Determinants of prescription opioid misuse among Black Americans: Evidence from the 2019 National Survey on Drug Use and Health.

BACKGROUND: Opioid misuse, including prescription opioid misuse, remains a significant public health concern impacting various ethnoracial groups in the United States, including non-Hispanic Black Americans. This study provides more recent evidence on prescription opioid misuse among Black Americans. METHODS: We used data from the 2019 National Survey on Drug Use and Health to examine the prevalence and determinants of prescription opioid misuse among Black American adults aged 18 and older. We compared these findings to non-Hispanic White American adults. RESULTS: The prevalence rate of past-year prescription opioid misuse was very similar among Black (3.4%) and White respondents (3.8%). Adjusted multivariate logistic regression analyses found no significant racial differences in prescription opioid misuse. Religious importance and rurality were negatively associated with misuse only among Black respondents. Depressive episodes, other drug use, age, and risk-taking behaviors were associated with prescription opioid misuse among both Black and White respondents. CONCLUSION: Black and White Americans remain at risk for prescription opioid-related problems. Religiosity and rurality require further investigation to understand how they may impact misuse among Black Americans.

Adherence to Opioid Prescribing Guidelines in a Statewide Surgical Quality Improvement Collaborative.

INTRODUCTION: The opioid crisis is an ongoing crisis in the United States. Postoperative patients who receive opioid prescriptions have a 3%-7% risk of developing a chronic opioid abuse problem. This study aims to describe on-target opioid prescribing and use of multimodal pain management strategies 2 y after the implementation of a multicomponent quality improvement initiative across our statewide collaborative. METHODS: From July 2020 to September 2021, we prospectively collected data on opioid-prescribing and multimodal strategies for 10 targeted procedures in general, gynecologic, and orthopedic surgery at three hospitals. Prescribing was on-target if a patient was prescribed ≤50 daily morphine milligram equivalents. Multimodal strategies were defined as two or more nonopioid adjuncts used within 48 h of surgery. RESULTS: One thousand and eleven targeted procedures were performed with prescription data available for 993 cases. The on-target prescribing rate was 79.6% (n = 790), with general surgery 92.5% (n = 285), gynecology 84.9% (n = 331), and orthopedic surgery 59.0% (n = 174). Patients who received multimodal pain approaches were associated with interventions such as patient education, transversus abdominus plane block, and prescriptions for nonopioid analgesics at discharge. There was no evidence to support a difference in the use of multimodal pain control approaches between patients whose opioid prescribing was on-target or not (73.8% versus 77.3%, P = 0.30). At the first postoperative visit, data on continued opioid use were missing in 57.3% of patients, number of pills used was missing in 93.8%, and adequate pain control was missing in 52.8%. CONCLUSIONS: On-target prescribing and multimodal strategies are common but vary by specialty. Additionally, postoperative pain control and opioid use are often not documented. To better match prescribing to patient needs, understanding patient-level and specialty-level opioid use is important.

High-risk Opioid Prescribing Associated with Postoperative New Persistent Opioid Use in Adolescents and Young Adults.

OBJECTIVE: In this study, we explored which postoperative opioid prescribing practices were associated with persistent opioid use among adolescents and young adults. BACKGROUND: Approximately 5% of adolescents and young adults develop postoperative new persistent opioid use. The impact of physician prescribing practices on persistent use among young patients is unknown. METHODS: We identified opioid-naïve patients aged 13 to 21 who underwent 1 of 13 procedures (2008-2016) and filled a perioperative opioid prescription using commercial insurance claims (Optum Deidentified Clinformatics Data Mart Database). Persistent use was defined as ≥ 1 opioid prescription fill 91 to 180 days after surgery. High-risk opioid prescribing included overlapping opioid prescriptions, co-prescribed benzodiazepines, high daily prescribed dosage, long-acting formulations, and multiple prescribers. Logistic regression modeled persistent use as a function of exposure to high-risk prescribing, adjusted for patient demographics, procedure, and comorbidities. RESULTS: High-risk opioid prescribing practices increased from 34.9% to 43.5% over the study period; the largest increase was in co-prescribed benzodiazepines (24.1%-33.4%). High-risk opioid prescribing was associated with persistent use (aOR 1.235 [1.12,1.36]). Receipt of prescriptions from multiple opioid prescribers was individually associated with persistent use (aOR 1.288 [1.16,1.44]). The majority of opioid prescriptions to patients with persistent use beyond the postoperative period were from nonsurgical prescribers (79.6%). CONCLUSIONS: High-risk opioid prescribing practices, particularly receiving prescriptions from multiple prescribers across specialties, were associated with a significant increase in adolescent and young adult patients' risk of persistent opioid use. Prescription drug monitoring programs may help identify young patients at risk of persistent opioid use.

Dynamic changes in methadone utilisation for opioid use disorder treatment: a retrospective observational study during the COVID-19 pandemic.

OBJECTIVES: Opioid use disorder (OUD) is a major public health concern in the USA, resulting in high rates of overdose and other negative outcomes. Methadone, an OUD treatment, has been shown to be effective in reducing the risk of overdose and improving overall health and quality of life. This study analysed the distribution of methadone for the treatment of OUD across the USA over the past decade and through the COVID-19 pandemic. DESIGN: Retrospective observational study using secondary data analysis of the Drug Enforcement Administration and Medicaid Databases. SETTING: USA. PARTICIPANTS: Patients who were dispensed methadone at US opioid treatment programmes (OTPs). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcomes were the overall pattern in methadone distribution and the number of OTPs in the USA per year. The secondary outcome was Medicaid prescriptions for methadone. RESULTS: Methadone distribution for OUD has expanded significantly over the past decade, with an average state increase of +96.96% from 2010 to 2020. There was a significant increase in overall distribution of methadone to OTP from 2010 to 2020 (+61.00%, p<0.001) and from 2015 to 2020 (+26.22%, p<0.001). However, the distribution to OTPs did not significantly change from 2019 to 2021 (-5.15%, p=0.491). There was considerable state-level variation in methadone prescribing to Medicaid patients with four states having no prescriptions. CONCLUSIONS: There have been dynamic changes in methadone distribution for OUD. Furthermore, pronounced variation in methadone distribution among states was observed, with some states having no OTPs or Medicaid coverage. New policies are urgently needed to increase access to methadone treatment, address the opioid epidemic in the USA and reduce overdose deaths.

Risk Factors Associated With Prolonged Opioid Use After Revision Total Shoulder Arthroplasty.

INTRODUCTION: The purpose of this study was to determine which preoperative factors are associated with prolonged opioid use after revision total shoulder arthroplasty (TSA). METHODS: The M157Ortho PearlDiver database was used to identify patients undergoing revision TSA between 2010 and 2021. Opioid use for longer than 1 month after surgery was defined as prolonged opioid use. Postoperative opioid use from 1 to 3 months was independently assessed. Multivariable logistic regression was used to evaluate the association between preoperative patient-related risk factors (age, Charlson Comorbidity Index, sex, depression, anxiety, substance use disorder, opioid use between 12 months to 1 week of surgery, tobacco use, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, osteoporosis, previous myocardial infarction, and chronic ischemic heart disease) with prolonged postoperative opioid use. Odds ratios (OR) and their associated 95% confidence intervals (CI) were calculated for each risk factor. RESULTS: A total 14,887 patients (mean age = 67.1 years) were included. Most of the patients were female (53.3%), and a large proportion were opioid familiar (44.1%). Three months after revision TSA, older age (OR = 0.96, CI 0.96 to 0.97) and male sex (OR = 0.90, CI 0.81 to 0.99) were associated with a decreased risk of prolonged postoperative opioid usage. Patients with preexisting depression (OR = 1.21, CI 1.08 to 1.35), substance use disorder (OR = 1.47, CI 1.29 to 1.68), opioid use (OR = 16.25, CI 14.27 to 18.57), and chronic obstructive pulmonary disorder (OR = 1.24, CI 1.07 to 1.42) were at an increased risk of prolonged postoperative opioid use. DISCUSSION: Older age and male sex were associated with a decreased risk of prolonged opioid use after revision TSA. Depression, substance use disorder, opioid familiarity, and COPD were associated with prolonged opioid use after revision TSA.

Are pharmacists on the front lines of the opioid epidemic? A cross-sectional study of the practices and competencies of community and hospital pharmacists in Punjab, Pakistan.

INTRODUCTION: Countries are grappling with a rapidly worsening upsurge in the opioid-related overdose deaths, misuse and abuse. There is a dearth of data in Pakistan regarding the practices and competencies of pharmacists in handling opioid-related issues. STUDY DESIGN: A cross-sectional study, conducted across Punjab, Pakistan. METHOD: The study deployed a validated survey to evaluate the competencies and practices of the community and hospital pharmacists. RESULTS: 504 community pharmacists and 279 hospital pharmacists participated in the survey with an overall response rate of 85.5%. Almost half of the respondents 'never' or 'sometimes' made clinical notes in a journal or dispensing software to monitor ongoing opioid use. Generally, pharmacists were reluctant to collaborate with physicians or notify police regarding the abuse/misuse of opioids. Hospital pharmacists achieved significantly higher mean competency scores than chain and independent community pharmacists (p<0.05). In competency evaluation, three priority areas emerged that require additional training, that is, 'opioid overdose management', 'opioid use monitoring' and 'therapeutic uses of opioids'. CONCLUSION: Both community and hospital pharmacists hold significant positions and potential to contribute meaningfully to the mitigation of harms and risks associated with opioids. Nevertheless, this study underscores notable deficiencies in the competence of pharmacists, whether in hospital or community settings in Punjab, concerning various aspects related to the dispensing and utilisation of opioids. It also highlights the pressing need for the development of strategies aimed at improving several practice areas including the documentation, the quality of patient counselling, the effectiveness of reporting mechanisms for opioid abuse and the stringent enforcement of regulatory policies to curtail opioid misuse. Thus, to mitigate the opioid epidemic in Pakistan, it is imperative to institute opioid stewardship initiatives aimed at rectifying the competency and procedural deficiencies within the pharmacist workforce.

Rapid Access Addiction Medicine Clinics for People With Problematic Opioid Use.

Importance: New approaches are needed to provide care for individuals with problematic opioid use (POU). Rapid access addiction medicine (RAAM) clinics offer a flexible, low-barrier, rapid access care model for this population. Objective: To assess the associations of RAAM clinics with emergency department (ED) visits, hospitalizations, and mortality for people with POU. Design, Setting, and Participants: A retrospective cohort study involving a matched control group was performed using health administrative data from Ontario, Canada. Anonymized data from 4 Ontario RAAM clinics (cities of Ottawa, Toronto, Oshawa, and Sudbury) were linked with health administrative data. Analyses were performed on a cohort of individuals who received care at participating RAAM clinics and geographically matched controls who did not receive care at a RAAM clinic. All visits occurred between October 2, 2017, and October 30, 2019, and data analyses were completed in spring 2023. A propensity score-matching approach was used to balance confounding factors between groups, with adjustment for covariates that remained imbalanced after matching. Exposures: Individuals who initiated care through the RAAM model (including assessment, pharmacotherapy, brief counseling, harm reduction, triage to appropriate level of care, navigation to community services and primary care, and related care) were compared with individuals who did not receive care through the RAAM model. Main Outcomes and Measures: The primary outcome was a composite measure of ED visits for any reason, hospitalization for any reason, and all-cause mortality (all measured up to 30 days after index date). Outcomes up to 90 days after index date, as well as outcomes looking at opioid-related ED visits and hospitalizations, were also assessed. Results: In analyses of the sample of 876 patients formed using propensity score matching, 440 in the RAAM group (mean [SD] age, 36.5 [12.6] years; 276 [62.7%] male) and 436 in the control group (mean [SD] age, 36.8 [13.8] years; 258 [59.2%] male), the pooled odds ratio (OR) for the primary, 30-day composite outcome of all-cause ED visit, hospitalization, or mortality favored the RAAM model (OR, 0.68; 95% CI, 0.50-0.92). Analysis of the same outcome for opioid-related reasons only also favored the RAAM intervention (OR, 0.47; 95% CI, 0.29-0.76). Findings for the individual events of hospitalization, ED visit, and mortality at both 30-day and 90-day follow-up also favored the RAAM model, with comparisons reaching statistical significance in most cases. Conclusions and Relevance: In this cohort study of individuals with POU, RAAM clinics were associated with reductions in ED visits, hospitalizations, and mortality. These findings provide valuable evidence toward a broadened adoption of the RAAM model in other regions of North America and beyond.

Should We Use COMM (Current Opioid Misuse Measure) to Screen for Opioid Abuse in Patients With Cancer Pain?

BACKGROUND: Growing concerns about opioid use disorder (OUD) and the resulting decrease in opioid availability for patients with cancer pain highlight the need for reliable screening tools to identify the subset of patients at increased risk for aberrant opioid use. Our study examines the utility of Current Opioid Misuse Measure (COMM) recommended by the NCCN Clinical Practice Guidelines in Oncology for Adult Cancer Pain. PATIENTS AND METHODS: We analyzed prospectively collected patient-reported outcomes of 444 consecutive patients with cancer seen in pain clinics of a cancer center at 2 time points within 100 days. The relationship of COMM to other OUD screening tools, pain, opioid doses, patient demographics, and mortality was examined using univariate and multivariable logistic regression. We also examined individual items of COMM for face validity. RESULTS: Among 444 patients who completed pain surveys at 2 time points, 157 (35.4%) did not complete COMM surveys. Using a COMM cutoff of ≥13, a total of 84 patients (29.3%; 84/287) scored positive for aberrant drug use. As patients remained on opioids for 49 to 100 days, the likelihood of improving COMM score (turning from positive to negative) was 6.1 times greater than the reverse. The number of patients with COMM ≥13 was 3.8 times higher than the number of patients with CPT diagnostic codes for OUD, 5.3 times higher than those with a positive urine drug screening, and 21 times higher than those with a positive CAGE (Cut Down, Annoyed, Guilty, Eye-Opener Questionnaire) score. COMM ≥13 was not associated with pain relief response (worst pain intensity score ≥2 points on the Brief Pain Inventory), opioid doses, gender, or age. Contrary to the intended use of COMM to identify aberrant opioid use, COMM ≥13 predicted mortality: patients with COMM ≥13 were 1.9 times more likely to die within 12 months. CONCLUSIONS: Our study found that using COMM in a cancer population may significantly overestimate the risk of opioid misuse. Using COMM without modifications can create an additional barrier to cancer pain management, such as limiting appropriate opioid use.

Opioid-Related Trends in Active Duty Service Members During the Coronavirus Disease 2019 Pandemic.

INTRODUCTION: The USA is experiencing an opioid epidemic. Active duty service members (ADSMs) are at risk for opioid use disorder (OUD). The Coronavirus disease 2019 (COVID-19) pandemic has disrupted health care and introduced additional stressors. METHODS: The Military Healthcare System Data Repository was used to evaluate changes in diagnosis of OUD, medications for OUD (MOUD), opioid overdose (OD), and opioid rescue medication. ADSMs ages 18-45 years enrolled in the Military Healthcare System between February 2019 and April 2022 were included. Joinpoint Trend Analysis Software calculated the average monthly percent change over the study period, whereas Poisson regression compared outcomes over three COVID-19 periods: Pre-lockdown (pre-COVID-19 period 0) (February 2019-February 2020), early pandemic until ADSM vaccination initiation (COVID-19 period 1 [CP1]) (March 2020-November 2020), and late pandemic post-vaccination initiation (COVID-19 period 2 [CP2]) (December 2020-April 2022). RESULTS: A total of 1.86 million eligible ADSMs received care over the study period. Diagnoses of OUD decreased 1.4% monthly, MOUD decreased 0.6% monthly, diagnoses of opioid OD did not change, and opioid rescue medication increased 8.5% monthly.Diagnoses of OUD decreased in both COVID-19 time periods: CP1 and CP2: Rate ratio (RR) = 0.74 (95% CI, 0.68-0.79) and RR = 0.72 (95% CI, 0.67-0.76), respectively. MOUD decreased in both CP1 and CP2: RR = 0.77 (95% CI, 0.68-0.88) and RR = 0.86 (95% CI, 0.78-0.96), respectively. Adjusted rates for diagnoses of opioid OD did not vary in either COVID-19 time period. Opioid rescue medication prescriptions increased in CP1 and CP2: RR = 1.09 (95% CI, 1.02-1.15) and RR = 6.02 (95% CI, 5.77-6.28), respectively. CONCLUSIONS: Rates of OUD and MOUD decreased, whereas rates of opioid rescue medication increased during the study period. Opioid OD rates did not significantly change in this study. Changes in the DoD policy may be affecting rates with greater effect than COVID-19 pandemic effects.

The Role of Non-Pharmaceutical Fentanyl-Contaminated Counterfeit Oxycodone in Increasing Opioid Overdoses: A Commentary Review.

Importance: Opioid misuse/abuse is a pervasive problem in the United States, and the growing use of fentanyl-contaminated products is adding fuel to the opioid crisis.Objective: To review the rising prevalence of nonprescription fentanyl in counterfeit oxycodone, paying specific attention to oxycodone for cost analysis.Evidence Review: A literature search was performed using 3 databases (Google Scholar, PubMed, and Clinical Key) to identify English-language articles published from January 2010 to October 2022. Search terms were street oxycodone and prescription oxycodone, street oxycodone. An additional search of fentanyl was performed to gather more information about the pharmacology behind fentanyl overdoses. Studies and articles were selected based on information related to the presence of non-prescription fentanyl in illicit supplies of oxycodone. Additional articles were included to demonstrate the cost, manufacturing, and overdose rates of fentanyl-laced counterfeit opioids. A total of 13 articles were included in the final review.Findings: The demand for illicit oxycodone provides an opportunity in which counterfeiters can thrive, using dangerous adulterating agents such as fentanyl to maximize their profits. Those purchasing oxycodone illicitly may or may not be aware of the presence of fentanyl in their tablets, which has clearly resulted in rising overdose numbers.Conclusion: Clinicians should counsel patients at risk for opioid misuse on the risks of counterfeit oxycodone.Prim Care Companion CNS Disord 2023;25(6):22nr03433. Author affiliations are listed at the end of this article.

New Persistent Opioid Use After Childbirth.

OBJECTIVE: To examine factors associated with new persistent opioid use after childbirth. METHODS: We conducted a population-based cohort study of individuals who initiated opioid therapy within 7 days of discharge from hospital after delivery between September 1, 2013, and September 30, 2021. The primary outcome was new persistent opioid use , which was defined as one or more prescriptions for an opioid within 90 days of the first postpartum prescription and one or more subsequent opioid prescriptions in the 91-365 days afterward. We used multivariable logistic regression to assess patient-, pregnancy-, and prescription-related factors associated with new persistent opioid use after delivery. RESULTS: We identified 118,694 unique deliveries after which opioids were initiated, including 99,399 cesarean (83.7%) and 19,295 vaginal (16.3%) deliveries. Among mothers who initiated an opioid after delivery, 1,282 (10.8/1,000 deliveries) met our definition of new persistent opioid use in the subsequent year. Rates of new persistent opioid use were appreciably higher after vaginal (16.0/1,000) compared with cesarean (9.8/1,000) deliveries. Each additional 30 morphine milligram equivalents in the initial opioid prescription was associated with an increased risk of new persistent use after cesarean (adjusted odds ratio [aOR] 1.06, 95% CI 1.04-1.08) and vaginal (aOR 1.05, 95% CI 1.02-1.08) delivery. A concomitant benzodiazepine prescription after cesarean delivery was associated with a markedly increased risk of persistent opioid use (aOR 2.69, 95% CI 1.60-4.52). CONCLUSION: Among people who filled an opioid prescription after delivery, about 1% displayed evidence of persistent opioid use in the subsequent year. Initial prescriptions for large quantities of opioids and a concurrent benzodiazepine prescription may be important modifiable risk factors to prevent new persistent opioid use after delivery.

Postmortem toxicology findings from the Camden Opioid Research Initiative.

The United States continues to be impacted by decades of an opioid misuse epidemic, worsened by the COVID-19 pandemic and by the growing prevalence of highly potent synthetic opioids (HPSO) such as fentanyl. In instances of a toxicity event, first-response administration of reversal medications such as naloxone can be insufficient to fully counteract the effects of HPSO, particularly when there is co-occurring substance use. In an effort to characterize and study this multi-faceted problem, the Camden Opioid Research Initiative (CORI) has been formed. The CORI study has collected and analyzed post-mortem toxicology data from 42 cases of decedents who expired from opioid-related toxicity in the South New Jersey region to characterize substance use profiles. Co-occurring substance use, whether by intent or through possible contamination of the illicit opioid supply, is pervasive among deaths due to opioid toxicity, and evidence of medication-assisted treatment is scarce. Nearly all (98%) of the toxicology cases show the presence of the HPSO, fentanyl, and very few (7%) results detected evidence of medication-assisted treatment for opioid use disorder, such as buprenorphine or methadone, at the time of death. The opioid toxicity reversal drug, naloxone, was detected in 19% of cases, but 100% of cases expressed one or more stimulants, and sedatives including xylazine were detected in 48% of cases. These results showing complex substance use profiles indicate that efforts at mitigating the opioid misuse epidemic must address the complications presented by co-occurring stimulant and other substance use, and reduce barriers to and stigmas of seeking effective medication-assisted treatments.

Reasons for emergency department visits of patients with opioid use disorder at an urban safety-net hospital: A retrospective records review.

OBJECTIVES: The purpose of this study was to describe the emergency department (ED) visit chief complaints and discharge diagnoses of patients with an opioid use disorder (OUD) empaneled to a primary care clinic. DESIGN: ED visits were retrospectively reviewed through electronic health records. Patients with a history of using multiple substances and medical or psychiatric conditions were compared to those without these conditions. SETTING: This study was conducted at Harbor-UCLA ED, a safety-net level one trauma center. PATIENTS AND PARTICIPANTS: Eligible participants were empaneled to the Harbor-UCLA Family Health Center with a diagnosis of OUD between January 1, 2018, and December 31, 2020. MAIN OUTCOME MEASURES: The primary outcome measures included number of ED visits, hospital admissions, chief complaints, and discharge diagnoses. RESULTS: The total number of patients was 59. The most common chief complaints were musculoskeletal (34 percent), gastrointestinal (18 percent), general (13 percent), and skin (8.6 percent). The most common discharge diagnoses were musculoskeletal (27 percent), gastrointestinal (20 percent), infectious (11 percent), substance use disorder related (11 percent), psychiatric (7 percent), and cardiovascular (7 percent). Co-occurring alcohol use was associated with a higher number of visits, 3.18 versus 1.15 (p = 0.021), and a higher percentage of patients with frequent visits, 46 percent versus 8 percent (p = 0.008). Patients with diabetes had more frequent visits, 40 percent versus 10 percent (p = 0.036), and were more likely to be admitted, 43 percent versus 15 percent (p = 0.010). CONCLUSIONS: This study highlights the importance of screening and the management of alcohol use and diabetes among patients with OUD.

Opioid dose risk, clinician and patient characteristics, and adherence to opioid prescribing recommendations in chronic non-cancer pain.

OBJECTIVE: This study aims to assess associations between morphine-equivalent daily dose (MEDD) of opioids, clinician and patient characteristics, and prescriber adherence to guidelines for long-term opioid therapy (LTOT) in chronic noncancer pain (CNCP) and to elucidate potential relationships associated with increased-risk opioid prescribing. DESIGN: Retrospective cross-sectional study. SETTING: Academic health system's 33 primary care clinics. PATIENTS: Adults (≥18 years old) prescribed LTOT (10 + outpatient prescriptions in the past year) for CNCP. MAIN OUTCOME MEASURE(S): Electronic health record data on prescribed opioids (for MEDD), clinician/patient characteristics, and adherence rates to LTOT guideline-concordant recommendations. RESULTS: A total of 2,738 patients were eligible, 61.6 percent Lower, 15.7 percent Moderate, and 22.7 percent Higher Risk MEDD (<50, 50-89, and ≥90 mg/day, respectively). Higher MEDD correlated (p < 0.001) with Medicare insurance, current cigarette smoking, higher pain intensity and interference scores, and the presence of opioid use disorder diagnoses. Male clinicians more frequently prescribed (p < 0.001) and male patients were more likely to be prescribed (p < 0.001) higher MEDD compared to their female counterparts. Higher Risk MEDD was associated with higher coprescribed benzodiazepines (p = 0.015), lower depression screening (p = 0.048), urine drug testing (p = 0.003), comparable active treatment agreement (p = 0.189), opioid misuse risk screening (p = 0.619), and prescription drug monitoring checks (p = 0.203). CONCLUSIONS: This study documented that higher MEDD was associated with risks of worse health outcomes without improved adherence to opioid prescribing guideline recommendations. Enhanced clinician awareness of factors associated with MEDD has the potential to mitigate LTOT risks and improve overall patient care.

Changes in opioid agonist treatment initiation among people prescribed opioids for pain following voluntary and mandatory prescription drug monitoring program implementation: A time series analysis.

INTRODUCTION: Prescription drug monitoring programs (PDMP) are increasingly used to identify people prescribed high-dose opioids. However, little is known about whether PDMPs impact opioid agonist treatment (OAT) uptake, the gold standard for opioid use disorder. This study examined the impact of PDMP implementation on OAT initiation among people prescribed opioids, in Victoria, Australia. METHODS: De-identified electronic records from all 464 Victorian general practices included in the POLAR database were used. OAT initiation was defined as a new OAT prescription between 1 April 2017 and 31 December 2020, with no OAT prescriptions in the year prior. Interrupted time series analyses were used to compare outcomes before (April 2017 to March 2019) and after (April 2019 to December 2020) PDMP implementation. Binary logistic regression was used to examine differences in patients' characteristics associated with OAT initiation prior to and after PDMP implementation. RESULTS: In total, 1610 people initiated OAT, 946 before and 664 after PDMP implementation. No significant immediate (step) or longer-term (slope) changes in the rates of OAT initiation were identified following PDMP implementation, after adjusting for seasonality. A high opioid dose (>100 mg oral morphine equivalent) in the 6-months prior to OAT initiation was the only significant characteristic associated with reduced odds of OAT initiation post-PDMP implementation (odds ratio 0.29; 0.23-0.37). DISCUSSION AND CONCLUSIONS: PDMP implementation did not have a significant impact on OAT initiation among people prescribed opioids. Findings suggest additional clinical initiatives that support OAT initiation are required to ensure PDMPs meet their intended target of reducing opioid-related harms.

Investigating the co-occurrence of marijuana use and prescription opioid misuse with multiple suicide attempts among adolescents with a history of suicidal ideation.

This study investigated the co-occurrent association of marijuana use and prescription opioid misuse with multiple suicide attempts among adolescents with a history of suicidal ideation. Data came from the 2019 Youth Risk Behavior Survey. The sample was comprised of adolescents ages 14-18 who reported suicidal ideation during the past year (n = 2,562). Multinomial logistic regression was used to examine the co-occurring association of marijuana use and prescription opioid misuse with multiple suicide attempts. Of the 2,562 adolescents who experienced suicidal ideation, 19.2 % also attempted suicide multiple times during the past year and 19.0 % reported ever using marijuana and misusing prescription opioids, 8.8 % misused prescription opioids only, and 33.3 % used marijuana only. In the multivariate model, for adolescents who used marijuana and misused prescription opioid, the risk of attempting suicide once was 1.77 times higher (RRR = 1.77, 95 % CI = 1.22-2.59) and the risk of multiple suicide attempts was 3.23 times higher (RRR = 3.23, 95 % CI = 1.95-5.33) when compared to adolescents who had never used marijuana nor misused prescription opioid. The risk of multiple suicide attempts was greater for bisexual and racial/ethnic minority adolescents and adolescents who felt sad or hopeless. Interventions that prevent prescription opioid misuse among adolescents may be effective in mitigating suicide attempts.

Prescription drugs with potential for misuse in Irish prisons: analysis of national prison prescribing trends, by gender and history of opioid use disorder, 2012 to 2020.

BACKGROUND: Pharmacotherapy is essential for the delivery of an equivalent standard of care in prison. Prescribing can be challenging due to the complex health needs of prisoners and the risk of misuse of prescription drugs. This study examines prescribing trends for drugs with potential for misuse (opioids, benzodiazepines, Z-drugs, and gabapentinoids) in Irish prisons and whether trends vary by gender and history of opioid use disorder (OUD). METHODS: A repeated cross-sectional study between 2012 and 2020 using electronic prescribing records from the Irish Prison Services, covering all prisons in the Republic of Ireland was carried out. Prescribing rates per 1,000 prison population were calculated. Negative binomial (presenting adjusted rate ratios (ARR) per year and 95% confidence intervals) and joinpoint regressions were used to estimate time trends adjusting for gender, and for gender specific analyses of prescribing trends over time by history of OUD. RESULTS: A total of 10,371 individuals were prescribed opioid agonist treatment (OAT), opioids, benzodiazepines, Z-drugs or gabapentinoids during study period. History of OUD was higher in women, with a median rate of 597 per 1,000 female prisoners, compared to 161 per 1,000 male prisoners. Prescribing time trends, adjusted for gender, showed prescribing rates decreased over time for prescription opioids (ARR 0.82, 95% CI 0.80-0.85), benzodiazepines (ARR 0.99, 95% CI 0.98-0.999), Z-drugs (ARR 0.90, 95% CI 0.88-0.92), but increased for gabapentinoids (ARR 1.07, 95% CI 1.05-1.08). However, prescribing rates declined for each drug class between 2019 and 2020. Women were significantly more likely to be prescribed benzodiazepines, Z-drugs and gabapentinoids relative to men. Gender-specific analyses found that men with OUD, relative to men without, were more likely to be prescribed benzodiazepines (ARR 1.49, 95% CI 1.41-1.58), Z-drugs (ARR 10.09, 95% CI 9.0-11.31), gabapentinoids (ARR 2.81, 95% CI 2.66-2.97). For women, history of OUD was associated with reduced gabapentinoid prescribing (ARR 0.33, 95% CI 0.28-0.39). CONCLUSIONS: While the observed reductions in prescription opioid, benzodiazepine and Z-drug prescribing is consistent with guidance for safe prescribing in prisons, the increase in gabapentinoid (primarily pregabalin) prescribing and the high level of prescribing to women is concerning. Our findings suggest targeted interventions may be needed to address prescribing in women, and men with a history of OUD.

The impact of COVID-19 on opioid toxicity deaths for people who experience incarceration compared to the general population in Ontario: A whole population data linkage study.

BACKGROUND: To inform preparedness and population health action, we need to understand the effects of COVID-19 on health inequities. In this study, we assess the impact of COVID-19 on opioid toxicity deaths among people who experience incarceration compared to others in the general population in Ontario, Canada. METHODS: We conducted a retrospective cohort study for the period of January 1, 2015 to December 31, 2020. We accessed and linked coronial data on all opioid toxicity deaths in Ontario with correctional data for people aged 18 years and older who were incarcerated in a provincial correctional facility. We used data from the Statistics Canada Census to calculate whole population rates. We used an interrupted time series design and segmented regression to assess for change in the level or rate of increase in deaths due to opioid toxicity coinciding with the COVID-19 pandemic. We compared the impact of COVID-19 on the opioid toxicity death rates for people exposed and not exposed to incarceration. RESULTS: Rates of opioid toxicity death increased with a linear positive slope in both persons exposed to incarceration and those not exposed over the study period. The start of COVID-19 measures coincided with a marked upward shift in the trend lines with modification of the effect of COVID-19 by both sex and exposure to incarceration. For persons exposed to incarceration, the risk ratio (RR) was 1.50 (95%CI 1.35-1.69) for males and 1.21 (95%CI 1.06-1.42) for females, and for persons not exposed to incarceration, the RR was 1.25 (95%CI 1.13-1.38) for males and not significant for females. CONCLUSIONS: COVID-19 substantially exacerbated the risk of opioid toxicity death, impacting males and females who experienced incarceration more than those who had not, with an immediate stepwise increase in risk but no change in the rate of increase of risk over time. Public health work, including pandemic preparedness, should consider the specific needs and circumstances of people who experience incarceration.