Stigma of opioid addiction: A narcoleptic patient blamed for being excessively sleepy during the day due to her opioid use disorder

This review aims to examine prescribed short-term opioid use in adolescents to treat acute pain. The review will analyze the influence of opioid use on future non-medical opioid use (misuse) or substance use disorders (addiction) in adolescents and young adults. Prescription opioids are medically indicated for acute pain. Descriptive studies of administrative datasets and surveys implicate adolescent opioid exposure as a risk factor for subsequent opioid misuse and addiction. This review will provide a synthesis of the literature on the association between prescribed opioid exposure to treat acute pain in adolescents and the subsequent development of opioid misuse or substance use disorders in adolescents and young adults. This review will consider quantitative studies on opioid misuse or substance use disorders in Canadian and US adolescents and young adults (12 to 25 years of age). Studies must include exposure during adolescence (12 to 17 years of age) to legitimately prescribed short-term opioid use to treat acute pain. Studies on chronic pain or exposure to opioids for longer duration (more than 30 doses or more than 7 days) will be excluded. This review will follow the JBI methodology for systematic reviews of etiology and risk. Published and unpublished studies will be sourced from multiple databases and resources. Two independent reviewers will screen, appraise, and extract data from studies that meet the inclusion criteria. Data synthesis will be conducted and a Summary of Findings will be presented. PROSPERO CRD42020179635.

Opioid use and stigma: The role of gender, language and precipitating events

About 1 in 8 children under age 17 live with a parent who has a substance use disorder. Research on treatment access identifies stigma as a significant barrier to treatment, particularly among mothers with young children. Well-meaning but punitive state policies further perpetuate stigma, which harms families and children. Explore the experiences of the stigma of addiction on mothers before, during and after treatment for substance use disorder. Procedures/data/observations: Descriptive Phenomenology was used to describe the experiences of stigma of mothers with opioid use disorder (OUD) through all stages of treatment and recovery. Mothers (n=20) participating in an outpatient treatment program interviewed. A semi-structured interview schedule was used to guide the interviews and thematic analysis was used identify themes related to stigma. Our analysis identified several main themes and subthemes related to internal and external sigma, including stigma against medication for opioid use dis order, stigma from the public and healthcare professionals, internalized shame, and how mothers learned to recover and heal from stigma.

The intertwined themes that emerge from these passionately told narratives demonstrate how difficult it can be to navigate chronic pain. Many authors describe the labor of living in chronic pain, and several refer to their use of opioid medication as a tool to facilitate participation. The relationship between tolerance, dependence, and addiction is touched on in a handful of narratives, with some authors confronting-and seemingly internalizing-the stigma of addiction in seeking to regulate their opioid use. A related theme is the reduction of opioid medication; a few authors pronounce consensual tapering as beneficial, while others denounce non-consensual tapering as harmful. Most authors also assert their right to make pain management decisions without bureaucratic interference, suggesting that they and other chronic pain patients face reduced access to opioid prescriptions as a result of inappropriately applied governmental guidelines. As richly detailed and informative as these narratives are, they scarcely engage with the reality that chronic pain disproportionately burdens patients who are less privileged in terms of education, race, gender, and class.

"Houston, We Have a Problem!": The Role of the Anesthesiologist in the Current Opioid Epidemic.

BackgroundThe purpose of this study was to investigate the use of opioids before and after total hip arthroplasty (THA), to find out the effect of opioid use on mortality in patients with THA, and to analyze whether preoperative opioid use is a risk factor for sustained opioid use after surgery using Korean nationwide cohort data.MethodsThis retrospective nationwide study identified subjects from the Korean National Health Insurance Service-Sample cohort (NHIS-Sample) compiled by the Korean NHIS. The index date (time zero) was defined as 90 days after an admission to a hospital to fulfill the eligibility criteria of the THA.ResultsIn the comparison of death risk according to current use and the defined daily dose of tramadol and strong opioids in each patient group according to past opioid use, there were no statistically significant differences in the adjusted hazard ratio for death compared to the current non-users in all groups (P > 0.05). Past tramadol and strong opioid use in current users increased the risk of the sustained use of tramadol and strong opioids 1.45-fold (adjusted rate ratio [aRR]; 95% confidence interval [CI], 1.12–1.87; P = 0.004) and 1.65-fold (aRR; 95% CI, 1.43–1.91; P < 0.001), respectively, compared to past non-users.ConclusionIn THA patients, the use of opioids within 6 months before surgery and within 3 months after surgery does not affect postoperative mortality, but a past-use history of opioid is a risk factor for sustained opioid use. Even after THA, the use of strong opioids is observed to increase compared to before surgery.

In reply:

Revisiting pharmacy-based naloxone with pharmacists and naloxone consumers in 2 states: 2017 perspectives and evolving approaches

Commentary: Everybody hurts, sometimes: ERAS against opioids

Opioids have been studied as a potential risk factor for dementia, but evidence concerning long-term noncancer opioid use and exclusive use of weak opioids and associated dementia risk is sparse. To assess the association between cumulative noncancer use of opioids and risk of age-related all-cause dementia. This nested case-control study within a population-based cohort included 1 872 854 individuals without previous dementia, cancer, opioid addiction, or opioid use in terminal illness. Data were obtained from national Danish registers. Each individual who developed dementia during follow-up was incidence-density matched to 5 dementia-free controls. Statistical analysis was performed from August 2023 to March 2024. Cumulative opioid exposure was based on filled prescriptions available from 1995 through 2020. Conditional logistic regression provided adjusted incidence rate ratios (IRRs) for associations between opioids and dementia. Among 1 872 854 individuals without previous dementia, cancer, opioid addiction, or opioid use in terminal illness included in the study, 93 638 (5.0%) developed all-cause dementia during follow-up (51 469 [55.0%] female; median [IQR] age, 78.1 [73.0-82.8] years) and were matched to 468 190 control individuals (257 345 [55.0%] female; median [IQR] age, 78.0 [73.0-82.8] years). Opioid use up to 90 total standardized doses (TSDs) was not consistently associated with dementia risk. Opioid exposure above 90 TSDs yielded increased IRRs of dementia occurring before age 90 years ranging from 1.29 (95% CI, 1.17-1.42) for 91 to 200 TSDs to 1.59 (95% CI, 1.44-1.76) for greater than 500 TSDs for age-band 60 to 69 years at dementia diagnosis. Corresponding IRRs were 1.16 (95% CI, 1.11-1.22) to 1.49 (95% CI, 1.42-1.57) for age-band 70 to 79 years and 1.08 (95% CI, 1.03-1.14) to 1.21 (95% CI, 1.16-1.27) for 80 to 89 years. Sensitivity analyses corroborated associations in individuals with chronic noncancer pain and with use of weak opioids. This study found that opioid use of less than 90 TSDs was not significantly associated with increased dementia risk. Above 90 TSDs of opioid use was associated with an elevated dementia risk before age 90 years, which persisted in individuals with chronic noncancer pain and in individuals solely exposed to weak opioids. Further research should ascertain whether the findings denote causality between opioids and dementia risk.

The downward spiral of chronic pain, prescription opioid misuse, and addiction: Cognitive, affective, and neuropsychopharmacologic pathways

The opioid epidemic is a recent focus of national initiatives to reduce opioid misuse and related addiction. As interstitial cystitis (IC) is a chronic pain state at risk for narcotic use, we sought to assess opioid prescription use in patients with IC. Data were accessed from the Virginia All Payers Claims Database. We identified female patients diagnosed with IC from 2011 to 2016 using International Classification of Disease codes. A patient identifier was used to link diagnoses with outpatient prescription claims for opioids using generic product identifiers. We then analyzed opioid prescriptions within 30days of a claim with a diagnosis of IC. A total of 6,884 patients with an IC diagnosis were identified. The median number of IC claims per patient was 2 (IQR 1 to 4). Mean patient age was 47.8. Twenty-eight percent of patients received at least 1 opioid prescription, with a median of 2 (IQR 1, 4) per patient. Among those receiving opioids, 185 (9.5%) had more than 10 opioid prescriptions, with a maximum of 129. The most common prescriptions were hydrocodone (n = 2,641, 32.3%), oxycodone (n = 2,545, 31.2%), and tramadol (n = 1,195, 14.6%). There was a decline in opioid prescriptions per month for IC, although the rate per IC diagnosis remained stable. A significant number of patients with IC are treated with opioids. Although the overall number of opioid prescriptions associated with IC had declined, the prescription rate per IC diagnosis had not. As part of the national initiative to reduce opioid use, our data suggest that IC treatment strategies should be examined.

Substitution of prescription opioid use by medical cannabis is not public health relevant, as it is restricted to substitution of a small subset of less potent opioids such as codeine. In addition, it substitutes one substance with abuse potential by another, and there are better alternatives available. Liang and colleagues 1 have presented a time–series analysis based on 21 years of state-level data of Medicaid records, in which they found that medical cannabis legalization was associated with substantial reductions in the number of Schedule III opioid prescriptions in the United States (−30%), their dosage (30%) and related Medicaid spending (−29%). Prescription opioids in Schedule III are characterized by lower abuse potential compared to opioids in Schedule II, with abuse of these opioids potentially leading to moderate or low physical dependence and/or high psychological dependence 2. In the analyses of Liang and colleagues 1, the Schedule III prescriptions made up only approximately 5% of all opioid prescriptions for the last year of analysis (2014), with codeine prescriptions comprising 99% of all Schedule III prescriptions. Codeine is used in the United States to treat mild to moderate pain and as a cough suppressant. Cannabis has been in use for both of these indications, and thus a substitution effect may be plausible. What would be the public health implications of a partial substitution? First, the overall substitution was not found to be affecting a large portion of the overall opioid prescription use. Secondly, however, codeine has an abuse potential. Although this abuse potential was evaluated to be lower compared to Schedule II opioids, abuse has been documented with both prescribed and over-the-counter codeine 3. Furthermore, codeine use may contribute as a gateway to other opioids, both prescription and illicit opioids, with high overdose potential 4, 5. Overall, the United States has, by far, globally the highest prescription opioid use per capita 6, and probably also the highest overall opioid use per capita in the world (i.e. combining prescription and illicit use), at least if indirectly inferred by opioid use disorders 7. The overall culture of medically overusing opioids has contributed markedly to this situation 8. What about cannabis? Its scheduling currently seems to be in flux, with many US states starting medical marijuana programs 9. However, while its consequences are not as detrimental as those of other drugs, in particular in terms of mortality 10, they are far from benign 11. Finally, the effectiveness of both codeine and cannabis for relieving moderate chronic pain seems to be limited, with no Cochrane Reviews supporting such a claim as primary drug of choice (e.g. 12, 13). Perhaps this judgement about effectiveness is premature for cannabis, with research to collect better evidence only now commencing, but it reflects the current evidence base. However, from a public health point of view, given the abuse potentials of both drugs involved, perhaps solutions should be sought with non-pharmacological therapies or with medications with less abuse potential than opioids or cannabis. The history of opioids in pain medication in North America should be a lesson. Despite limited evidence for effectiveness, prescription opioids were seen as a wonder drug, especially for pain management, with rapidly accelerating use to the point where they contributed markedly to a high level of opioid addiction on the population level and a major public health crisis 14, and decreasing life expectancies 15, 16. As a result, new national guidelines for opioid pain prescription stress non-pharmacological therapies and non-opioid medication as first-line treatment 17. We should not repeat this history with yet another wonder drug installed before proper evidence for effectiveness and well-documented unintentional consequences. Given the current evidence, there is no good reason not to start pain management with non-pharmacological therapies, but there are good reasons to limit the use of drugs with high abuse potential to the highest degree possible. None. The author acknowledges funding from the Canadian Institutes of Health Research, Institute of Neurosciences, Mental Health and Addiction (CRISM Ontario Node grant no. SMN-13950).

Long-term effects of opioids on the cardiovascular system

In an opioid epidemic that is imposing heavy health burdens on individuals, families and health systems, nurses are the main front-line caregivers in the battle against the unrelenting increase in opioid medication misuse. Yet, little research has been conducted on nurses' opinions and knowledge surrounding this issue worldwide and in Israel as well. To evaluate Israeli nurses' attitudes, their knowledge about opioid use and misuse, their perception of institutional support, and their perception of their role and self-efficacy in preventing and treating opioid misuse. Cross-sectional study. The data were collected through an electronic questionnaire from 414 Israeli registered nurses using the Qualtrics platform for on-line surveys. The majority of the sample perceived their role positively, held positive attitudes toward people with opioid addiction, and were willing to take care of persons who misused opioids. Nurses reported low scores on knowledge, perceived institutional support, and self-efficacy relating to the issues surrounding opioid pain medication use and misuse. The results clearly indicate a lack of up-to-date knowledge among nurses concerning opioids use. This situation must be urgently corrected through revisiting the subject of opioids across undergraduate, graduate, and continuing nursing education programs. Improved knowledge, combined with a supportive organizational culture, should strengthen nursing care provided to this frequently neglected patient population. Broad insight into nurses' attitudes, their level ofknowledgeabout opioid use and misuse, and their perceptions of their own role in preventing and treating such misuseare essential for creating targeted, relevant educational interventions for nurses with the aim of providing safe and effective opioid treatment for individuals with pain.