of overall prescription opioid, sedative, and stimulant use. Higher scores reflect riskier drug-use patterns, which are calculated based on (1) the number of prescribing providers, (2) the number of dispensing pharmacies, (3) milligram equivalence doses, (4) coprescribed potentiating drugs, and (5) overlapping prescription days. The aforementioned factors have not been incorporated into association measures between preoperative prescription drug use and adverse events after THA. In addition, the utility of the NCS as a scalar measure in predicting post-THA complications has not been explored. QUESTIONS/PURPOSES: (1) Is the NarxCare score (NCS) associated with 90-day readmission, reoperation, emergency department visits, length of stay, and discharge disposition after primary THA; and are there NCS thresholds associated with a higher risk for those adverse outcomes if such an association exists? (2) Is there an association between the type of preoperative active drug prescription and the aforementioned outcomes? METHODS: Of 3040 primary unilateral THAs performed between November 2018 and December 2019, 92% (2787) had complete baseline information and were subsequently included. The cohort with missing baseline information (NCS or demographic/racial determinants; 8%) had similar BMI distribution but slightly younger age and a lower Charlson Comorbidity Index (CCI). Outcomes in this retrospective study of a longitudinally maintained institutional database included 90-day readmissions (all-cause, procedure, and nonprocedure-related), reoperations, 90-day emergency department (ED) visits, prolonged length of stay (> 2 days), and discharge disposition (home or nonhome). The association between the NCS category and THA outcomes was analyzed through multivariable regression analyses and a confirmatory propensity score-matched comparison based on age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, which removed significant differences at baseline. A similar regression model was constructed to evaluate the association between the type of preoperative active drug prescription (opioids, sedatives, and stimulants) and adverse outcomes after THA. RESULTS: After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, an NCS of 300 to 399 was associated with a higher odds of 90-day all-cause readmission (odds ratio 2.0 [95% confidence interval 1.1 to 3.3]; p = 0.02), procedure-related readmission (OR 3.3 [95% CI 1.4 to 7.9]; p = 0.006), length of stay > 2 days (OR 2.2 [95% CI 1.5 to 3.2]; p < 0.001), and nonhome discharge (OR 2.0 [95% CI 1.3 to 3.1]; p = 0.002). A score of 400 to 499 demonstrated a similar pattern, in addition to a higher odds of 90-day emergency department visits (OR 2.2 [95% CI 1.2 to 3.9]; p = 0.01). After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, we found no clinically important association between an active opioid prescription and 90-day all-cause readmission (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.05), procedure-related readmission (OR 1.003 [95% CI 1.001 to 1.006]; p = 0.02), length of stay > 2 days (OR 1.003 [95% CI 1.002 to 1.005]; p < 0.001), or nonhome discharge (OR 1.002 [95% CI 1.001 to 1.003]; p = 0.019); the large size of the database allowed us to find statistical associations, but the effect sizes are so small that the finding is unlikely to be clinically meaningful. A similarly small association that is unlikely to be clinically important was found between active sedative use and 90-day ED visits (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.02). CONCLUSION: Preoperative prescription drug use, as reflected by higher NCSs, has a dose-response association with adverse outcomes after THA. Surgeons may use the preoperative NCS to initiate and guide a patient-centered discussion regarding possible postoperative risks associated with prescription drug-use patterns (sedatives, opioids, or stimulants). An interdisciplinary approach can then be initiated to mitigate unfavorable patterns of prescription drug use and subsequently lower patient NCSs. However, given its nature and its reflection of drug-use patterns rather than patients' current health status, the NCS does not qualify as a basis for surgical denial or ineligibility. LEVEL OF EVIDENCE: Level III, diagnostic study.

Pharmaceutical Opioid Use Patterns and Indicators of Extramedical Use and Harm in Adults With Chronic Noncancer Pain, 2012-2018.

Importance: Despite concern about harms related to long-term prescribed opioid use among individuals with chronic noncancer pain (CNCP), no study has examined whether the same patients engage in a risky pattern of use consistently for the long term. Objective: To examine the prevalence, incidence, persistence, and cessation of a range of opioid behaviors, indicators of extramedical use, and harm among individuals who are prescribed opioids. Design, Setting, and Participants: This 5-year prospective cohort study in communities across Australia included 1514 adults who were prescribed opioids for CNCP. Data collection took place from August 2012 to December 2018, and data analysis took place from February to November 2020. Exposure: Prescription opioid use. Main Outcomes and Measures: High-dose opioid use (≥200 oral morphine equivalent [OME] mg/d); requesting an increase in opioid dose; requesting an early prescription renewal; tampering with opioid medication; diversion of medication to others; and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision opioid dependence. Cessation of opioid use was also assessed. Results: Of the 1514 participants, 672 (44.39%) were men, the mean (SD) age was 58 (19) years, and 737 (48.68%) were unemployed. At each annual interview, approximately 1 in 8 people (10.98% [95% CI, 10.33%-11.63%] to 14.73% [95% CI, 13.98%-15.48%] at any given interview) were taking more than 200 OME mg/d; comparatively more had requested an increased dosage in the previous 3 months (8.46% [95% CI, 7.89%-9.03%] to 23.77% [95% CI, 22.82%-24.73%]); and fewer asked for an early prescription renewal (4.61% [95% CI, 4.19%-5.03%] to 13.97% [95% CI, 13.24%-14.70%]). In any given interview, between 3.06% (95% CI, 2.72%-3.40%) and 7.86% (95% CI, 7.31%-8.41%) of respondents reported tampering and between 0.47% (95% CI, 0.33%-0.60%) and 1.39% (95% CI, 1.16%-1.62%) reported diversion to others. Between 8.28% (95% CI, 7.71%-8.84%) and 13.06% (95% CI, 12.35%-13.77%) met criteria for opioid dependence at each interview. Opioid cessation increased across interviews, from year 1 (9.15% [95% CI, 8.55%-9.74%]) to year 5 (20.02% [19.14%-20.89%]). There was considerable incidence and cessation in all behaviors from 1 interview to the next: most who engaged in any of these behaviors only did so at only 1 interview. For pharmaceutical opioid dependence, between 55.26% (95% CI, 53.81%-56.71%) and 64.44% (95% CI, 62.87%-66.00%) of cases in 1 interview did not meet dependence criteria in the following interview. Conclusions and Relevance: These findings suggest considerable fluidity in opioid use, extramedical behaviors, and opioid dependence among people with CNCP. This reinforces the need for reassessment of the effectiveness and safety of prescription opioid use over time.

"Doctor and pharmacy shopping": A fading signal for prescription opioid use monitoring?

BACKGROUND: The term "doctor and pharmacy shopping" colloquially describes patients with high multiple provider episodes (MPEs)-a threshold count of distinct prescribers and/or pharmacies involved in prescription fulfillment. Opioid-related MPEs are implicated in the global opioid crisis and heavily monitored by government databases such as U.S. state prescription drug monitoring programs (PDMPs). We applied a widely-used MPE definition to examine U.S. trends from a large, commercially-insured population from 2010 to 2017. Further, we examined the proportion of enrollees identified as "doctor shoppers" with evidence of a cancer diagnosis to examine the risk of false positives. METHODS: Using a large, commercially-insured population, we identified patients with opioid-related MPEs: opioid prescriptions (Schedule II-V, no buprenorphine) filled from ≥5 prescribers AND ≥ 5 pharmacies within the past 90 days ("5x5x90d"). Quarterly rates per 100,000 enrollees (two specifications) were calculated between 2010 and 2017. We examined the trend in a recently published all-payer, 7 state cohort from the U.S. Centers for Disease Control and Prevention for comparison. Cancer-related ICD-9/10-CM codes were used. RESULTS: Quarterly MPE rates declined by approximately 73 % from 18.2-4.9 per 100,000 enrollee population with controlled substance prescriptions. In 2017, nearly one fifth of these commercially-insured enrollees identified by the 5x5x90d algorithm were diagnosed with cancer. Approximately 8% of this sample included patients with ≥ 1 buprenorphine prescriptions. CONCLUSIONS: Opioid "shopping" flags are a long-standing but rapidly fading PDMP signal. To avoid unintended consequences, such as identifying legitimate medical encounters requiring high healthcare utilization or opioid treatment, while maintaining vigilance, more nuanced and sophisticated approaches are needed.

Prevalence and drug use correlates of extra-medical use of prescription medications for sleep among adults in the United States: Results of the 2015-2018 National Survey on Drug Use and Health.

BACKGROUND: This paper examines the epidemiology of extra-medical use of prescription medications for sleep among a nationally representative sample of U.S. adults. METHODS: We analyzed data from the 2015-2018 National Surveys on Drug Use and Health. The sample includes 3410 U.S. adults who reported extra-medical use of prescription medications for sleep. Multinomial logistic regression models identified correlates of type of drug used [i.e., sedatives and/or tranquilizers-only (ST-only), prescription pain relievers-only (PPR-only), or sedatives, tranquilizers, and prescription pain relievers (ST + PPR)], and logistic regression models identified correlates of reasons for extra-medical use (i.e., sleep-only vs. sleep and recreational). RESULTS: About 60% (95%CI = 58.9, 63.5) of the sample reported extra-medical use of ST-only, followed by PPR-only (29.9%, 95%CI = 27.5, 32.5), and ST + PPR (8.9%, 95%CI = 7.7, 10.4). Recreational use was reported by 28.4% (95% CI = 26.5, 30.4) of the sample. The odds of extra-medical use of PPR-only (aRRR = 3.1, 95%CI = 2.1, 4.5) and ST + PPR (aRRR = 1.9, 95%CI = 1.2, 3.1) as opposed to ST-only, were greater among Non-Hispanic Blacks than Non-Hispanic Whites. Compared to non-alcohol users, those with a past-12 months diagnosis of alcohol use disorder were more likely to use ST + PPR rather than ST-only (aIRR = 2.0, 95%CI = 1.1, 3.7). Non-Hispanic Blacks (aOR = 0.6, 95%CI = 0.4, 08) and individuals living in rural areas (aOR = 0.5, 95%CI = 0.3, 09) were less likely to report extra-medical use of prescription medications for recreational reasons than Non-Hispanic Whites and those residing in large metropolitan areas, respectively. CONCLUSIONS: Extra-medical use of PPR-only and ST + PPR as an aid to sleep, is prevalent among Non-Hispanic Blacks, young adults, and those residing in rural areas. Most individuals reported that extra-medical use of prescription medications was primarily motivated by sleep reasons, rather than by sleep and recreational reasons. Potential interventions include access to sleep treatments, education on the effectiveness and risk associated with extra-medical use and co-use of prescription medications for sleep, and research on sleep-related disparities.

Sexual Identity and Motivations for Prescription Drug Misuse Among U.S. Adults.

Purpose: Although we know that sexual minority populations, particularly bisexual individuals, tend to be at increased risk for substance use, less research has focused on prescription drug misuse (PDM). The current study is the first to assess differences in motivations for PDM by sexual identity and sex. This is important as research has established a link between certain motivations and adverse outcomes. Methods: This study used data from multiple years of the National Survey on Drug Use and Health (2015-2018). Respondents who reported past-year PDM were asked follow-up questions to identify motivations for PDM. We ran several weighted cross-tabulations to estimate the prevalence and 95% confidence intervals for motivations for PDM by sexual identity (i.e., heterosexual, lesbian or gay, and bisexual) for males and females separately. When chi-square tests were significant, post hoc comparisons using design-based multivariable regressions were conducted. Results: Prevalence rates for both PDM and substance use disorder associated with prescription drugs were higher among sexual minority adults than heterosexual adults. With regard to motives, bisexual females were more likely to endorse recreational motives (i.e., to get high) for prescription opioids, tranquilizers, and stimulants than heterosexual females. Gay males were more likely to endorse self-treatment motives (e.g., to relax, to lose weight) than both bisexual and heterosexual males. Conclusion: High prevalence rates and endorsement of recreational motives identify bisexual females as an important at-risk population. It is important for clinicians to consider how prevention, treatment, and intervention strategies focused on PDM may be improved to best target this unique population.

Trends in Dispensed Opioid Analgesic Prescriptions to Children in South Carolina: 2010-2017.

BACKGROUND AND OBJECTIVES: Despite published declines in opioid prescribing and dispensing to children in the past decade, in few studies have researchers evaluated all children in 1 state or examined changes in mean daily opioid dispensed. In this study, we evaluated changes in the rate of dispensed opioid analgesics and the mean daily opioid dispensed to persons 0 to 18 years old in 1 state over an 8-year period. METHODS: We identified opioid analgesics dispensed to children 0 to 18 years old between 2010 and 2017 using South Carolina prescription drug monitoring program data. We used generalized linear regression analyses to examine changes over time in the following: (1) rate of dispensed opioid prescriptions and (2) mean daily morphine milligram equivalents (MMEs) per prescription. RESULTS: From the first quarter of 2010 to the end of the fourth quarter of 2017, the quarterly rate of opioids dispensed decreased from 18.68 prescriptions per 1000 state residents to 12.03 per 1000 residents (P < .0001). The largest declines were among the oldest individuals, such as the 41.2% decline among 18-year-olds. From 2010 through 2017, the mean daily MME dispensed declined by 7.6%, from 40.7 MMEs per day in 2010 to 37.6 MMEs per day in 2017 (P < .0001), but the decrease was limited to children 0 to 9 years old. CONCLUSIONS: The rate of opioid analgesic prescriptions dispensed to children 0 to 18 years old in South Carolina declined by 35.6% over the years 2010-2017; however, the MME dispensed per day declined minimally, suggesting that more can be done to improve opioid prescribing and dispensing.

Beyond the 'purple drank': Study of promethazine abuse according to the European Medicines Agency adverse drug reaction reports.

BACKGROUND: Promethazine is a medicinal product, available on its own or in combination with other ingredients including dextromethorphan, paracetamol and/or expectorants. Anecdotal reports have however indicated that promethazine may have a misuse potential, especially in adolescents. OBJECTIVE: We here aimed at studying how this phenomenon has been reported to the European Monitoring Agency Adverse Drug Reactions database. METHODS: After a formal request to the European Monitoring Agency, the promethazine-specific dataset has been studied, performing a descriptive analysis of misuse/abuse/dependence-related adverse drug reaction reports. The study was approved by the University of Hertfordshire (LMS/PGR/UH/03234). RESULTS: The analysis of promethazine data showed increasing levels of misuse/abuse/ dependence issues over time (2003-2019). Out of a total number of 1543 cases of adverse drug reactions, the abuse/misuse/dependence-related cases reported were 557, with 'drug abuse' (300/557: 53.8%) and 'intentional product misuse' (117/557: 21.0%). being the most represented adverse drug reactions. A high number of fatalities were described (310/557: 55.6%), mostly recorded as 'drug toxicity/drug abuse' cases, with opiates/opioids having been the most commonly reported concomitant drugs used. CONCLUSION: Anecdotal promethazine misuse/abuse reports have been confirmed by European Monitoring Agency data. Promethazine misuse/abuse appears to be an alarming issue, being associated with drug-related fatalities. Thus, healthcare professionals should be warned about a possible misuse of promethazine and be vigilant, as in some countries medicinal products containing promethazine can be purchased over the counter. Since promethazine is often available in association with opioids, its abuse may be considered a public health issue, with huge implications for clinical practice.

Changes in opioid prescribing after implementation of mandatory registration and proactive reports within California's prescription drug monitoring program.

BACKGROUND: In 2016, California updated its prescription drug monitoring program (PDMP), adding two key features: automated proactive reports to prescribers and mandatory registration for prescribers and pharmacists. The effects of these changes on prescribing patterns have not yet been examined. We aimed to evaluate the joint effect of these two PDMP features on county-level prescribing practices in California. METHODS: Using county-level quarterly data from 2012 to 2017, we estimated the absolute change associated with the implementation of these two PDMP features in seven prescribing indicators in California versus a control group comprising counties in Florida and Washington: opioid prescription rate per 1000 residents; patients' mean daily opioid dosage in milligrams of morphine equivalents[MME]; prescribers' mean daily MME prescribed; prescribers' mean number of opioid prescriptions per day; percentage of patients getting >90 MME/day; percentage of days with overlapping prescriptions for opioids and benzodiazepines; multiple opioid provider episodes per 100,000 residents. RESULTS: Proactive reports and mandatory registration were associated with a 7.7 MME decrease in patients' mean daily opioid dose (95 %CI: -11.4, -2.9); a 1.8 decrease in the percentage of patients prescribed high-dose opioids (95 %CI: -2.3, -0.9); and a 6.3 MME decrease in prescribers' mean daily dose prescribed (95 %CI: -10.0, -1.3). CONCLUSIONS: California's implementation of these two PDMP features was associated with decreases in the total quantity of opioid MMEs prescribed, and indicators of patients prescribed high-dose opioids compared to states that had PDMP's without these features. Rates of opioid prescribing and other high-risk prescribing patterns remained unchanged.

Prevalence and minority-stress correlates of past 12-month prescription drug misuse in a national sample of transgender and gender nonbinary adults: Results from the U.S. Transgender Survey.

BACKGROUND: Prescription drug (PD) misuse, particularly opioid misuse, is a major US public health concern. While transgender and gender nonbinary (TGNB) individuals experience numerous health disparities, including substance use disparities, little research has focused on PD misuse in this population. METHODS: Data for this secondary analysis come from the US Transgender Survey (N = 26,689). First, we examined bivariate differences in past 12-month PD misuse among binary transgender women, binary transgender men, nonbinary individuals assigned-female-at-birth (AFAB), and nonbinary individuals assigned-male-at-birth (AMAB). We then used multivariable logistic regression (separately based on sex-assigned-at-birth) to examine the relationship between gender-identity related discrimination and PD misuse. RESULTS: PD misuse was significantly more common among binary transgender men (17.3 %), nonbinary AFAB individuals (18.7 %), and nonbinary AMAB individuals (18.0 %); compared to binary transgender women (13.5 %). In multivariable analyses, nonbinary identity was associated with higher odds of PD misuse among TGNB AFAB individuals (OR = 1.121; 95 %CI 1.021-1.232) and AMAB individuals (OR = 1.315; 95 % CI 1.133-1.527). Controlling for overall health status and psychological distress, public accommodations discrimination was associated with PD misuse among TGNB AMAB individuals (OR = 1.578, 95 %CI 1.354-1.839). Among both groups, healthcare discrimination was associated with PD misuse (AFAB OR = 1.388, 95 %CI 1.255-1.534; AMAB OR = 1.227, 95 %CI 1.073-1.404). CONCLUSION: In this national sample of TGNB individuals, nonbinary individuals were at greater risk for PD misuse than binary individuals, possibly due to less societal affirmation. Similar to other TGNB health disparities, discrimination based on gender identity/expression was associated with PD misuse. This highlights the importance of interventions to reduce discrimination against TGNB individuals.