High Risk Of Overdose Research Articles

High Risk of Overdose, Suicide After Stopping Opioids.

Log in or Register Subscribe to journalSubscribe Get new issue alertsGet alerts Enter your Email address: Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. Subscribe to eTOC Secondary Logo Journal Logo All Articles Images Videos Podcasts Blogs Advanced Search Toggle navigation Subscribe Register Login Articles & Issues Current IssueArchivesePub Ahead-of-Print Collections Acute/Critical CareArt of Nursing Back to BasicsCase ReportsContinuing EducationDisaster and Emergency PreparednessEnvironmental Health and IssuesEthics Evidence-Based Practice, Step by StepFamily CaregiversGeriatric NursingHolistic NursingIn The CommunityInfectious DiseaseInfluenza Classics from the AJN ArchivesInternational TopicsLegal ClinicMental HealthMilitary and Veterans Health Care New to NursingNurse's Week 2019Nursing Research, Step By StepNursing ResourcesPalliative CarePatient SafetyPatient Safety-Safety MonitorPolicy and PoliticsProfessional Development, Leadership and ScholarshipProfessional Partners Supporting Diverse Family Caregivers Across SettingsProfilesPutting Patients First – The Planetree CollectionQI: Quality ImprovementResearchSocial Media and Information TechnologySpecial SupplementsStrip SavvySupporting Family Caregivers: No Longer Home AloneSystematic Reviews Step by StepTeaching For PracticeTransforming Care at the Bedside (TCAB)Uniforms (Nursing)Uniting States, Sharing StrategiesWomen's HealthWriting Resources Multimedia PodcastsVideosHow to Try This VideosNew Look at the Old VideosSupporting Family CaregiversWebinars CE/NCPDFor Authors Submit a ManuscriptInformation for AuthorsLanguage Editing ServicesAuthor Permissions Journal Info About the JournalAdvertising and BusinessAJN Photo Exhibit: Faces of CaringAuthor Guidelines - ReflectionsAward WinnersBook of the Year AwardsContact InfoEditorial BoardInformation for FacultyInformation for MediaInformation for Peer ReviewersLetters to the EditorNurse Faculty Scholars / AJN Mentored Writing AwardOpen AccessReprintsRights and PermissionsSubscription ServicesNurses: Submit Your Photos! All Articles Images Videos Podcasts Blogs Advanced Search

Barriers to Medications for Opioid Use Disorder Among Veterans Involved in the Legal System: a Qualitative Study

Veterans involved in the legal system are at high risk for overdose but have lower receipt of medications for opioid use disorder than other veterans. The study aimed to understand barriers to medication access from the perspective of legally involved veterans with opioid use disorder and people who work with these veterans in the Veterans Health Administration (VHA) and the legal system. This national qualitative study interviewed veterans and stakeholders from 14 geographically diverse VHA facilities to explore perceptions of barriers to medications for opioid use disorder. Participants included veterans with a history of opioid use disorder and legal involvement (n = 18), VHA Veterans Justice Programs Specialists (n = 15), VHA and community substance use disorder treatment providers (n = 5), and criminal justice staff (n = 12). We conducted interviews based on the Consolidated Framework for Implementation Research. Interview transcripts were analyzed using a team-based approach. Four key barriers, noted by group, were identified: (1) a preference for counseling along with or instead of medications (veterans, Specialists, treatment providers, criminal justice staff); (2) concerns about veterans using medications without a prescription, selling them, or providing them to others (veterans, Specialists, treatment providers, criminal justice staff); (3) concerns about perceived stigma towards medication use (veterans, Specialists, treatment providers, criminal justice staff); and (4) concerns about medication discontinuation after recurrent opioid use (veterans, criminal justice staff). A fifth theme, education, was noted by all stakeholders except providers as important to facilitating use of medications for opioid use disorder. All five themes mapped to the framework construct of knowledge and beliefs about the intervention. Based on identified barriers, interventions focused on enhancing medication knowledge, reducing stigma towards use of medications, and increasing knowledge that opioid use may recur during treatment may help increase access to medication for veterans with legal involvement.

Identification and structure characterization of five synthetic opioids: 3,4-methylenedioxy-U-47700, o-methyl-acetylfentanyl, 2-thiophenefentanyl, benzoylfentanyl and benzoylbenzylfentanyl

PurposeThe number of new synthetic opioids, especially fentanyl analogs, on the illicit market is increasing each year and becoming a disturbing phenomenon. Due to the very high potency, ease of addiction and high risk of overdose with the fatal effect, they pose a serious threat to public health. The ever-changing drug market, lack of reference standards and low doses make this class of new psychoactive substances (NPS) a continual analytical challenge in terms of detection and identification. Structure elucidations of five synthetic opioids are described in this paper.MethodsUnequivocal identifications were performed using liquid chromatography–high resolution tandem mass spectrometry with quadrupole time-of-flight analyzer (LC–QTOF-MS/MS) and nuclear magnetic resonance (NMR) spectroscopy with prior chromatographic purification of the sample in each case.ResultsIdentified NPS included one non-fentanyl opioid belonging to “U-compounds group”—3,4-methylenedioxy-U-47700 and four fentanyl analogs: o-methyl-acetylfentanyl, benzoylfentanyl, 2-thiophenefentanyl and benzoylbenzylfentanyl.ConclusionsComplementary LC–QTOF-MS/MS and NMR techniques enabled the unambiguous identification of new synthetic opioids. To the best of our knowledge, this is the first comprehensive characterization of these five NPS with complete data which are published to facilitate their detection and identification by forensic and clinical laboratories.

Anticipated use of a supervised drug consumption site among syringe services program clients in King County, Washington: Assessing the role of opioid overdose and injection behavior

BackgroundUS jurisdictions are considering implementing supervised drug consumption sites (SCSs) to combat the overdose epidemic. No sanctioned SCS exists in the US, but King County, Washington has proposed Community Health Engagement Locations (CHELs), which would include supervised drug consumption. We assessed characteristics of people engaged in syringe services programs (SSPs) who anticipated SCS use. MethodsWe estimated prevalence of anticipated SCS use in a 2017 cross-sectional sample of King County SSP participants (N = 377). We used Poisson regression with robust standard errors to estimate likelihood of anticipated SCS use by overdose history (experienced, witnessed only, neither), public injection frequency (always, some/most times, never), drug use behaviors, and sociodemographic characteristics. ResultsThe sample was primarily male (66.8 %), white (69.5 %), and averaged 37 years old. Almost two-thirds of participants witnessed or experienced an overdose in the past year (43.2 % witnessed only; 19.6 % experienced overdose). Four in five SSP participants (83.0 %) anticipated any SCS use. Anticipated SCS use was higher among participants who experienced an overdose (risk ratio [RR] = 1.14, 95 % CI = 1.04, 1.24) than those with no overdose experience. In multivariable analyses, anticipated SCS use was higher among people reporting injecting publicly (e.g., always vs. never: aRR = 1.26, 95 % CI = 1.11, 1.43), and lower among people primarily using methamphetamine (aRR = 0.80, 95 % CI = 0.67, 0.96) compared to people primarily using opioids. ConclusionsIn King County, SCS services would be used by people at high risk of overdose, including SSP participants reporting injecting in public. SCSs could be an important step to promote health and safety across communities.

High willingness to use overdose prevention sites among female sex workers in Baltimore, Maryland

BackgroundOverdose Prevention Sites (OPS) operate worldwide as spaces where people can consume previously purchased drugs under supervision, and are linked to reductions in HIV/HCV transmission and fatal overdoses. As the United States weighs their merits and legality, research is needed to estimate acceptability and use among populations at high risk for overdose. We examine willingness to use OPS among street-based female sex workers (FSW) with prevalent drug use and associated morbidities. MethodsWe describe self-reported willingness, barriers and conditions around use of a hypothetical OPS among 141 FSW engaged in active drug use in Baltimore City, and describe trends using Pearson’s χ2 and Fisher’s exact tests. ResultsMost women had history of overdose (55 %) and were likely to use OPS (77 %). Willingness was higher among women who: were sexual minorities (97 %;P=0.002),experienced homelessness (82 %;P=0.019), injected drugs (82 %;P=0.013), shared syringes (82 %;P=0.007), experienced sexual violence (92 %;P=0.045) or reported heroin use (83 %;P=0.039) in the past 3 months. Common anticipated barriers included transportation (45 %) and fear of arrest (41 %). ConclusionsThis study highlights a population of uniquely high-risk women who would benefit from an OPS integrated with other services. Conditions and barriers discussed are informative for planning and implementation.

A Low-Barrier and Comprehensive Community-Based Harm-Reduction Site in Vancouver, Canada.

"The Molson" is a low-barrier, peer-staffed, supervised consumption site located in Vancouver, Canada. In addition to overdose response, this site offers drug checking and a colocated injectable hydromorphone treatment program, and it distributes tablet and liquid hydromorphone to service users at high risk of overdose. Our evaluation suggests benefits of this program in creating service continuums and preventing overdose deaths. From September 2017 to August 2019, the site had 128 944 visits, reversed 770 overdoses, and had no overdose deaths.

Evaluation of naloxone access, pricing, and barriers to dispensing in Tennessee retail community pharmacies

ObjectivesTennessee has one of the highest rates of opioid prescribing in the United States; therefore, the objectives of this study were to examine availability, pricing, and pharmacist-initiated recommendations of naloxone in retail community pharmacies in Eastern and Western Tennessee; to identify the most common barriers to naloxone dispensing and strategies to improve access; and to determine regional differences in access to naloxone. DesignA cross-sectional survey conducted via telephone. Setting and participantsAll retail community pharmacies located in the most populous counties in the eastern and western regions of Tennessee were eligible for inclusion, as were all retail community pharmacies in the 5 counties in each region that had the highest rates of opioid prescriptions (316 pharmacies identified in 12 counties). Outcome measuresOutcome measures included availability, price, and pharmacist-initiated recommendations of naloxone products, barriers to dispensing, and suggestions to improve naloxone access. Survey responses were summarized as descriptive statistics. Chi-square, independent samples t test, and inductive content analysis were conducted. ResultsResponse rate was 56.3%. Most participants (92.7%) reported that naloxone (Narcan) was available from their pharmacies at a mean cash price of $132.49, with no statistically significant differences between regions. The most commonly reported barrier was cost (70.2%). When queried about recommendations to various groups at a high risk of overdose, as advised by the U.S. Department of Health and Human Services, 42.1% to 69.1% of pharmacies reported recommending naloxone to at least 50% of high-risk patients. Suggestions to increase naloxone access included lowering the cost and improving naloxone-related education for patients, pharmacists, and other providers. ConclusionAlthough Narcan was widely available, cost was a frequently cited barrier to dispensing. Pharmacist-initiated recommendations for coprescribing and dispensing naloxone to patients at a high risk of overdose were limited. Addressing cost issues in addition to increasing patient and pharmacist education concerning the use and benefit of naloxone were suggested to improve naloxone access.

Non-invasive brain stimulation modalities for the treatment and prevention of opioid use disorder: a systematic review of the literature

The U.S. is currently facing an unprecedented epidemic of opioid-related deaths. Despite the efficacy of the current treatments for opioid use disorder (OUD), including psychosocial interventions and medication-assisted therapy (MAT), many patients remain treatment-resistant and at high risk for overdose. A potential augmentation strategy includes the use of non-invasive brain stimulation (NIBS) techniques, such as transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and auricular vagus nerve stimulation (aVNS). These approaches may have therapeutic benefits by directly or indirectly modulating the neurocircuitry affected in OUD. In this review, we evaluate the available studies on NIBS in the context of OUD withdrawal and detoxification, maintenance, and cravings, while also considering analgesia and safety concerns. In the context of opioid withdrawal and detoxification, a percutaneous form of aVNS has positive results in open-label trials, but has not yet been tested against sham. No randomized studies have reported on the safety and efficacy of NIBS specifically for maintenance treatment in OUD. TMS and tDCS have demonstrated effects on cravings, although published studies were limited by small sample sizes. NIBS may play a role in reducing exposure to opioids and the risk of developing OUD, as demonstrated by studies using tDCS in an experimental pain condition and TMS in a post-operative setting. Overall, while the preliminary evidence and safety for NIBS in the prevention and treatment of OUD appears promising, further research is needed with larger sample sizes, placebo control, and objective biomarkers as outcome measures before strong conclusions can be drawn.

Detection of aspirin traces in blood by means of surface‐enhanced Raman scattering spectroscopy

AbstractAspirin being freely available as an over the counter drug has a high overdose risk and can cause severe health symptoms. The methods used in clinics for the detection of such drugs (pharmaceuticals) in bodily fluids are mostly based on liquid chromatography and mass spectroscopy. These methods are known to be precise; however, they both require long and laborious sample preparation; thus, it takes time to acquire the required information. Because in the case of an overdose, the time has high importance, and faster methods would be beneficial. This work presents an application of a Surface‐enhanced Raman scattering (SERS) spectroscopic method for the detection of salicylic acid as a metabolite of aspirin in the blood serum of the patient under examination. In this research, the various colloidal solutions were employed for the preparation of SERS active substrates. The choice of the most efficient colloidal solution and the challenges of collecting SERS spectra of whole blood or its components are discussed. The spectra of both the model and the real‐life blood samples containing metabolite of aspirin were collected with a Fourier transform Raman spectrometer. The analysis of the collected spectra revealed that label‐free SERS can be used for the detection of salicylic acid with concentration down to 3 mM in blood serum corresponding to consumption of at least eight standard pills of aspirin (equivalent to mild toxicity). The proposed diagnostic method could be applied faster than the standard methods and could allow sensitive and fast diagnosis of aspirin consumption in the human blood.

Assessing the impact of clinical pharmacists on naloxone coprescribing in the primary care setting.

Opioid use and overdose are epidemic in the United States. While there is concern regarding the abuse of illegal opioids, overdose is also strongly associated with prescription opioids. The Centers for Disease Control and Prevention supports coprescribing of naloxone with opioids; however, a review of naloxone prescriptions recorded within a primary care group indicated limited use of the reversal agent. Through the collaboration of pharmacy and information services personnel, a report was created to identify all patients receiving chronic opioid therapy. To assess the risk of overdose, a validated risk scoring method was used. If patients were determined to be at high risk for overdose, outreach by a clinical pharmacist was conducted to educate them on the benefits of naloxone. For patients agreeable to receiving naloxone, prescriptions were entered into the electronic health record for primary care provider (PCP) verification. Contact was made following order verification to ensure patient understanding of proper naloxone use and naloxone accessibility. Prior to the project (ie, in calendar year 2016), only 5 prescriptions for naloxone had been prescribed within the medical group. During the naloxone coprescribing initiative, 230 patients were identified by clinical pharmacists as being at elevated risk for opioid overdose. Of these, 86 (37%) were deemed ineligible for naloxone. Out of the 144 patients determined to be eligible, 63 (44%) were agreeable to receiving naloxone. Further review determined that 7 additional patients were agreeable after a follow-up conversation with their PCP. Of the patients that agreed to receive naloxone, 48 (76%) confirmed that they had picked up naloxone from their pharmacy. The naloxone coprescribing initiative was an innovative project that focused on an epidemic that affects communities across the United States. This program embraced the strengths of multiple departments for the good of the patient, in keeping with the idea of team-based care. The pharmacy-driven approach highlighted the importance of having pharmacists within an ambulatory care setting and allowed high-level pharmacist practice without adding to the workload of other members of the healthcare team.

Legal requirements and recommendations to prescribe naloxone

BackgroundThe continued toll of opioid-related overdoses has motivated efforts to expand availability of naloxone to persons at high risk of overdose, with 2016 federal guidance encouraging clinicians to co-prescribe naloxone to patients with increased overdose risk. Some states have pursued analogous or stricter legal requirements that could more heavily influence prescriber behavior. MethodsWe conducted a systematic legal review of state laws that mandate or recommend that healthcare providers prescribe naloxone to patients with indicators for opioid overdose risk. We coded relevant statutes and regulations for: applicable populations, patient criteria, educational requirements, and exemptions. ResultsAs of September 2019, 17 states had enacted naloxone co-prescribing laws, the earliest of which was implemented by Louisiana in January 2016. If patient overdose risk criteria are met, over half of these states mandate that providers prescribe naloxone (7 states, 41.1 %) or offer a naloxone prescription (2 states, 11.8 %); the remainder encourage prescribers to consider prescribing naloxone (8 states). Most states (58.8 %) define patient overdose risk based on opioid dosages prescribed, although the threshold varies substantially; other common overdose risk criteria include concomitant opioid and benzodiazepine prescriptions and patient history of substance use disorder or mental illness. ConclusionsA growing minority of states has adopted a naloxone prescribing law, although these policies remain less prevalent than other naloxone access laws. By targeting higher-risk patients during clinical encounters, naloxone prescribing requirements could increase naloxone prescribed, destigmatize naloxone use, and reduce overdose harms. Further investigation into policy effectiveness, unintended consequences, and appropriate parameters is warranted.

Prevalence and Correlates of Providing and Receiving Assistance With the Transition to Injection Drug Use.

Preventing the transition to injection drug use is an important public health goal, as people who inject drugs (PWID) are at high risk for overdose and acquisition of infectious disease. Initiation into drug injection is primarily a social process, often involving PWID assistance. A better understanding of the epidemiology of this phenomenon would inform interventions to prevent injection initiation and to enhance safety when assistance is provided. We conducted a systematic review of the literature to 1) characterize the prevalence of receiving (among injection-naive persons) and providing (among PWID) help or guidance with the first drug injection and 2) identify correlates associated with these behaviors. Correlates were organized as substance use behaviors, health outcomes (e.g., human immunodeficiency virus infection), or factors describing an individual's social, economic, policy, or physical environment, defined by means of Rhodes' risk environments framework. After screening of 1,164 abstracts, 57 studies were included. The prevalence of receiving assistance with injection initiation (help or guidance at the first injection) ranged 74% to 100% (n=13 estimates). The prevalence of ever providing assistance with injection initiation varied widely (range, 13%-69%; n=13 estimates). Injecting norms, sex/gender, and other correlates classified within Rhodes' social risk environment were commonly associated with providing and receiving assistance. Nearly all PWID receive guidance about injecting for the first time, whereas fewer PWID report providing assistance. Substantial clinical and statistical heterogeneity between studies precluded meta-analysis, and thus local-level estimates may be necessary to guide the implementation of future psychosocial and sociostructural interventions. Further, estimates of providing assistance may be downwardly biased because of social desirability factors.

Polysubstance use in rural West Virginia: Associations between latent classes of drug use, overdose, and take-home naloxone

BackgroundRural communities in the United States have been disproportionately affected by the opioid crisis. Little research has explored the relationship between polysubstance use and overdose experiences among people who inject drugs (PWID) in rural communities. We sought to identify classes of polysubstance drug use among rural PWID and evaluate the associations between polysubstance drug use classes, recent overdose experiences, and receipt of take-home naloxone (THN). MethodsWe surveyed 420 PWID (June-July 2018) who had injected drugs in the previous 6 months in Cabell County, West Virginia. Participants were recruited from the local syringe services program and through street-based recruitment. We conducted a latent class analysis using 9 measures of injection and non-injection drug use and tested for associations with having experienced an overdose in the past 6 months and having received THN in the past 6 months. ResultsWe identified four substance use classes in our sample: polydrug/polyroute use (35.0% of the sample), polyroute stimulant/injection opioid use (33.3%), polyroute stimulant use (20.3%), and injection opioid use (11.3%). Overall, 42.6% of the sample had experienced an overdose in the past 6 months. The classes differed in terms of overdose (χ=91.53, p<0.001), with the polydrug/polyroute use class having the highest probability of overdose and the polyroute stimulants class having the lowest. Only 46.5% of participants had received THN, and probabilities differed between classes (χ=21.93, p<0.001). The polyroute stimulants/injection opioid use and polydrug/polyroute use classes had the highest levels of THN receipt while the polyroute stimulants use class had the least. ConclusionAmong rural PWID in West Virginia, polysubstance use was prevalent and associated with overdose and THN acquisition. These analyses demonstrate the importance of scaling up naloxone distribution in rural settings. Overdose prevention initiatives are reaching persons at high risk of overdose, but expansion of services is needed.

Opioid Prescriptions for New Low Back Pain: Trends and Variability by State.

The United States is facing a widespread opioid epidemic that disproportionately affects the working-age population. In the clinical setting, new low back pain is one of the most common reasons for opioid prescriptions, despite national recommendations advising against their use until nonopioid treatments have been trialed. In this study, we aimed to examine national opioid prescribing practices among primary care physicians after the evaluation of low back pain in working-age patients. This study used a national claims database's billing codes to identify patients in the outpatient setting with a new encounter for isolated low back pain following a 1-year look-back period. The primary outcome was whether an opioid prescription was filled within 30 days after the encounter. Patients with a daily morphine milligram equivalence (MME/day) known to be associated with a higher risk of overdose were also analyzed. A total of 418,565 patients between January 1, 2011 and November 30, 2016 were included. The proportion of patients with filled opioid prescriptions declined significantly between 2011 and 2016 (P < .01; 28.5% in 2011, 27.6% in 2012, 26.3% in 2013, 25.5% in 2014, 23.5% in 2015, and 20.4% in 2016). Nationally, the proportion of patients with a filled opioid prescription varied significantly between states (P < .01), ranging from 12.9% in Hawaii to 33.6% in Arkansas. We found that the overall frequency of opioid prescriptions for low back pain is decreasing nationally, which speaks favorably for future initiatives to change physician prescribing patterns. However, we identified that there is large variation in prescribing patterns among physicians in different states.

Methamphetamine Involved in Rising Number of Heroin Treatment Admissions

Back to table of contents Previous article Next article Clinical & ResearchFull AccessMethamphetamine Involved in Rising Number of Heroin Treatment AdmissionsTerri D’ArrigoTerri D’ArrigoSearch for more papers by this authorPublished Online:16 Oct 2019https://doi.org/10.1176/appi.pn.2019.10b9AbstractIn a trend that cuts across demographics, adolescents and young adults are among the groups hardest hit.Methamphetamine use is involved in an increasing number of heroin treatment admissions, a study in Addiction has found. In 2017, 12.4% of heroin treatment admissions involved methamphetamine, up from 2.1% in 2008. The trend was pronounced in adolescents and young adults but also cut across sex, age, race, ethnicity, and census regions nationwide.Treatment plans for patients who use heroin and methamphetamine should include medication treatment for opioid use disorder, says Christopher M. Jones, Pharm.D., Dr.P.H., M.P.H.Centers for Disease Control and PreventionThe findings point to a need for more dialogue between health professionals and patients about using multiple substances, lead author Christopher M. Jones, Pharm.D., Dr.P.H., M.P.H., told Psychiatric News. Jones is a senior advisor and the associate director of the Office of Strategy and Innovation in the Injury Center at the Centers for Disease Control and Prevention.“Clinicians should discuss with their patients not only opioid use, but also methamphetamine and other substance use. These drugs work in different ways, and prior research indicates that there are varying motivations for their combined use. These include synergistic euphoric effects or balancing effects, such as using methamphetamine to counter the sedating effects of opioids,” Jones told Psychiatric News. “Understanding why patients are using methamphetamine in addition to opioids can help guide decisions related to treatment and recovery-support services.”Prompted by reports of increased rates of simultaneous opioid and methamphetamine use, Jones and his colleagues analyzed data from more than 3.5 million treatment admissions between 2008 and 2017 in which heroin was the primary substance of use. The data came from the Treatment Episode Data Set, a national database that provides information on the admissions of people aged 12 years and older to substance use treatment centers that receive federal funds.“There were a small number of local studies that had come out in the last two years that started to document this phenomenon. We were interested to see what the patterns looked like in a larger dataset as the findings could help to inform ongoing efforts to combat the evolving opioid overdose epidemic,” Jones said.The researchers found that in 2017, people aged 12 to 24 had the highest rates of admissions for heroin use involving methamphetamine of all the age groups examined: 27.8% of primary heroin treatment admissions for adolescents aged 12 to 17 years involved methamphetamine, and 17.4% of heroin treatment admissions for young adults aged 18 to 24 involved methamphetamine.“Not only do these findings highlight a need to focus intervention and treatment efforts aimed at reaching younger age groups, but together with the finding that early age of heroin initiation was associated with methamphetamine use at treatment admission, these findings underscore the importance of expanding policies, programs, and practices that can prevent initiation of these substances in the first place,” Jones and colleagues wrote.Among females, 15.1% of primary heroin treatment admissions involved methamphetamine in 2017, compared with 10.8% among males. The researchers noted that prior research suggests that females use more methamphetamine and transition from recreational use to dependence more quickly than males.More than 37% of primary heroin treatment admissions among non-Hispanic American Indian or Alaska Natives involved methamphetamine, the highest among all races and ethnicities. Only 2% of primary heroin treatment admissions among non-Hispanic black people involved methamphetamine, the lowest among all races and ethnicities.“Given the increase in risk for negative health outcomes among people using both substances, comprehensive prevention, treatment, and harm-reduction strategies that address the polysubstance nature of opioid use and are appropriately tailored to specific demographic groups and at-risk populations are needed,” Jones and colleagues wrote.Yet despite the greater risk of poor outcomes in people who mix illicit opioids with other drugs, admissions for the use of heroin and methamphetamine are 35% less likely to include medication treatment for opioid use disorder as part of the treatment plan, the study revealed.“Ensuring that the patient treatment plan utilizes evidence-based medications for opioid use disorder treatment along with nonmedication services, especially those that have shown benefit for patients using methamphetamine, is essential,” Jones said. “In addition, given the high risk for overdose among this population, patients should be given or prescribed naloxone for opioid-overdose reversal and trained in its use.” ■“Increases in Methamphetamine Use Among Heroin Treatment Admissions in the United States, 2008-2017,” is posted here. ISSUES NewArchived

Legal and policy changes urgently needed to increase access to opioid agonist therapy in the United States

The United States continues to face a public health crisis of opioid-related harm, the effects of which could be dramatically reduced through increased access to opioid agonist therapy with the medications methadone and buprenorphine. Despite overwhelming evidence of their efficacy, unduly restrictive federal, state, and local regulation significantly impedes access to these life-saving medications. We outline immediate, concrete steps that federal, state, and local governments can take to change law from barrier to facilitator of evidence-based treatment for opioid use disorder. These include removing onerous restrictions on the prescription and dispensing of buprenorphine and methadone for opioid agonist therapy, requiring insurance coverage of these medications, and mandating that they be provided in correctional settings and promoted by drug courts. Finally, we argue that jurisdictions should proactively offer opioid agonist therapy to individuals at high risk of overdose, remove barriers to establishing methadone treatment facilities, and address underlying social determinants and barriers to treatment. These changes have the ability to save thousands of lives annually.

Patterns of polysubstance use and overdose among people who inject drugs in Baltimore, Maryland: A latent class analysis

BackgroundOpioid-related overdose rates continue to climb. However, little research has examined the reach of overdose education and naloxone trainings among people who inject drugs (PWID). Understanding gaps in coverage is essential to improving the public health response to the ongoing crisis. MethodsWe surveyed 298 PWID in Baltimore City, MD. We conducted a latent class analysis of drug use indicators and tested for differences by class in past month overdose, having received overdose training, and currently having naloxone. ResultsThree classes emerged: cocaine/heroin injection (40.2%), heroin only injection (32.2%), and multi-drug/multi-route use (27.6%). The prevalence of past month overdose differed marginally by class (p = 0.06), with the multi-drug/multi-route use class having the highest prevalence (22.5%) and the heroin only class having the lowest (4.6%). The prevalence of previous overdose training differed significantly by class (p = 0.02), with the heroin/cocaine class (76.5%) having more training than the other two classes. Training was least common amongst the multi-drug/multi-route class (60.3%), though not statistically different from the heroin only class (63.0%). Classes did not differ significantly in current naloxone possession, although the multi-drug/multi-route class exhibited the lowest prevalence of naloxone possession (37.2%). ConclusionsPeople who inject multiple substances are at high risk for overdose and are also the least likely to receive overdose trainings. The current service landscape does not adequately reach individuals with high levels of structural vulnerability and high levels of drug use and homelessness. Actively including this subgroup into harm reduction efforts are essential for preventing overdose fatalities.

To What Extent do Naloxone Prescriptions Increase Naloxone in The Hands of Patients At High Risk for Overdose?

Patients' attitudes toward deprescribing are crucial to understand before developing interventions, but no such data exists in the medically underserved, health disparities population of rural Appalachian United States.Assess Appalachian women's openness to deprescribing medications and determine if polypharmacy influenced their attitudes toward deprescribing.Before and after a cognitive behavioral therapy intervention, middle-aged Appalachian women self-reported medication use and completed the revised Patients’ Attitudes Toward Deprescribing Questionnaire (rPATD). Responses were described, stratified by presence of polypharmacy.30 women completed the rPATD pre- and post-intervention (mean [SD] age 55.8 [6.6] years; 96.7% white). Those with polypharmacy (n = 16) had higher burden and involvement scores (median 2.8 vs 2.0, p = 0.01; 4.9 vs 4.6, p = 0.06), and lower appropriateness scores (3.4 vs 3.9, p = 0.04). Burden, concerns about stopping, and involvement factor scores were similar before and after the intervention (p = 0.08, 0.86, and 0.41 respectively). ≥90% of participants were satisfied with their current medications yet would be willing to stop one or more.Middle-aged women in rural Appalachian United States are open to deprescribing; polypharmacy is associated with lower belief in the appropriateness of medications. Larger studies are needed to inform future deprescribing interventions for this and other similarly disadvantaged populations.

Evaluation of a Safer Opioid Prescribing Protocol (SOPP) for Patients Being Discharged From a Trauma Service.

The aims of this study were to evaluate the effects on opioid medication prescribing, patient opioid safety education, and prescribing of naloxone following implementation of a Safer Opioid Prescribing Protocol (SOPP) as part of the electronic health record (EHR) system at a Level I trauma center. This was a prospective observational study of the EHR of trauma patients pre- (n = 191) and post-(n = 316) SOPP implementation between 2014 and 2016. At a comparison Level I trauma site not implementing SOPP, EHRs for the same time period were assessed for any historical trends in opioid and naloxone prescribing. After SOPP implementation, the implementation site increased the use of nonnarcotic pain medication, decreased dispensing high opioid dose (≥100 MME [milligram morphine equivalent]), significantly increased the delivery of opioid safety education to patients, and initiated prescribing naloxone. These changes were not found in the comparison site. Opioid prescribing for acute pain can be effectively reduced in a busy trauma setting with a guideline intervention incorporated into an EHR. Guidelines can increase the use of nonnarcotic medications for the treatment of acute pain and increase naloxone coprescription for patients with a higher risk of overdose.

Acceptability of implementing community-based drug checking services for people who use drugs in three United States cities: Baltimore, Boston and Providence

BackgroundNorth America is experiencing a rising trend of opioid overdose exacerbated primarily in recent years through adulteration of the heroin supply with fentanyl and its analogues. The east coast of the United States has been particularly hard hit by the epidemic. In three east coast states of Maryland, Massachusetts and Rhode Island, fentanyl has been detected in over half of all overdoses with available toxicology screens. To determine the acceptability of drug checking involving fentanyl test strips (FTS) or other technologies among those at high risk for overdose, we assessed correlates of intention to utilize such services and logistical preferences among people who use drugs (PWUD). MethodsThrough FORECAST (the Fentanyl Overdose REduction Checking Analysis STudy), street-based PWUD (N = 334) were recruited in Baltimore, Maryland, Boston, Massachusetts, and Providence, Rhode Island. Questionnaires 7were administered from June to October 2017 and ascertained drug use, overdose history, fentanyl knowledge, and drug checking intent and logistical preferences. Pearson’s χ2 and logistic regression determined factors associated with drug checking intent. ResultsOverall, 84% were concerned about fentanyl, 63% had ever overdosed, and 42% had ever witnessed a fatal overdose. Ninety percent felt drug checking would help them prevent an overdose, the majority of those interested would utilize drug checking at least daily (54%). Factors independently associated with intent to use drug checking included: older age (aOR: 1.5, 95% CI: 1.3–1.8); homelessness (aOR: 0.6, 95% CI: 0.5–0.7); being non-white (aOR: 2.0, 95% CI: 1.0–4.0); witnessing ≥1 fatal overdose (aOR: 1.6, 95% CI:1.1–2.3); and suspected recent fentanyl exposure (aOR: 1.8, 95% CI: 1.1–3.1). ConclusionsThe majority of PWUD endorsed drug checking for overdose prevention, with intent amplified by having witnessed a fatal overdose and recent fentanyl exposure. Drug checking should be part of a comprehensive approach to address the risks associated with the proliferation of fentanyl.