Increase In Opioid-related Mortality Research Articles

Operating in an Opioid Crisis: A Temporal Analysis of Pain Medication Prescribing Practices in Plastic Surgery.

In response to the opioid epidemic, the United States declared a public health emergency in 2017. We evaluated pain medication prescribing practices among plastic and reconstructive surgeons, assessing pain medication prescription rates and opioid-related mortality both nationally and regionally within the United States. A retrospective analysis of Medicare Part D prescriber data among plastic surgeons from 2013 through 2017 was conducted. Pain medications were categorized as opioid and nonopioid medications. Trends in surgeon prescribing habits were evaluated using the Cochrane-Armitage trend test. A total of 708,817 pain medication claims were identified: 612,123 claims (86%) were for opioid pain medications and 96,694 claims (14%) were for nonopioid pain medications. Total pain medication claims decreased from 44% of all medications in 2013 to 37% in 2017 (P < 0.001). Opioid medications decreased from 37% of total medication claims to 32% (P < 0.001). The overall opioid prescription rate fell from 1.53 claims per beneficiary in 2013 to 1.32 in 2017 (P < 0.001). Nonopioid pain medications decreased from 7% in 2013 to 6% in 2017 (P < 0.001); nonsteroidal anti-inflammatory drug claims increased by 44%. The prescription rate of nonopioid medications decreased from 2.40 claims per beneficiary in 2013 to 2.32 in 2017 (P < 0.001). An overall increase in opioid-related mortality was observed. Trends in pain medication prescriptions varied significantly among US regions and divisions. Plastic surgeons are prescribing less opioids and relying more on nonopioid pain medications. Increased adoption of multimodal pain treatment approaches among surgeons is a likely explanation for this trend in face of the current opioid crisis.

Discontinuation of Buprenorphine Treatment for Opioid Use Disorder During the Coronavirus Disease-2019 Pandemic: A Multilevel Framework.

The coronavirus disease-2019 pandemic has been associated with large increases in opioid-related mortality, yet it is unclear whether specific subpopulations were especially likely to discontinue buprenorphine treatment for opioid use disorder as the pandemic ensued. The aim was to assess predictors of buprenorphine discontinuation in the early months of the coronavirus disease-2019 pandemic (April-July 2020) compared with a prepandemic period (April-July 2019). In each time period, we estimated a multilevel regression models to assess risk of discontinuation in April-July for people who started buprenorphine in January-February. Models included person-level, prescriber-level, and area-level covariates. Individuals age 18 years or older in the all-payer IQVIA Longitudinal Prescription Claims. The primary outcome was buprenorphine discontinuation (ie, no filled prescriptions during the follow-up periods). Overall, 13.98% of patients discontinued buprenorphine in April-July 2020, less than the 15.71% in 2019 (P<0.001). In 2020, patient-level factors associated with discontinuation included younger age, male sex, shorter baseline possession ratio, and payment by cash. Compared with patients with a primary care physician prescriber, specialties most associated with discontinuation were pain medicine and physician assistant/nurse practitioner. Compared with the South Atlantic region, discontinuation risk was lowest in New England and highest in the West South Central States. The association between patient, prescriber, and geographic variables to risk of discontinuation was very similar in 2019 and 2020. While clinical and policy interventions may have mitigated opioid use disorder treatment discontinuation following the pandemic, such discontinuation is nevertheless common and varies by identifiable patient, provider and geographic factors.

Determination of synthetic opioids in oral fluid samples using fabric phase sorptive extraction and gas chromatography-mass spectrometry

New psychoactive substances (NPS) continue to emerge in the drug market every year, becoming a global threat to public health and safety. These compounds are mostly synthetic cannabinoids and designer cathinones. However, synthetic opioids have appeared on the recreational drug markets in recent years, particularly fentanyl and its derivatives (“fentanyls”). Fentanyl and its analogs are related to harmful intoxications and an increase in opioid-related mortality in many countries, such as in the United States and Europe in the last years. Taking the drug related global crisis into consideration, this work developed and validated an effective and sensitive method based on fabric phase sorptive extraction (FPSE) followed by gas chromatography-mass spectrometry (GC-MS) for the simultaneous determination of 11 fentanyl analogs in oral fluid samples. The extraction was carried out using a sol-gel Carbowax 20 M sorbent immobilized on 100% cellulose fabric substrate and using ethyl acetate as the desorption solvent. The limits of detection (LODs) and quantification (LOQs) ranged from 1 to 15 ng mL−1 and 5 to 50 ng mL−1, respectively. Intra-day and inter-day precision were found within 8.2% and 8.6%, respectively, while accuracy ranged from -5.5 to 9.1%, in accordance with the established criteria. The absolute recovery values were in the range of 94.5%–109.1%. The validated method demonstrated its great potential to detect and quantify fentanyl analogs in possible forensic work and off-site analysis in road traffic cases.

Opioid abuse and austerity: Evidence on health service use and mortality in England

Opioid abuse has become a public health concern among many developed countries, with policymakers searching for strategies to mitigate adverse effects on population health and the wider economy. The United Kingdom has seen dramatic increases in opioid-related mortality following the financial crises in 2008. We examine the impact of spending cuts resulting from government prescribed austerity measures on opioid-related hospitalisations and mortality, thereby expanding on existing evidence suggesting a countercyclical relationship with macroeconomic performance. We take advantage of the variation in spending cuts passed down from central government to local authorities since 2010, with reductions in budgets of up to fifty percent in some areas resulting in the rescaling of vital public services. Longitudinal panel data methods are used to analyse a comprehensive, linked dataset that combines information from spending records, official death registry data and large administrative health care data for 152 local authorities (i.e., unitary authorities and county councils) in England between April 2010 and March 2017. A total of 280,827 people experienced a hospital admission in the English National Health Service because of an opioid overdose and 14,700 people died from opioids across the study period. Local authorities that experienced largest spending cuts also saw largest increases in opioid abuse. Interactions between changes in unemployment and spending items for welfare programmes show evidence about the importance for governments to protect populations from social-risk effects at times of deteriorating macroeconomic performance. Our study carries important lessons for countries aiming to address high rates of opioid abuse, including the United States, Canada and Sweden.

Employing telehealth strategies for opioid addiction during COVID-19: implications for social work health care

ABSTRACT As the COVID-19 global pandemic continues, more than 40 states have reported increases in opioid-related mortality. The issue of service access and delivery poses a major concern for those struggling with mental illness and substance use disorders in the United States. To ensure the continuity of health care during the pandemic and the co-occurring opioid crisis, the United States continues to adapt its healthcare delivery strategies, which include the introduction of telehealth. Telehealth is a relatively new concept and requires rapid systems changes as well as adjustments from both service providers and recipients. The proper adaptation to the new service delivery method could result in process optimization and improved outcomes for those struggling with opioid dependency. This study aims to bring attention to the opioid crisis that may be overlooked in light of the global pandemic and encourage social workers and other mental health professionals to utilize modern technological advancements to improve service delivery to their clients. This paper offers a literature review with four themes: (1) a retrospect on pain and opioids, (2) current telehealth models and practical strategies, (3) social work roles and functions in telehealth care, and (4) next steps and implications of telehealth for social work as a much-needed health-care delivery tool at the clinical and community social work practice level.

Tracking Trends in the Opioid Epidemic in North Carolina : Early Results from the Opioid Action Plan Metrics.

BACKGROUND Deaths from unintentional opioid overdose have increased markedly over the last decade in North Carolina. In 2017 the state created a North Carolina Opioid Action Plan, which laid out a multisectoral response to the crisis that included the medical community, law enforcement, emergency medical services, and treatment professionals. It also created a website providing county-level data associated with the crisis. Using this publicly available data, we examine trends and associations between opioid-related mortality and strategies to reduce opioid prescriptions, reduce fatality of overdose, and improve treatment and recovery.METHOD We examine yearly trends from 2010-2017 for statewide unintentional opioid-related death rates, prescription of opioid pills, buprenorphine prescription rates, naloxone administrations, and number of Certified Peer Support Specialists. We compare recent opioid-related death rates for 2015-2017 with an earlier period (2010-2012) at the county level, and examine the association between death rates and rates of the supply, treatment, and recovery metrics.RESULTS Trends for all metrics increased from 2010-2017, although the number of opioid pills per capita has declined since 2015. Between 2010 and 2017, 84 of the state's 100 counties experienced an increase in opioid-related mortality. County-level mortality was positively associated with opioid prescription rate (r = +0.12, P = 0.24) and with naloxone administrations (r = +0.20, P = 0.05). Prescription of buprenorphine was associated with a reduction in opioid mortality (r = -0.27, P = 0.01). The effect of Certified Peer Support Specialists was not discernable.LIMITATIONS Data are available for only eight years and aggregated at the county level. Mortality data are based on death certificates using ICD-10 codes from the North Carolina State Center for Health Statistics, Vital Statistics, which may not capture all opioid-related fatalities. Drug-related deaths may involve multiple non-opioid substances; in addition, determining the intent of the deceased individual may be difficult (suicide versus unintentional). Naloxone administration data only includes data from emergency medical services, not community-administered naloxone, because that data was only available for 2013 and later and is based only on self-reports.CONCLUSIONS The potential efficacy of buprenorphine is promising and should be further explored. All interventions should be monitored.

Patients seeking treatment for opioid use disorder face more challenges during pandemic

Patients seeking treatment for opioid use disorder face more challenges during pandemic

The role of pharmacists in opioid stewardship: Protocol.

The opioid crisis is a worldwide public health concern. In North America, evidence suggests that the increase in opioid prescriptions correlates with the observed increase in opioid-related mortality and morbidity. Pharmacists are in a strategic position to promote effective opioid stewardship as they have a central role on healthcare teams. However, in many contexts, pharmacists do not have a harmonized scope of practice and no standardized opioid stewardship approach has been implemented. A scoping review will be conducted to identify and summarize evidence on the role of pharmacists in opioid stewardship and identify areas for future study. The scoping review will be conducted according to the methodological framework proposed by Arksey and O'Malley, which was further modified by the Joanna Briggs Institute. Six databases will be searched which include PubMed, Embase, International Pharmaceutical Abstracts, Scopus, Cochrane Library, and APA PsycInfo. The findings of this review will identify opioid stewardship activities that can contribute towards reducing the impact of the opioid crisis. Additionally, it will provide foundational strategies to promote policy level change and foster a harmonized scope of practice. This review has the potential to inform future research, impact pharmacy practice, and drive policy change.

Protocolization of Post-Transforaminal Lumbar Interbody Fusion Pain Control with Elimination of Benzodiazepines and Long-Acting Opioids.

The opioid epidemic continues to worsen with a concomitant increase in opioid-related mortality. In response, the Department of Defense and Veterans Health Agency recommended against the use of long-acting opioids (LAOs) and concurrent use of opioids with benzodiazepines. Subsequently, we eliminated benzodiazepines and LAOs from our postoperative pain control regimen. To evaluate the impact of removing benzodiazepines and LAOs on postoperative pain in single-level transforaminal lumbar interbody fusion (TLIF) patients. A retrospective cohort study of single-level TLIF patients from February 2016-March 2018 was performed. Postoperative pain control in the+benzodiazepine cohort included scheduled diazepam with or without LAOs. These medications were replaced with nonbenzodiazepine, opioid-sparing adjuncts in the -benzodiazepine cohort. Pain scores, length of hospitalization, trigger medication use, and opioid use and duration were compared. Among 77 patients, there was no difference between inpatient pain scores, but the -benzodiazepine cohort experienced a faster rate of morphine equivalent reduction (-18.7%, 95% CI [-1.22%, -36.10%]), used less trigger medications (-1.55, 95% CI [-0.43, -2.67]), and discharged earlier (0.6 d; 95% CI [0.01, 1.11 d]). As outpatients, the -benzodiazepine cohort was less likely to receive opioid refills at 2 wk (29.2% vs 55.8%, P=.021) and 6 mo postoperatively (0% vs 13.2%, P=.039), and was less likely to be using opioids by 3 mo postoperatively (13.3% vs 34.2%, P=.048). Replacement of benzodiazepines and LAOs in the pain control regimen for single-level TLIFs did not affect pain scores and was associated with decreased opioid use, a reduction in trigger medications, and shorter hospitalizations.

A decade of extreme oscillations in opioid control and availability: implications for public health in a Canadian setting.

We comment on developments in and impacts of medical opioid control and availability in the province of British Columbia (Canada). Population-level dispensing of (strong) prescription opioids doubled in 2005-2011, yet subsequently declined by half 2011-2018 following implementation of various opioid control measures. Notwithstanding this inversion, BC has featured the highest population rates of opioid-related mortality and morbidity in Canada. The erratic opioid availability patterns presumably facilitated major increases in opioid misuse, morbidity, and mortality. Tangible benefits for pain care from increased medical opioid availability remain un-evidenced. Rather, recent decreases in medical opioid dispensing have not been matched by equivalent reductions in demand for (non-)medical use yet have coincided with widespread proliferation of toxic, illicit opioid supply and related major increases in opioid-related mortality. These developments appear to have undermined rather than benefitted public health and offer a poignant case study in ineffective psychotropic drug control and public health policy towards preventing similar experiences elsewhere.

Preoperative quality-of-life measures predict acute postoperative pain in endoscopic sinus surgery.

Recent increases in opioid-related mortality have prompted a critical evaluation of postoperative pain management across all specialties. However, successfully limiting narcotic overprescription requires perioperative identification of patients who are at risk for high postoperative pain. Unfortunately, quality data to guide practice patterns are lacking. We therefore prospectively investigated several possible predictive factors of postoperative pain after endoscopic sinus surgery (ESS). Sixty-four consecutive patients undergoing ESS were enrolled. Baseline 22-item SinoNasal Outcomes Test (SNOT-22) and Short-Form 8 (SF-8) scores were obtained. Pain scores were collected postoperatively using a numeric rating scale. Spearman correlations and univariate linear regression models were used to investigate relationships between postoperative pain, patient factors, and SNOT-22/SF-8 domain scores. Multivariate linear regression was then performed to control for potential confounding variables. Day-of-surgery pain scores were significantly correlated with the SF-8 role-physical domain (Rs = 0.32, P = 0.04). Whereas SF-8 pain scores were initially nonsignificant, at postoperative day 3 (POD3) the preoperative SF-8 pain score became correlated with self-reported pain (Rs = 0.39, P = 0.02). SNOT-22 total and subdomain scores were not associated with pain scores at any time point. Multivariate linear regression modelling identified baseline SF-8 role-physical and pain scores, smoking status, and undergoing a modified Lothrop procedure as significant independent predictors of POD3 pain (adjusted R2 = 0.359, P < 0.0001). Baseline patient-reported global quality-of-life measures are associated with postoperative pain after ESS. Large multicenter studies are necessary to validate these findings and investigate additional factors associated with postoperative pain following ESS. 2c Laryngoscope, 129:1274-1279, 2019.

The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime

The United States is experiencing an epidemic of opioid abuse. In response, many states have increased access to naloxone, a drug that can save lives when administered during an overdose. However, naloxone access may unintentionally increase opioid abuse through two channels: (1) reducing the risk of death per use, thereby making riskier opioid use more appealing, and (2) saving the lives of active drug users, who survive to continue abusing opioids. By increasing the number of opioid abusers who need to fund their drug purchases, naloxone access laws may also increase theft. We exploit the staggered timing of naloxone access laws to estimate the total effects of these laws. We find that broadening naloxone access led to more opioid-related emergency room visits and more opioid-related theft, with no reduction in opioid-related mortality. These effects are driven by urban areas and vary by region. We find the most detrimental effects in the Midwest, including a 14% increase in opioid-related mortality in that region. We also find suggestive evidence that broadening naloxone access increased the use of fentanyl, a particularly potent opioid. While naloxone has great potential as a harm-reduction strategy, our analysis is consistent with the hypothesis that broadening access to naloxone encourages riskier behaviors with respect to opioid abuse.

The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime

The United States is experiencing an epidemic of opioid abuse. In response, many states have increased access to naloxone, a drug that can save lives when administered during an overdose. However, naloxone access may unintentionally increase opioid abuse through two channels: (1) reducing the risk of death per use, thereby making riskier opioid use more appealing, and (2) saving the lives of active drug users, who survive to continue abusing opioids. By increasing the number of opioid abusers who need to fund their drug purchases, naloxone access laws may also increase theft. We exploit the staggered timing of naloxone access laws to estimate the total effects of these laws. We find that broadening naloxone access led to more opioid-related emergency room visits and more opioid-related theft, with no reduction in opioid-related mortality. These effects are driven by urban areas and vary by region. We find the most detrimental effects in the Midwest, including a 14% increase in opioid-related mortality in that region. We also find suggestive evidence that broadening naloxone access increased the use of fentanyl, a particularly potent opioid. While naloxone has great potential as a harm-reduction strategy, our analysis is consistent with the hypothesis that broadening access to naloxone encourages riskier behaviors with respect to opioid abuse.

The Impact of Opioids on Cardiac Electrophysiology.

Synthetic opioid agents have been used in modern medicine for over a century and for opioid addiction treatment for over a half-century. Liberal use of opioids in the United States has been attended by an extraordinary increase in opioid-related mortality, with over 16,000 deaths in 2012. As there have been advances in opioid agents for pain and addiction, so have there been advances in our understanding of the cardiac effects of these agents. In the last 10 years, significant data regarding electrophysiologic effects of these agents have been collected. We aim in this review to discuss the effects on cardiac electrophysiology of the various opioid agents currently in use and the evidence that these effects are contributing to the rise in opioid-related mortality.

Postoperative opioids

Postoperative opioids

Opioid Dose and Drug-Related Mortality in Patients With Nonmalignant Pain

Opioids are widely prescribed for chronic nonmalignant pain, often at doses exceeding those recommended in clinical practice guidelines. However, the risk-benefit ratio of high-dose opioid therapy is not well characterized. The objective of this study was to characterize the relationship between opioid dose and opioid-related mortality. We conducted a population-based nested case-control study of Ontario, Canada, residents aged 15 to 64 years who were eligible for publicly funded prescription drug coverage and had received an opioid from August 1, 1997, through December 31, 2006, for nonmalignant pain. The outcome of interest was opioid-related death, as determined by the investigating coroner. The risk of opioid-related death was compared among patients treated with various daily doses of opioids. Among 607,156 people aged 15 to 64 years prescribed an opioid over the study period, we identified 498 eligible patients whose deaths were related to opioids and 1714 matched controls. After extensive multivariable adjustment, we found that an average daily dose of 200 mg or more of morphine (or equivalent), was associated with a nearly 3-fold increase in the risk of opioid-related mortality (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.79-4.63) relative to low daily doses (<20 mg of morphine, or equivalent). We found significant but attenuated increases in opioid-related mortality with intermediate doses of opioids (50-99 mg/d of morphine: OR, 1.92; 95% CI, 1.30-2.85; 100-199 mg/d of morphine: OR, 2.04; 95% CI, 1.28-3.24). Among patients receiving opioids for nonmalignant pain, the daily dose is strongly associated with opioid-related mortality, particularly at doses exceeding thresholds recommended in recent clinical guidelines.

Palliative Care Pharmacotherapy Literature Summaries and Analyses

ABSTRACTTimely and important studies are reviewed and commentaries provided by leading palliative care clinicians. Symptoms, interventions, and treatment-related adverse events addressed in this issue are the addition of nutritional support for the treatment of pressure ulcers; advantages of hypertonic saline solution plus high-dose intravenous (IV) furosemide over repeated paracentesis plus albumin in the management of cirrhosis-associated refractory ascites; increases in opioid-related mortality with the availability of long-acting oxycodone in Canada; the safety and efficacy of ABT-594 for diabetic neuropathic pain; and examination of the influence nursing home cultural characteristics on use of feeding tubes.

Dying for heroin: the increasing opioid-related mortality in the Republic of Ireland, 1980–1999

Over the past 20 years there has been a steady rise in mortality associated with opioid misuse in several Western countries. We aimed to examine trends in opioid-related mortality over a 20-year period in the Republic of Ireland. Retrospective analysis of deaths attributed to ICD-9 codes 304.0 (morphine-type dependence) and E850.0 (accidental poisoning by opiates and related narcotics) in the Republic of Ireland between 1980 and 1999. The Republic of Ireland has seen a rapid increase in the number of opioid-related deaths over the 20-year period studied, from 0.01% of total deaths in 1980 to 0.15% in 1999. This is most marked in the younger age groups where, for example, it rose to 23% of 15-19 year old male deaths for 1997. The opioid-related mortality rate in the 15-44 years age range increased by nearly 14 times between 1980-1984 and 1995-1999. Over the whole period, 87% of opioid-related deaths were amongst males. Outside Dublin there has been a considerable increase in opioid-related mortality, nearly doubling the percentage of the total from 6% in the 1980s to 11% in the 1990s. Opioid-related mortality is an increasing problem in the Republic of Ireland, as in other Western countries. Today, young people have a very low mortality rate, and hence this rapid increase may need specific targeted interventions. The spread of opioid-related mortality outside Dublin to rural and other urban areas will have implications for service planning and provision.