Prescription Opioid Abuse Research Articles

Preparing Your Pediatric Patients and Their Families for the Operating Room: Reducing Fear of the Unknown.

1. Adam C. Adler, MS, MD*,‡ 2. Stephanie Leung, BS, CCLS† 3. Benjamin H. Lee, MD*,‡ 4. Scott R. Dubow, MD§ 1. *Department of Anesthesiology, Perioperative and Pain Medicine and 2. †Department of Child Life, Texas Children’s Hospital, Houston, TX 3. ‡Baylor College of Medicine, Houston, TX 4. §Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA * Abbreviations: BiPAP: : bilevel positive airway pressure CLS: : child life specialist CPAP: : continuous positive airway pressure DEA: : Drug Enforcement Administration IV: : intravenous MRI: : magnetic resonance imaging OSA: : obstructive sleep apnea Clinicians should: identify the resources available to patients and families to allow for a smooth perioperative experience; understand the long-term effects and potential maladaptive changes associated with an anxiety-provoking perioperative period; understand the most common parental and patient concerns and misconceptions regarding surgery; understand the most common and up-to-date perioperative anesthesia practices; understand the indication for referral to the preoperative anesthesia clinic for patient evaluation to avoid unnecessary cancellation. Pediatricians are often tasked with preparing children and their families for the preoperative period and dealing with questions related to postoperative issues and concerns. Instruction based on current practice and new research and techniques may help patients and families cope with the stressors of surgery. Determining which patients may benefit from a medical or child life preoperative visit is of crucial importance. After completing this article, the reader should be able to: 1. Describe common preoperative anesthesia practice. 2. Recognize the role of a child life specialist in preparing children for surgery. 3. Differentiate children who would benefit from a preoperative anesthesia and/or child life evaluation. 4. Instruct patients and families on issues related to the perioperative period. 5. Address a wide array of parental concerns regarding surgery, anesthesia, and postoperative pain management. The period of time surrounding a planned surgical procedure can be tumultuous and anxiety provoking for both pediatric patients and their parents. The “mysterious place” that is the operating room often remains a mystery to many health care providers, including those tasked with caring for patients both before and after a procedure. As the health care provider most familiar to patients and their families, the pediatrician is in a …

Perioperative Celecoxib and Postoperative Opioid Use in Hand Surgery: A Prospective Cohort Study.

Prescription opioid abuse is an epidemic in the United States; multimodal analgesia has been suggested as a potential solution to decrease postoperative opioid use. The primary aim of this study was to determine the effect of perioperative celecoxib on opioid intake. Secondary goals were to determine whether perioperative administration of celecoxib decreased postoperative patient-reported pain and whether patient demographic characteristics could predict postoperative pain and opioid intake. This prospective cohort study enrolled patients undergoing mass excision or carpal tunnel, trigger finger, or de Quervain release by 1 of 3 fellowship-trained hand surgeons. Patients in the experimental group were given 200 mg celecoxib tablets taken twice a day starting the day before surgery and continued for 5 days after surgery. Both groups received hydrocodone-acetaminophen tablets 5 mg/325 mg as needed after surgery. After surgery, patients completed daily opioid consumption and pain logs for 7 days and underwent a pill count. Outcomes included morphine milligram equivalents (MME) consumed and postoperative pain. A total of 123 patients were enrolled: 68 control patients and 54 celecoxib patients. Fifty (74%) and 37 (69%) patients, respectively, completed the study. Overall, the median number of MMEs consumed was 25 (range, 0-330). During the first postoperative week, patients in the celecoxib and control groups were similar with respect to postoperative pain experienced (median visual analog scale score, 2.0 vs 1.4, respectively) and amount of opioid taken (median MMEs= 30 vs 20, respectively). Patients taking perioperative celecoxib had similar postoperative pain and opioid intake compared with patients not prescribed celecoxib in the study. Regardless of study group, 4 to 10 hydrocodone tablets were sufficient to control postoperative pain for most patients undergoing soft tissue ambulatory hand surgery. This may be the result of the limited duration and mild nature of pain after outpatient elective hand surgery. Therapeutic II.

Opioids with abuse-deterrent properties: A regulatory and technological overview.

Three concurrent public health problems coexist in the United States: endemic nonmedical use/misuse of opioid analgesics, epidemic overdose fatalities involving opioid analgesics, and endemic chronic pain in adults. These intertwined issues comprise an opioid crisis that has spurred the development of formulations of opioids with abuse-deterrent properties and label claims (OADP). To reduce abuse and misuse of prescription opioids, the federal Food and Drug Administration (FDA) has issued a formal Guidance to drug developers that delineates four categories of testing to generate data sufficient for a description of a product's abuse-deterrent properties, along with associated claims, in its Full Prescribing Information (FPI). This article reviews the epidemiology of the crisis as background for the development of OADP, summarizes the FDA Guidance for Industry regarding abuse-deterrent technologies, and provides an overview of some technologies that are currently employed or are under study for incorporation into OADP. Such technologies include physical and chemical barriers to abuse, combined formulations of opioid agonists and antagonists, inclusion of aversive agents, use of delivery systems that deter abuse, development of new molecular entities and prodrugs, and formulation of products that include some combination of these approaches. Opioids employing these novel technologies are one part of a comprehensive intervention strategy that can deter abuse of prescription opioid analgesics without creating barriers to the safe use of prescription opioids. The maximal public health contribution of OADP will probably occur only when all opioids have FDA-recognized abuse-deterrent properties and label claims.

Prescription Opioid Abuse and Addiction: How Can We Curb the Trends?

Prescription Opioid Abuse and Addiction: How Can We Curb the Trends?

Public Opinion and Public Policy: Heroin and Other Opioids

Virginia, much like other states, has experienced unprecedented rates of heroin and prescription opioid abuse, overdoses, and deaths. Given the wide range of competing voices concerning drug policy and the complicated situation of the contemporary opioid epidemic, this study examines whether public opinion is reflected in public policy toward illicit involvement with opioids. The 2016 Commonwealth Public Policy Survey, a statewide representative sample of 1,000 Virginia residents, found that Virginians are supportive of treatment over arrest for heroin and prescription pill abusers and factors such as race, education, and political affiliation are predictive of support for treatment over arrest. More importantly, the results of this poll converge with legislative policies of the 2017 General Assembly, supporting the notion that public support can have an influence on the policymaking process. Policy implications are discussed.

Impact of a chronic pain management pathway on opioid administration and prescribing in an Emergency Department

Context: Prescription opioid abuse and misuse is a significant public health crisis. In 2012, an opioid prescribing pathway for patients with chronic pain presenting to the Emergency Department (ED) was implemented. The objective of this study is to determine the impact of the pathway for administration of opioids in the ED as well as the prescribing of opioids for home use after discharge.Methods: Retrospective pre- and post-intervention time series study of consecutive patients presenting to the ED with acute and chronic pain complaints before and after implementation of the pathway. For the purposes of this study, we included patients with chronic abdominal or back pain – defined as pain present for greater than three months – and acute pain as acute long bone fracture.Results: Before pathway implementation, there was no statistically significant difference in the mean morphine equivalent (MEQ) dose administered for chronic or acute pain patients. After pathway implementation, there was a decrease in IV/IM morphine administered to patients with chronic pain (p = .0200) but not to patients with acute pain (p = .0820). Overall, MEQs administered did not change in either group. In the acute pain group, no significant differences were found in the number of patients who received opioid prescriptions upon discharge (p = .7749). However, in the chronic pain group, the number of patients who received opioid prescriptions upon discharge decreased with statistical significance (p = .0017).Conclusions: After the implementation of a chronic pain management pathway in an ED, there is a decrease noted in opioids administered to patients with chronic pain both in the ED and prescriptions on discharge. In patients presenting with acute pain, there was no change in administration or prescription of opioids.

The Effects of Kentucky's Comprehensive Opioid Legislation on Patients Presenting with Prescription Opioid or Heroin Abuse to One Urban Emergency Department

BackgroundPrescription opioid abuse has increased to epidemic proportions in the United States. Kentucky, along with other states, passed comprehensive legislation to monitor and curb opioid prescribing. ObjectivesThis paper characterizes patients who presented to the emergency department (ED) after abusing prescription opioids and heroin prior to and after the passage of House Bill 1 (HB1) in April 2012. MethodsBased on a retrospective review of ED visits from 2009–2014 in one urban adult facility, patients were included if the chief complaint or diagnosis was directly related to prescription opioid or heroin abuse. The primary outcome is the number and type of substance abused by each ED patient. ResultsFrom 2009–2014, 2945 patients presented to the ED after prescription opioid or heroin abuse. The number of prescription opioid patients decreased from 215 (of 276 patients) in 2009 to 203 (of 697 patients) in 2014; 77.9% of patients abused opioids in 2009, vs. 29% in 2014 (a 63% decrease). The number of heroin patients increased from 61 in 2009 to 494 in 2014; 22% of patients in 2009 abused heroin, vs. 71% in 2014 (a 221% increase). Both piecewise regression and autoregressive integrated moving average trend models showed an increased trend in patient heroin abuse beginning in 2011–2012. ConclusionsOur facility experienced a decrease in the number of patients who abused prescription opioids and an increase in the number of patients who abused heroin over the study period. The transition seemed to occur just prior to, or concurrent with, enforcement of statewide opioid legislation.

Exploring perceptions and experiences of patients who have chronic pain as state prescription opioid policies change: a qualitative study in Indiana

ObjectivesThe misuse and abuse of prescription opioids (POs) is an epidemic in the USA today. Many states have implemented legislation to curb the use of POs resulting from inappropriate prescribing....

Role of the Perioperative Surgical Home in Optimizing the Perioperative Use of Opioids.

Several federal agencies have recently noted that the United States is in the midst of an unprecedented "opioid epidemic," with an increasing number of opioid-related overdoses and deaths. Providers currently face 3 population-level, public health challenges in providing optimal perioperative pain care: (1) the continued lack of overall improvement in the excessive incidence of inadequately treated postoperative pain, (2) minimizing or preventing postoperative opioid-related side effects, and (3) addressing current opioid prescribing patterns, and the accompanying problematic surge in prescription opioid diversion, misuse, abuse, addiction, and overdose. In the Perioperative Surgical Home model, anesthesiologists and other pain medicine specialists are uniquely qualified and positioned to develop, implement, and coordinate a comprehensive perioperative analgesic plan, which begins with the formal preoperative patient assessment and continues throughout the postdischarge, convalescence period. The scope and practice of pain management within the Perioperative Surgical Home should thus (a) expand to include routine preoperative patient-level pain-risk stratification (including the chronic use of opioid and nonopioid analgesics), (b) address the multitude of biopsychosocial factors that contribute to interpatient pain variability, and (c) extend and be well coordinated across all 4 phases of the surgical pain experience (preoperative, intraoperative, postoperative, and postdischarge). Specifically, safe and effective perioperative pain management should include a plan of care that is tailored to the individual patient's underlying disease(s), presence of a chronic pain condition and preoperative use of opioids, and the specific surgical procedure-with evidence-based, multimodal analgesic regimens being applied in the vast majority of cases. An iteratively evolutionary component of an existing institutional Perioperative Surgical Home program can be an integrated Transitional Pain Service, which is modeled directly after the well-established prototype at the Toronto General Hospital in Ontario, Canada. This multidisciplinary, perioperative Transitional Pain Service seeks to modify the pain trajectories of patients who are at increased risk of (a) long-term, increasing, excessive opioid consumption and/or (b) developing chronic postsurgical pain. Like the Perioperative Surgical Home program in which it can be logically integrated, such a Transitional Pain Service can serve as the needed but missing linkage to improve the continuum of care and perioperative pain management for elective, urgent, and emergent surgery. Even if successfully and cost-efficiently embedded within an existing Perioperative Surgical Home, a new perioperative Transitional Pain Service will require additional resources.

Assessment, stratification, and monitoring of the risk for prescription opioid misuse and abuse in the primary care setting

To evaluate potential for and incidence of aberrant drug-related behaviors among patients with chronic, moderate-to-severe pain in a primary care setting and to determine investigator compliance with universal precautions (UP) approach to pain management. Open label, multicenter. Primary care centers (N = 281) across the United States. Opioid naïve and opioid experienced with chronic, moderate-to-severe pain (N = 1,487). Morphine sulfate extended-release capsules for < or = 4 months. Tools comprising UP approach were treatment agreement, card for obtaining/tracking prescriptions, Screener and Opioid Assessment for Patients with Pain-Revised questionnaire, pill counts, pain-patient follow-up tool, investigator assessment/plan, and urine drug screens (UDSs). Proportion of patients at low, moderate, and high risk of opioid misuse/abuse based on prespecified criteria and investigator judgment, proportion of patients with aberrant drug-related behaviors, and proportion of investigators compliant with UP approach. Patients were primarily white (87 percent), women (57 percent); mean age, 53 years (range, 21-92years). At baseline, 47 percent were considered low risk for opioid misuse/abuse, 52 percent moderate, and 1 percent high. UDSs were positive for illicit/nonprescribed drugs in a proportion of patients throughout the study. Overall, 64 percent of investigators were compliant with major components of UP approach in > or = 75 percent of their patients. However, there was a tendency for investigators to assign risk levels for opioid misuse/abuse as lower than protocol specified. Most patients in these primary care study centers were categorized as at least moderate risk for opioid misuse/abuse at baseline. Most primary care investigators complied with the UP approach to pain management and risk assessment. The completion of the brief training and clinical use of the tools during the study led to retained behavior change, but there was a tendency for investigators to assign lower risk levels than those that were protocol-specified, suggesting a need for better understanding of factors influencing investigator decisions.

Opioids for the Treatment of Chronic Pain: Mistakes Made, Lessons Learned, and Future Directions.

An overreliance on opioids has impacted all types of pain management, making it undoubtedly a root cause of the "epidemic" of prescription opioid abuse in the United States. Yet, an examination of the statistics that led the US Centers for Disease Control and Prevention to declare that prescription opioid abuse had reached epidemic levels shows that the abuse occurrences and deaths are arising outside the hospital or hospice setting, which strongly implicates the outpatient use of opioids to treat chronic pain. Such abuse and related deaths are occurring in chronic pain patients themselves and also through diversion. Overprescribing to outpatients has afforded distressed and vulnerable individuals access to these highly addictive drugs. The focus of this article is on what we have learned since opioid treatment of chronic pain was first popularized at the end of the 20th century and how this new information can guide chronic pain management in the future.

Plasticity of Signaling by Spinal Estrogen Receptor α, κ-Opioid Receptor, and Metabotropic Glutamate Receptors over the Rat Reproductive Cycle Regulates Spinal Endomorphin 2 Antinociception: Relevance of Endogenous-Biased Agonism.

We previously showed that intrathecal application of endomorphin 2 [EM2; the highly specific endogenous μ-opioid receptor (MOR) ligand] induces antinociception that varies with stage of the rat estrous cycle: minimal during diestrus and prominent during proestrus. Earlier studies, however, did not identify proestrus-activated signaling strategies that enable spinal EM2 antinociception. We now report that in female rats, increased spinal dynorphin release and κ-opioid receptor (KOR) signaling, as well as the emergence of glutamate-activated metabotropic glutamate receptor 1 (mGluR1) signaling, are critical to the transition from an EM2 nonresponsive state (during diestrus) to an analgesically responsive state (during proestrus). Differential signaling by mGluR1, depending on its activation by membrane estrogen receptor α (mERα; during diestrus) versus glutamate (during proestrus), concomitant with the ebb and flow of spinal dynorphin/KOR signaling, functions as a switch, preventing or promoting, respectively, spinal EM2 antinociception. Importantly, EM2 and glutamate-containing varicosities appose spinal neurons that express MOR along with mGluRs and mERα, suggesting that signaling mechanisms regulating analgesic effectiveness of intrathecally applied EM2 also pertain to endogenous EM2. Regulation of spinal EM2 antinociception by both the nature of the endogenous mGluR1 activator (i.e., endogenous biased agonism at mGluR1) and changes in spinal dynorphin/KOR signaling represent a novel mechanism for modulating analgesic responsiveness to endogenous EM2 (and perhaps other opioids). This points the way for developing noncanonical pharmacological approaches to pain management by harnessing endogenous opioids for pain relief.SIGNIFICANCE STATEMENT The current prescription opioid abuse epidemic underscores the urgency to develop alternative pharmacotherapies for managing pain. We find that the magnitude of spinal endomorphin 2 (EM2) antinociception not only varies with stage of reproductive cycle, but is also differentially regulated during diestrus and proestrus. This finding highlights the need for sex-specific and cycle-specific approaches to pain management. Additionally, our finding that spinal EM2 antinociception in female rats is regulated by both the ebb and flow of spinal dynorphin/κ-opioid receptor signaling over the estrous cycle, as well as the nature of the endogenous mGluR1 activator, could encourage noncanonical pharmacological approaches to pain management, such as harnessing endogenous opioids for pain relief.

Association Between Opioid Prescribing Patterns and Abuse in Ophthalmology

Drug overdoses have become the number 1 cause of mortality in American adults 50 years and younger. Prescription opioid abuse is a growing concern that has garnered widespread attention among policymakers and the general public. To determine the opioid prescribing patterns among ophthalmologists and elucidate their role in the prescription opioid abuse epidemic. In this observational cohort study, beneficiaries and their physicians were analyzed using 2013 to 2015 Medicare Part D Prescriber Data. The Centers for Medicare and Medicaid Services Medicare Part D Prescriber Public Use Files for 2013, 2014, and 2015 were accessed. Analysis began in June 2017. Data were collected and analyzed regarding the prescribing patterns for opioid drugs (eg, number of prescriptions written including refills, number of days' supply, and prescriber rates) for all participating ophthalmologists. The mean number of opioid prescriptions written annually by ophthalmologists; prescriber rates compared with all prescriptions written; and geographic distribution of opioid prescriptions written per ophthalmologist. In 2013, 4167 of 19 615 ophthalmologists were women (21.2%). Consistently, most ophthalmologists (88%-89%) wrote 10 opioid prescriptions or fewer annually. Approximately 1% (0.94%-1.03%) of ophthalmologists wrote more than 100 prescriptions per year. On average, ophthalmologists wrote 7 opioid prescriptions per year (134 290 written annually by 19 638 physicians, on average) with a mean supply of 5 days. The 6 states with the highest volume of opioid prescriptions written annually per ophthalmologist were located in the southern United States. In general, ophthalmologists show discretion in their opioid prescribing patterns. The present opioid abuse epidemic should prompt physicians to consider revisiting their prescribing protocols given the high risk for dependency.

The Opioid Epidemic: Crisis and Solutions.

The widespread abuse of prescription opioids and a dramatic increase in the availability of illicit opioids have created what is commonly referred to as the opioid epidemic. The magnitude of this epidemic is startling: About 4% of the adult US population misuses prescription opioids, and in 2015, more than 33,000 deaths were attributable to overdose with licit and illicit opioids. Increasing the availability of medication-assisted treatments (such as buprenorphine and naltrexone), the use of abuse-deterrent formulations, and the adoption of US Centers for Disease Control and Prevention prescribing guidelines all constitute short-term approaches to quell this epidemic. However, with more than 125 million Americans suffering from either acute or chronic pain, the development of effective alternatives to opioids, enabled at least in part by a fuller understanding of the neurobiological bases of pain, offers the best long-term solution for controlling and ultimately eradicating this epidemic.

Reviewing opioid use, monitoring, and legislature: Nursing perspectives

The phenomena of prescription opioid misuse and abuse have a complicated history of contributing factors including policies, practices, and prescribing leading to contemporary phenomena. Some factors implicated in the opioid drug abuse problem include inefficient prescribing and improper use, lack of knowledge related to interpretation and assessment of pain levels, and decreased oversight and regulation from government and policy agents. Nurses, often frontline providers, need to be knowledgeable and embrace the guidelines, and necessary implications associated with both prescribing and administration of opioids. Additionally, all providers including physicians, physician assistants, nurse practitioners, and bedside nurses must have a firm understanding of the improper use and abuse of opioids. The examination and review of opioid policies at the state and federal level has revealed inconsistency with regulations, policies, and guidelines that have lead to the current situation. The use of an interdisciplinary team with nurses and various other practitioners is a good strategy to help reduce this problem.

Safe Opioid Prescription: A SMART on FHIR Approach to Clinical Decision Support.

Prescription opioid pain medication overuse, misuse and abuse has been a significant contributing factor in the opioid epidemic. The rising death rates from opioid overdose has caused healthcare practitioners and researchers to work on optimizing pain therapy and limiting the prescriptions for pain medications. The state of New York has implemented a prescription drug monitoring program(PDMP), amended public health law to limit the prescription of opioids for acute pain and utilized the resources of the state and county health departments to help in curbing this epidemic. The recent publication of guidelines for prescription opioids from CDC [2] and ASIPP (American Society of Interventional pain practitioners) [4] have independently reviewed literature and found good evidence of limiting opioid prescription for acute and chronic non cancer pain.MethodClinical Decision Support Systems (CDSS) have been developed over the last decade to help in the work flow of healthcare providers since advanced technology is increasing the complexity of electronic health records systems. There are several systematics reviews on the effectivity and utility of CDSSs. The common consensus seems to be that commercially and locally developed CDSS are effective in improving patient measures while actual workload improvement and efficient cost cutting measure are not significantly improved by CDSS. Patient provider involvement in developing CDSS is a determinant of its success and utilization rates. In this light, a plug and play form of CDSS which is independent of the vendors of Electronic Health Records and can be implemented from an external platform through secure channels would be more effective.The Health Level Seven’s (HL7) open licensed interoperability standard called Fast Health Interoperability Resources (FHIR) has a platform, Substitutable Medical Applications and Reusable Technologies (SMART) for CDSS app development by a third party. (Mandl and Kohane) [13] We adopted these open source standard to develop an app for proper implementation of the recently published guidelines for management of pain with opioid pain medications.The goal for this CDSS tool would be to achieve proper monitoring of prescription drugs, patients’ medication list and potential interactive medications, surveillance for abuse/ misuse, patient involvement in alternative therapy, reporting problems and obtaining adequate pain control.

The novel dopamine D3 receptor antagonists/partial agonists CAB2-015 and BAK4-54 inhibit oxycodone-taking and oxycodone-seeking behavior in rats

The use of prescription opioid analgesics, particularly oxycodone, has dramatically increased, and parallels escalated opioid abuse and drug-related deaths worldwide. Understanding the molecular mechanisms underlying the development of opioid dependence and expanding treatment options to counter prescription opioid abuse has become a critical public health matter. In the present study, we first evaluated the reinforcing effects of oxycodone in a rat model of self-administration and then explored the potential utility of two novel high affinity dopamine D3 receptor (D3R) antagonists/partial agonists, CAB2-015 and BAK4-54, for treatment of prescription opioid abuse and dependence. We found that rats acquired oxycodone self-administration rapidly within a range of unit doses that was similar to that for heroin, confirming that oxycodone has significant abuse potential. Strikingly, pretreatment with either CAB2-015 or BAK4-54 (0.4–10 mg/kg, i.p.) dose-dependently decreased oxycodone self-administration, and shifted the oxycodone dose-response curve downward. Repeated pretreatment with CAB2-015 or BAK4-54 (0.4–4 mg/kg) facilitated extinction and inhibited oxycodone-induced reinstatement of drug-seeking behavior. In addition, pretreatment with CAB2-015 or BAK4-54 (4–10 mg/kg) also dose-dependently decreased oxycodone-enhanced locomotor activity, but only CAB2-015 decreased oral sucrose self-administration. These data suggest that D3R antagonists may be suitable alternatives or adjunctive to opioid-based medications currently used clinically in treating opioid addiction and that the D3R-selective ligands (CAB2-015 or BAK4-54) provide new lead molecules for development.

Patterns of abuse and routes of administration for immediate-release hydrocodone combination products.

PurposePrescriptions for hydrocodone immediate‐release (IR) combination products have recently decreased, yet they represent the majority of opioid prescriptions dispensed and are commonly abused analgesics among both adults and adolescents. Little data exist to understand the contribution of IR products to the problem of prescription opioid abuse. This study aimed to better understand abuse patterns for hydrocodone IR combination products among adult and adolescent substance abusers.MethodsThis cross‐sectional study examines abuse prevalence (including abuse adjusted for prescription volume and morphine milligram equivalents) and abuse characteristics for hydrocodone IR combination products and other prescription opioids among separate samples of adults and adolescents assessed for substance abuse problems or entering treatment from January 2012 through June 2015.ResultsResults indicate higher abuse for hydrocodone IR combination products than other opioid categories per 100 assessments but lower per prescriptions dispensed. Hydrocodone IR combination products had similar abuse prevalence to all extended‐release and long‐acting opioids when considering abuse measured per morphine milligram equivalents dispensed. An upward trend in hydrocodone IR combination product abuse was observed among adult substance abusers comparing the period prior to and after Drug Enforcement Administration rescheduling of these products in October 2014. Most individuals reported oral abuse of hydrocodone IR combination products, but snorting, reported by 23% of hydrocodone IR combination product abusers, also appears to be a route of abuse that may have public health relevance.ConclusionsGiven their high prescription volume, hydrocodone IR combination products, even at a relatively low prevalence of abuse, may contribute substantially to the overall problem of prescription opioid abuse. Additional public health interventions, including development of abuse‐deterrent formulations for these types of opioid products may aid in reducing their abuse.

Changes in misuse and abuse of prescription opioids following implementation of Extended-Release and Long-Acting Opioid Analgesic Risk Evaluation and Mitigation Strategy.

An unintended consequence of extended-release (ER) and long-acting (LA) prescription opioids is that these formulations can be more attractive to abusers than immediate-release (IR) formulations. The US Food and Drug Administration recognized these risks and approved the ER/LA Opioid Analgesic Risk Evaluation and Mitigation Strategy (ER/LA REMS), which has a goal of reducing opioid misuse and abuse and their associated consequences. The primary objective of this analysis is to determine whether ER/LA REMS implementation was associated with decreased reports of misuse and abuse. Data from the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS(R)) System Poison Center Program were utilized. Poison center cases are assigned a reason for exposure, a medical outcome, and a level of health care received. Rates adjusted for population and drug utilization were analyzed over time. RADARS System Poison Center Program data indicate a notable decrease in ER/LA opioid rates of intentional abuse and misuse as well as major medical outcomes or hospitalizations following implementation of the ER/LA REMS. While similar decreases were observed for the IR prescription opioid group, the decreasing rate for the ER/LA opioids exceeded the decreasing rates for the IR prescription opioids and was distinctly different than that for the prescription stimulants, indicating that the ER/LA REMS program may have had an additional effect on decreases in opioid abuse and intentional misuse beyond secular trends.

Relative Abuse of Crush-Resistant Prescription Opioid Tablets via Alternative Oral Modes of Administration.

ObjectiveSome crush-resistant tablet formulations (CRTs) reduce prescription opioid abuse by nonoral routes of administration (ROAs), especially insufflation and injection, while oral abuse increases. Oral abuse involving product manipulation vs swallowing whole for CRTs and comparators was examined.MethodsAbuse by oral modes of administration (e.g., swallowing whole, chewing, dissolving in the mouth), was examined using the ASI-MV, a computerized, clinical interview for adults in substance abuse treatment from January 2009 to March 2015. CRTs (reformulated oxycodone extended-release [ER], reformulated oxymorphone ER, and tapentadol ER) were compared with non-CRT versions, morphine ER, and oxycodone immediate-release single entity. Analyses employed descriptive statistics and logistic regression.ResultsAmong 364,329 unique assessments, 18,135 patients reported oral abuse of the CRTs and comparators examined. CRTs had a higher prevalence of oral abuse involving product manipulation than comparators (P < 0.0001) among all abusers of product. Oral abuse involving product manipulation for CRTs was greater among the subset of patients reporting oral abuse and significantly higher than comparators (P < 0.003). CRTs were significantly less likely than comparators to be swallowed whole (P < 0.0001) and significantly more likely to be chewed (P < 0.003). CRTs were more likely to be dissolved in the mouth than most comparators.ConclusionsResults suggest the need for abuse-deterrent formulations designed to reduce abuse by oral administration with product manipulation, such as chewing. Advances in this area may reduce the overall abuse of prescription opioids and interrupt the progression from abuse by swallowing whole to oral administration involving product manipulation and other ROAs.