Non-prescription Opioids Research Articles

Modeling of overdose and naloxone distribution in the setting of fentanyl compared to heroin

BackgroundFentanyl has replaced most other non-prescribed opioids in much of North America. There is controversy over whether a hypothetical reduced efficacy of naloxone in reversing fentanyl is a major contributor to the coincident rising overdose mortality. MethodsWe modified an existing Markov decision analytic model of heroin overdose and naloxone distribution to account for known risks of fentanyl by adjusting overdose risk, the likelihood of death in the event of overdose, and the proportion of cases in which available naloxone was administered in time to prevent death. We assumed near-universal survival when naloxone was administered promptly for heroin or fentanyl overdose, but allowed that to decline in sensitivity analyses for fentanyl. We varied the proportion of use that was fentanyl and adjusted the modified parameters accordingly to estimate mortality as the dominant opioid shifted. ResultsAbsent naloxone, the annual overdose death rate was 1.0% and 4.1% for heroin and fentanyl, respectively. With naloxone reaching 80% of those at risk, the overdose death rate was 0.7% and 3.6% for heroin and fentanyl, respectively, representing reductions of 26.4% and 12.0%. Monte Carlo simulations resulted in overdose mortality with fentanyl of 3.3–5.2% without naloxone and 2.6–4.9% with naloxone, with 95% certainty. Positing reduced efficacy for naloxone in reversing fentanyl resulted in 3.6% of fentanyl overdose deaths being prevented by naloxone. ConclusionsHeightened risk for overdose and subsequent death, alongside the time-sensitive need for naloxone administration, fully account for increased mortality when fentanyl replaces heroin, assuming optimal pharmacologic efficacy of naloxone.

Assessing the Relationship between Controlled Substance Prescribing and Opioid Poisoning Toxicology

This study updates previously reported drug overdose deaths in Allen County, Indiana with the purpose to evaluate changes in physician prescribing and drug overdose deaths following introduction of more restrictive Indiana controlled substance prescribing laws. In a retrospective review of drug overdose deaths, 2013-2017, Allen County, IN, autopsy, toxicology, police reports and prescribing data from the Indiana Scheduled Prescription Electronic Collection and Tracking Program (INSPECT) for 12 months preceding death were analyzed. Descriptive and correlational statistical measures were used. A total of 533 drug overdose deaths were reported: 414 deaths with complete records (369 unintentional, 42 intentional, 3 undetermined). Decedents, mean age 42.3 years, were more likely male (60.6%), Caucasian (89.1%) and employed (70.2%). Overdose deaths increased significantly between 2014 (n=53) and 2017 (n=133). Non-prescribed opioids were present in 293 (70.8%) deaths and 298 (72%) deaths involved multiple substances. Fentanyl-related deaths markedly increased (2 (3.2%) in 2013, 67 (50.5%) in 2017) and correlate with police fentanyl seizures. The average number of prescribed controlled substances significantly decreased. Non-prescribed controlled substances including opioids contributed to most deaths. While gains have been made with responsible opioid prescribing, the current crisis is fueled by illicit opioids.

Evaluation of Discharge Opioid Prescribing in Coronary Artery Bypass Patients Following an Opioid Stewardship Intervention for Providers.

Introduction: Opioid stewardship efforts can promote safe and effective use of opioids to optimize pain control and minimize unintended consequences. The purpose of this study is to assess the difference in post-operative opioid discharge prescribing in patients undergoing coronary artery bypass graft (CABG) surgery following implementation of a tripartite opioid stewardship intervention. Methods: This was a single-center, quality improvement study at a large, quaternary academic medical center. Adult patients undergoing CABG from July 2019 to June 2020 (pre-intervention) and November 2020 to February 2021 (post-intervention) were included. The intervention included adopting hospital-wide post-surgical opioid discharge prescribing guidelines, discharge prescriber education, and electronic medical record changes. The primary outcome was the proportion of patients receiving an opioid prescription at discharge. Secondary outcomes included total morphine milligram equivalents (MME) prescribed and non-opioid analgesics prescribed at discharge. Results: A total of 200 patients were included in the study; 100 pre- and 100 post-intervention. There was no difference in opioid discharge prescribing at discharge (74% pre-intervention vs. 72% post-intervention; P = .87). There was no difference in MMEs prescribed at discharge (145.6 ± 57 pre- vs. 162.2 ± 95 post-; P = .202). No difference was seen in non-opioid analgesic prescriptions prescribed at discharge (35% pre- vs. 40% post-; P = .56). Conclusion: A multipronged opioid stewardship intervention did not lead to a reduction in opioid prescribing at discharge. Post-intervention, there was a non-statistically significant increase in the proportion of patients who received non-opioid analgesics discharge. Future studies should assess the effect of different stewardship interventions on prescribing and patient outcomes.

Influence of Primary Care Provider Type on Chronic Pain Management Among Veterans

Chronic pain disproportionately impacts veterans and is often treated in primary care, where physician shortages in the Veterans Health Administration (VHA) healthcare system are well documented. Nurse practitioners (NPs) may represent a solution to the care shortage; however, concerns of NP opioid overprescribing have led to NP practice and prescribing restrictions in individual VHA facilities and at the state level. Little is known regarding the prescribing patterns of NPs and physician assistants (PAs) for veterans with chronic pain in the VHA. The purpose of this study was to compare opioid and non-opioid prescribing patterns of physicians, NPs, and PAs for chronic pain patients at VHA centers. We used data from the U.S. Department of Veterans Affairs Survey of Healthcare Experience of Patients and Corporate Data Warehouse from October 2015 to September 2016. Patient medical records for the year were analyzed by provider type (physician, NP, or PA) for differences in providers' rates of prescribing opioid and non-opioid medications, as well as characteristics of the opioid prescriptions (e.g., high daily morphine milligram equivalent [90 MME/day] dose, long-term opioid therapy [90 days]). Medical records of a total of 39,936 patients were included. In FY 2016, 55% of patients received one opioid prescription, whereas 83.8% received one non-opioid prescription. Compared to patients of NPs and PAs, patients of physicians had higher odds of receiving opioid (vs. NPs: OR = 1.13, p < 0.01; vs. PAs: OR = 1.16, p < 0.01) and non-opioid prescriptions (vs. NPs: OR=1.08, p = 0.02; vs. PAs: OR=1.20, p < 0.01) after adjusting for patient characteristics. There were no differences in high MME/day dose (p = 0.59) or long-term opioid therapy (p = 0.99). In a national sample of veterans with chronic pain, NPs and PAs did not have higher odds of opioid prescribing. Concerns of NP or PA opioid overprescribing may be addressed by considering evidence that patients of these providers are not at higher odds of receiving an opioid prescription.

Utilizing primary care to engage patients on opioids in a psychological intervention for chronic pain.

Context: Chronic pain, one of the most prevalent issues encountered in primary care, is often treated with opioid prescriptions. Overuse of these medications can cause overdose and death, creating a dire need for alternative treatment methods. Psychological interventions are effective for improving pain and distress, yet are underutilized. Physicians report difficulty engaging patients already on opioids in these interventions; it is possible that offering this intervention in a primary care setting may alleviate this barrier. Objective: Determine whether opioid prescriptions are related to patients engaging in a brief psychological intervention for chronic pain management in primary care. Study Design: Secondary analysis of a pilot randomized clinical trial of a 5-session psychological intervention for chronic pain. Setting: Primary care clinic in an urban setting Patient Population: Patients with chronic pain (N= 220) were approached to enroll in a pilot randomized clinical trial (RCT) for a brief, psychological intervention for pain in primary care. Of these, 60 participated and 160 declined. Instruments: Electronic health records were reviewed to determine whether patients were prescribed opioids or pain medications at the time they were approached about the RCT. Main outcome: Comparing opioid prescriptions in enrollees versus non-enrollees. Results: There was not a significant difference between enrollees and non-enrollees in the rate of opioid prescriptions (18.3% vs. 20%, p= .78), the morphine milligram equivalent dose of opioids (M= 17.64, SD= 22.91 vs. M= 18.07, SD= 18.19; p= .95), or the rate of non-opioid pain prescriptions (33.3% vs. 40%, p = .37). When examining for gender differences, among women, there were similar rates between enrollees and non-enrollees in the rate of opioid prescriptions (23.4% vs. 17%, p = .36). However, no males with an opioid prescription enrolled, whereas 25% of men who did not enroll had an opioid prescription. Conclusions: Among all patients, opioid prescriptions were not related to enrollment in the RCT. This suggests that engaging patients who are on opioids in a psychological treatment for chronic pain, specifically in a primary care setting, may increase utilization. However, this may be true for women, but not men. Further work needs to be done to identify methods to increase psychological intervention engagement among all patients receiving opioids, but especially men.

Epidemiology and routine care treatment of patients with hip or knee osteoarthritis and chronic lower back pain: real-world evidence from Germany

AimMusculoskeletal disorders are a major public health problem in most developed countries. As a main cause of chronic pain, they have resulted in an increasing prescription of opioids worldwide. With regard to the situation in Germany, this study aimed at estimating the prevalence of musculoskeletal diseases such as chronic low back pain (CLBP) and hip/knee osteoarthritis (OA) and at depicting the applied treatment patterns.Subject and methodsGerman claims data from the InGef Research Database were analyzed over a 6-year period (2011–2016). The dataset contains over 4 million people, enrolled in German statutory health insurances. Inpatient and outpatient diagnoses were considered for case identification of hip/knee OA and CLBP. The World Health Organization (WHO) analgesic ladder was applied to categorize patients according to their pain management interventions. Information on demographics, comorbidities, and adjuvant medication was collected.ResultsIn 2016, n = 2,693,481 individuals (50.5% female, 49.5% male) were assigned to the study population; 62.5% of them were aged 18–60 years. In 2016, n = 146,443 patients (5.4%) with CLBP and n = 307,256 patients (11.4%) with hip/knee OA were identified. Of those with pre-specified pain management interventions (CLBP: 66.3%; hip/knee OA: 65.1%), most patients received WHO I class drugs (CLBP: 73.6%; hip/knee OA: 68.7%) as the highest level.ConclusionThis study provides indications that CLBP and hip/knee OA are common chronic pain conditions in Germany, which are often subjected to pharmacological pain management. Compared to non-opioid analgesic prescriptions of the WHO I class, the dispensation of WHO class II and III opioids was markedly lower, though present to a considerable extent.

333. Comparing COVID-19-related Morbidity and Mortality between Patients with and without Substance Use Disorder: A Retrospective Cohort Study

BackgroundEarly data suggest that people with substance use disorder (SUD) who develop coronavirus disease 2019 (COVID-19) have increased intubation and mortality rates when compared to those without SUD. Information on other COVID-19-related complications in this population is limited. We evaluated COVID-19 outcomes in patients with and without SUD.MethodsWe created a retrospective cohort of patients with COVID-19 admitted to an urban safety net hospital from 3/16/2020 to 4/8/2020. Inclusion criteria were admission with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 and age greater than 18 years. SUD included alcohol use disorder or heavy alcohol use as defined by the National Institute on Alcohol Abuse and Alcoholism, use of cocaine, non-prescribed opioids or amphetamines. Primary outcome was inpatient mortality. Secondary outcomes were clinical complications (intubation, secondary infections, renal failure, venous thromboembolism, stroke, hepatitis, myocardial infarct, multisystem organ failure) and resource utilization (length of stay, intensive care unit [ICU] admission, ICU days, readmission). We used multivariable regression to assess factors associated with mortality and length of stay, and univariate analyses for other outcomes.ResultsOf 409 included patients, 70 (17.1%) had SUD. Those with SUD were more likely to be male and have pulmonary disease or hepatitis C. There were no differences in other comorbidities, mean age or race/ethnicity. After multivariable analysis, SUD was not associated with mortality (aOR 1.60; 95% CI, 0.60-3.81). Similarly baseline oxygenation defined as the ratio of oxygen saturation to fraction of inspired oxygen (aOR 1.57; 0.11-13.0) and administration of immunomodulatory therapy (tocilizumab, sarilumab or anakinra) (aOR 1.41; 0.65-3.01) did not affect mortality. In contrast, age (aOR 1.06; 1.03-1.09), sex (aOR 2.30; 1.04-5.47) and obstructive sleep apnea (aOR 4.07; 1.64-9.66) were associated with mortality. We did not find any associations with secondary outcomes.ConclusionOur findings suggest that substance use alone may not increase COVID-19 adverse outcomes. Future studies should evaluate these results in the current period of improved COVID-19 therapy.Disclosures All Authors: No reported disclosures

The Impact of Multidisciplinary Conferences on Healthcare Utilization in Chronic Pain Patients

Approximately 100 million adults in the United States have chronic pain, though only a subset utilizes the vast majority of healthcare resources. Multidisciplinary care has been shown to improve outcomes in a variety of clinical conditions. There is concern that multidisciplinary care of chronic pain patients may overwhelm existing resources and increase healthcare utilization due to the volume of patients and the complexity of care. We report our findings on the use of multidisciplinary conferences (MDC) to facilitate care for the most complex patients seen at our tertiary center. Thirty-two of nearly 2,000 patients seen per year were discussed at the MDC, making up the top 2% of complex patients in our practice. We evaluated patients' numeric rating score (NRS) of pain, medication use, hospitalizations, emergency department visits, and visits to pain specialists prior to their enrollment in MDC and 1 year later. Matched samples were compared using Wilcoxon's signed rank test. Patients' NRS scores significantly decreased from 7.64 to 5.54 after inclusion in MDC (p < 0.001). A significant decrease in clinic visits (p < 0.001) and healthcare utilization (p < 0.05) was also observed. Opioid and non-opioid prescriptions did not change significantly (p = 0.43). 83% of providers agreed that MDC improved patient care. While previous studies have shown the effect of multi-disciplinary care, we show notable improvements with a team established around a once-a-month MDC.

Changes in Social, Romantic, and General Life Satisfaction Over the Course of a Substance Use Disorder.

Background: The pandemic has highlighted the importance of social connection for health and well-being. Satisfaction across domains of life is associated with substance use outcomes, such as risk of relapse and mortality. Previous work has delineated the relationship between substance use and social connections, yet there is a lack of research exploring the relationship between substance use and satisfaction with domains of life over time.Methods: We retrospectively assessed satisfaction with social life, romantic life, and general life across five phases of substance use among 339 adults, of whom 289 identify as formerly having a problem with substance use, and a comparison group of 50 who report no history of problematic drug use. We compared those whose primary drug of choice was alcohol, marijuana, methamphetamine, non-prescription opioids, and prescription opioids.Results: Those who used prescription opioids reported a larger drop in satisfaction in social life, romantic life, and general life during the course of substance use than those who used other drugs. However, we report no significant differences in current satisfaction, social well-being, or quality of life between people in recovery and people with no history of problematic substance use.Conclusions: These findings—alongside neuropsychological work on the opioid system and sociality—paint a picture that those who formerly used prescription opioids may experience lower satisfaction across life domains during the course of their substance use than those who used other substances. However, people in prolonged recovery—regardless of their drug of choice—all show similar levels of satisfaction compared to people with no history of problematic substance use.

Comparing the feasibility of four web-based recruitment strategies to evaluate the treatment preferences of rural and urban adults who misuse non-prescribed opioids

This cross-sectional study examined the feasibility of using four different web-based strategies to recruit rural and urban adults who use opioids non-medically for a survey on opioid use disorder (OUD) treatment preferences, and compared the treatment preferences of rural versus urban participants. Preferences for medication for opioid use disorder (MOUD) formulation and OUD treatment models were assessed through an online survey. Recruitment advertisements were shown on Facebook, Google AdWords, Reddit, and Amazon Mechanical Turk (MTurk). Participants were categorized by zip code into urban versus rural residence using the Centers for Medicaid and Medicaid Health Resources and Services Administration definitions. OUD treatment preferences were compared using chi-square and t-tests. Among the 851 participants recruited, 815 provided zip codes and were classified as residing in rural (n = 200, 24.5%) or urban (n = 615, 75.4%) regions. A crowdsourcing service (MTurk) recruited the most rural participants, while posts on a social news website (Reddit) recruited the most urban participants (χ23 = 17.0, p < 0.01). While preferred MOUD formulation and OUD treatment model did not differ by rurality, rural participants were more likely to report a willingness to receive OUD treatment integrated with general medical care (χ21 = 18.9, p < 0.0001). This study demonstrated that web-based strategies are feasible for recruiting rural adults who misuse opioids. Results suggest OUD treatment preferences largely did not differ by rural residence, and highlight the importance of enhancing the availability and increasing education about MOUD formulations in rural regions.

Patient, Provider, and Clinic Characteristics Associated with Opioid and Non-Opioid Pain Prescriptions for Patients Receiving Low Back Imaging in Primary Care.

To describe characteristics of patients, providers, and clinics associated with opioid or non-opioid pain medication prescribing patterns for patients who received lower spine imaging in primary care clinics. In these secondary analyses of the Lumbar Imaging with Reporting of Epidemiology (LIRE) study, a randomized controlled trial conducted in 4 health systems in the United States, we evaluated characteristics associated with receipt of pain medication prescriptions. The outcomes were receipt of prescriptions for opioid or, separately, non-opioid pain medications within 90 days after imaging. Among patients who received opioid or non-opioid prescriptions, we evaluated receipt of multiple prescriptions in the year following imaging. Mixed models were used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Compared with whites, patients identified as Asian (OR, 0.53; 95% CI, 0.51-0.56), Native Hawaiian/Pacific Islander (OR, 0.73; 95% CI, 0.64-0.83), multiracial (OR, 0.84; 95% CI, 0.71-0.98) or Black (OR, 0.92; 95% CI, 0.89-0.96) had significantly reduced odds for receiving prescriptions for opioids within 90 days. Patients identified as Native American/Alaska Native had greater odds for receiving prescriptions for non-opioid pain medications within 90 days (OR, 1.12; 95% CI, 1.01-1.24). Receipt of pain prescriptions 120 days before imaging was strongly predictive of subsequent receipt of pain prescriptions across all categories. After adjusting for factors that could affect prescribing, the strongest differences observed in pain-medication prescribing were across racial categories and for patients with previous pain prescriptions. Further research is needed to understand these differences and to optimize prescribing.

PD60-06 OMISSION OF AMBULATORY NARCOTICS IS SAFE AFTER THE MAJORITY OF INPATIENT PEDIATRIC UROLOGIC SURGERIES

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making V (PD60)1 Sep 2021PD60-06 OMISSION OF AMBULATORY NARCOTICS IS SAFE AFTER THE MAJORITY OF INPATIENT PEDIATRIC UROLOGIC SURGERIES Jeffrey Villanueva, Benjamin Pifer, Marc Colaco, Valentina Grajales, Omar Ayyash, Rajeev Chaudhry, Francis Schneck, Glenn Cannon, and Janelle Fox Jeffrey VillanuevaJeffrey Villanueva More articles by this author , Benjamin PiferBenjamin Pifer More articles by this author , Marc ColacoMarc Colaco More articles by this author , Valentina GrajalesValentina Grajales More articles by this author , Omar AyyashOmar Ayyash More articles by this author , Rajeev ChaudhryRajeev Chaudhry More articles by this author , Francis SchneckFrancis Schneck More articles by this author , Glenn CannonGlenn Cannon More articles by this author , and Janelle FoxJanelle Fox More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002097.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Opiate overdose has reached epidemic levels in the United States, and as such several states have implemented various strategies to curb usage. In November 2016 Pennsylvania passed Act 125 requiring written consent when prescribing opiates to a minor and limiting opiate prescriptions to a seven day course. The purpose of this study is to examine the effect of this state mandate on narcotic utilization and pain related outcomes after inpatient pediatric urologic surgeries. METHODS: A retrospective analysis was performed examining all patients who underwent inpatient pediatric urologic surgery at the Children’s Hospital of Pittsburgh between August 2015 and February 2020. Subjects were separated into pre-mandate and post-mandate cohorts (subtracting a 6 month window immediately after November 2016 to account for transition). We then assed the frequency of inpatient and ambulatory opiate utilization between cohorts as well as the use of alternative pain management approaches. Frequencies of adverse events including delayed prescriptions or emergency department visits within 30 days were also identified. RESULTS: After accounting for a 6-month transition period following policy implementation, 462 major pediatric urologic procedures were identified. The frequency of discharge opiate prescriptions decreased from 68.4% prior to the transition period to 10.7% afterward (p <0.001). Morphine milligram equivalents per prescription decreased from 75(IQR 45-150) to 45(IQR 22.5-75) (p <0.001). There was no change in the rate of delayed non-opioid analgesic prescriptions (6.6 % vs 7.4%), delayed opioid prescriptions (1.5% vs 0.3%), or emergency department visits (11.8% vs 12.6%) (p=0.809). The effect of the intervention was durable, where 1.7% of major pediatric urologic surgeries in the final 12 months of the study were discharged with an opioid. CONCLUSIONS: Omission of ambulatory narcotics is safe for most major pediatric urologic surgeries and does not require an increase in regional anesthesia utilization. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1062-e1062 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeffrey Villanueva More articles by this author Benjamin Pifer More articles by this author Marc Colaco More articles by this author Valentina Grajales More articles by this author Omar Ayyash More articles by this author Rajeev Chaudhry More articles by this author Francis Schneck More articles by this author Glenn Cannon More articles by this author Janelle Fox More articles by this author Expand All Advertisement Loading ...

Characterization of Bodily Pain and Use of Both Prescription and Non-Prescription Opioids in Tenants of Precarious Housing

Background opioid use, which includes both prescribed and non-prescribed drugs, is relatively common amongst marginalized populations. Past research has shown that among those who use non-prescribed or diverted opioids recreationally, many were first exposed to the drug as prescribed pain medication. Objective: to better understand the relationship between pain and opioid use in tenants of precarious housing. Methods: in the present study, 440 individuals from a cohort living in homeless or precariously housed conditions in a neighborhood with high rates of poverty and drug use were interviewed for their bodily pain and opioid use. We examined the relationship between bodily pain levels, assessed using the Maudsley Addiction Profile questionnaire, and prescribed, non-prescribed and combined self-reported opioid use in the prior 28 days assessed using the Timeline Followback and Doctor-Prescribed Medication Timeline Followback questionnaires. Results: Analysis of the results indicated that sex (female), age (younger) and early exposure to opioids (≤ age 18) predicted current opioid use, but there was no association between current bodily pain levels and opioid use. Conclusions: these unexpected findings indicate the complex nature of the relationship between pain and opioid use in this population.

Protocol for a multicenter randomized controlled trial comparing a non-opioid prescription to the standard of care for pain control following arthroscopic knee and shoulder surgery

BackgroundOpioids continue to be the analgesic of choice for postoperative pain control following arthroscopic knee and shoulder surgery. Despite their widespread use, there are limited evidence-based clinical practice guidelines for postoperative opioid prescribing. The Non-Opioid Prescriptions after Arthroscopic Surgery in Canada (NO PAin) Trial is a randomized controlled trial (RCT) designed to determine whether a non-opioid analgesia approach to postoperative pain, compared to usual care, reduces oral morphine equivalents (OME) consumed in patients undergoing outpatient knee and shoulder arthroscopy.MethodsThis is a multi-centre, RCT with a target sample size of 200 patients. Adult (18+ years of age) patients undergoing outpatient knee and shoulder arthroscopy will be randomized to a non-opioid postoperative protocol (intervention) or the current standard of care (control). The intervention will consist of a standardized non-opioid analgesic prescription, a limited rescue opioid prescription, and a patient education infographic. The control is defined as the treating surgeons’ pre-trial postoperative analgesic regimen. Exclusion criteria include chronic opioid use, concomitant open surgery, contraindications to the prescribed analgesics or ongoing workers compensation/litigation. The primary outcome is OMEs consumed at 6 weeks postoperatively. Secondary outcomes will include patient-reported pain and satisfaction, quantity of OMEs prescribed, number of opioid refills, and any adverse events up to 6 weeks postoperatively. Utilizing the intention to treat principle for all analyses, independent samples t-test and presented with a p-value as well as a mean difference (MD) with 95% confidence intervals (CIs) will be performed for primary and secondary outcomes.DiscussionThe ongoing opioid epidemic and overprescribing of opioids in orthopaedics serve as the rationale for this trial. There is a lack of evidence upon which to develop post-operative pain management guidelines for patients undergoing arthroscopic surgery. A prospective evaluation of this relatively inexpensive intervention will demonstrate whether an explicit effort to reduce the number of opioids prescribed results in a reduction in the amount of opioids consumed and help to inform future studies and guidelines.Trial registrationThe NO PAin trial has been prospectively registered with clinicaltrials.gov (NCT04566250).

The \u201cblack box\u201d of treatment: Patients\u2019 perspective on what works in opioid maintenance treatment for opioid dependence

BackgroundA lack of conceptual modeling of how the components of opioid maintenance treatment (OMT) for opioid dependence (OD) work causes it to occasionally be labeled the “black-box” of treatment. This study had a two-fold objective: First, to analyze which factors related to OMT for OD contribute to the abstinence of problematic use of non-prescribed opioids and sustain recovery, from the patients’ perspective; second, to understand which changes OMT produced in the individuals’ lives might significantly contribute to relapse prevention.MethodsWe used qualitative methods of design, inquiry, and analysis from a convenience sample of 19 individuals in a Swedish treatment setting.ResultsAll the participants reported previous cycles of problematic use of non-prescribed opioids and other non-prescribed psychoactive substances, treatment, abstinence, recovery, and relapse before starting the current OMT program. During the pre-treatment stage, specific events, internal processes, and social environments enhanced motivation toward abstinence and seeking treatment. During the treatment stage, participants perceived the quality of the human relationships established with primary social groups as important as medication and the individual plan of care in sustaining recovery. From the participants’ perspective, OMT was a turning point in their life course, allowing them a sense of self-fulfillment and the reconstruction of personal and social identity. However, they still struggled with the stigmatization produced by a society that values abstinence-oriented over medication-assisted treatments.ConclusionOMT is not an isolated event in individuals’ lives but rather a process occurring within a specific social context. Structural factors and the sense of acceptance and belonging are essential in supporting the transformation. Treatment achievements and the risk for relapse vary over time, so the objectives of the treatment plan must account for characteristics of the pre-treatment stage and the availability and capacity of individuals to restructure their social network, besides the opioid maintenance treatment and institutional social care.

Incarceration and compulsory rehabilitation impede use of medication for opioid use disorder and HIV care engagement in Vietnam

BackgroundNon-prescribed opioid use is illegal in Vietnam. People who are apprehended for use of non-prescribed opioids may be arrested and incarcerated or sent to compulsory rehabilitation centers. For those on medication to treat opioid use disorder (MOUD), incarceration in either setting may disrupt treatment. This study estimates the effects of incarceration and compulsory rehabilitation on MOUD and HIV treatment outcomes in Vietnam. MethodsData are from a clinical trial testing the effects of MOUD on HIV viral suppression in six Vietnamese HIV clinics. Participants were assessed quarterly for 12 months. We assessed the associations between incarceration or compulsory rehabilitation during months 0–9 and study outcomes of receipt of MOUD, HIV clinic engagement, and antiretroviral therapy prescription during months 9–12, among those who were released by month 9 of the study, using logistic regression and zero-inflated negative binomial models. ResultsAt nine months, 25 of 258 participants (9.7%) were incarcerated or sent to compulsory rehabilitation at least once and completed the month 9 assessment. Of those, 19 (76.0%) did not receive MOUD in months 9 through 12. Both incarceration and compulsory rehabilitation were negatively associated with subsequent receipt of MOUD (aOR = 0.05, 95% CI = (0.01, 0.24); 0.14 (0.04, 0.50), respectively) and HIV clinic engagement (aOR = 0.13, 95% CI = (0.03, 0.71); 0.09 (0.02, 0.39), respectively). In the final three months of the study, participants who were incarcerated had 42.5 fewer days of MOUD (95% CI = 23.1, 61.9), and participants in compulsory rehabilitation had 46.1 fewer days of MOUD (95% CI = 33.8, 58.4) than those not incarcerated or in compulsory rehabilitation. ConclusionOur findings suggest that both incarceration and compulsory rehabilitation disrupt MOUD and HIV treatment among people with HIV and Opioid Use Disorder in Vietnam. Prioritization of evidence-based strategies to support engagement in care for people who use drugs could potentially expand HIV and Opioid Use Disorder treatment access and curb substance use more effectively than reliance on incarceration or compulsory rehabilitation.

Naturalistic follow-up after a trial of medications for opioid use disorder: Medication status, opioid use, and relapse

AimThis report examined naturalistic opioid use outcomes and utilization of medications for opioid use disorder (MOUD) 36 weeks post-randomization in the National Drug Abuse Treatment Clinical Trials Network (CTN) Extended-Release Naltrexone (XR-NTX) versus Buprenorphine-Naloxone (BUP-NX) for Opioid Treatment trial (CTN-0051, X:BOT). DesignX:BOT was a multisite, randomized, 24-week comparative effectiveness trial of BUP-NX (N = 287) and XR-NTX (N = 283). Study medications were discontinued following treatment completion, relapse, or dropout. Participants were encouraged to continue MOUD. This report examined opioid use outcomes in 428 (75%) of the 570 participants who attended the 36-week follow-up visit. Setting and participantsAdults with opioid use disorder recruited from 8 community treatment programs across the United States. MeasurementsOutcomes included medication status (on/off MOUD), type of MOUD (BUP-NX, XR-NTX, or methadone), abstinence from non-prescribed opioids, opioid use days, relapse, and other substance use 30 days prior to the 36-week visit. Relapse was defined as opioid use for 4 consecutive weeks or 7 consecutive days in the past month. Baseline and clinical variables included opioid use severity, intravenous drug use, study medication assignment, and induction status. FindingsOf the 428 participants who completed the 36-week visit, 225 (53%) of participants were receiving MOUD and 203 (47%) were not. Compared to those off medication, participants on medication had fewer opioid use days (4.4 days (SD 9.0) versus 9.8 days (SD 12.1)), fewer met relapse criteria (37 (16.4%) versus 79 (38.9%)), and reported less stimulant use (34 (15.2%) versus 56 (27.7%)) and sedative use (14 (6.3%) versus 31 (15.3%)). There was no difference in abstinence rates between those on or off MOUD. A greater proportion of participants on XR-NTX (47 (53.4%) of 88 participants) were abstinent from non-prescribed opioids compared to those on buprenorphine (28 (23.3%) of 120 participants). ConclusionsNaturalistic outcomes data showed that despite potential barriers to continuing treatment in the community, about half of individuals were on opioid use disorder pharmacotherapy at follow-up and those on medication generally had better outcomes. Future research should explore barriers and facilitators to treatment retention in community settings; and developing interventions tailored to improve treatment engagement and adherence.

Trends in opioid prescription for craniomaxillofacial trauma in the United States: An 11-year retrospective study of emergency room and office visits

BackgroundFacial trauma is associated with significant long-term morbidity and pain. These patients are routinely prescribed opioid medication and are at risk for opioid dependence. Rates and trends in opioid prescription in the ambulatory setting for management of craniofacial trauma are unknown. MethodsThe National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data were analyzed from 2006 to 2016. Using International Classification of Diseases codes, 7,997,454 visits for craniomaxillofacial trauma were identified. Trends in opioid and nonopioid prescriptions were studied, with variables of interest including demographics, geographic region, expected source of payment, and injury location. ResultsOver the study period, trends in both opioid and nonopioid prescriptions remained stable, with about 13.4% of all visits receiving opioid prescriptions. Patients aged 18 to 44 (P < .001) and lower face trauma (P = .047) were associated with increased rates, while Medicare and charity payers (P < .001) were associated with lower rates of opioid prescriptions. There was no significant difference in prescription rates across geographical regions, by ethnicity, or sex. ConclusionOpioid medication forms the cornerstone for ambulatory management of craniofacial trauma. Despite increased awareness and emphasis on multimodal pain management, opioid prescription trends have remained relatively stable over time.

Opioid Prescriptions by Orthopaedic Surgeons in a Medicare Population: Recent Trends, Potential Complications, and Characteristics of High Prescribers.

Orthopaedic surgeons prescribe an estimated 7.7% of all US opioid prescriptions, and understanding prescribing patterns is important to curtail the inappropriate dispensing of these drugs. The purpose of this study was to characterize recent trends in opioid prescribing patterns by orthopaedic surgeons within a Medicare population and to identify demographical characteristics associated with the highest prescribers. This study used Medicare Part D beneficiary prescription between 2013 and 2016. The number of prescriptions written per orthopaedic surgeon, prescriptions received by each beneficiary, and the length of each prescription were compared across years. Top prescribers were identified and compared with the remainder of prescribers to identify differences in sex, professional degree, and geographic regions. Between 2013 and 2016, an average of 24,100 unique orthopaedic prescribers were identified. There was a decrease in the average number of prescriptions written per year from 157 to 148 and per beneficiary from 2.1 to 1.8 from 2013 to 2016, respectively. The most commonly prescribed opioids were hydrocodone/acetaminophen (47.1% of all opioids prescribed) and oxycodone/acetaminophen (17.5%). The total number of opioid prescriptions decreased by 372,045, and nonopioid pain medications increased by 269,917 between 2013 and 2016. Orthopaedic surgeons were more likely to have a high total opioid prescription count if they were male, lived in the south, and had an osteopathic degree (P < 0.001 for all). Orthopaedic surgeons prescribe an estimated 7.7% of all US opioid prescriptions; however, in recent years, there has been a decrease in the number of prescriptions written per surgeon, per beneficiary, total opioid prescriptions, and an increase in total nonopioid prescriptions. These changes may reflect an increase in public awareness of the opioid epidemic and subtle changes in physician behavior. Differences in opioid prescription volume by sex, professional degree, and region also illustrate a lack of consensus on opioid prescription guidelines in orthopaedic surgery.

Predictors of pharmacologic therapy for neonatal opioid withdrawal syndrome: a retrospective analysis of a statewide database.

Identify factors associated with the need for pharmacologic therapy (PT) among opioid exposed newborn (OENs). Retrospective analysis of a statewide database of OENs from 2017 through 2019. Multivariable mixed-effects logistic regression modeled the association of maternal characteristics, infant characteristics, and family engagement practices on the receipt of PT. Of 2098 OENs, 44.8% required PT for NOWS. Higher odds of PT were associated with in-utero exposure to medication treatment for opioid use disorder (MOUD) and non-prescribed opioids in addition to MOUD; nicotine, benzodiazepines, SSRIs; male; out-born infants and mother's ineligibility to provide breast-milk. Lower odds were associated with increasing birth year, skin-to-skin (STS) care, and rooming-in. Male, out-born infants exposed to MOUD with additional non-prescribed opioids, nicotine, benzodiazepines and SSSRIs with mothers ineligible to provide breast-milk were more likely to require PT, while modifiable care practices including STS care, and rooming-in decreased the likelihood of PT.