Non-prescription Opioids Research Articles

Effects of Including Epidemiologic Data in Lumbar Spine Imaging Reports on Prescribing Non-Opioid Medications for Pain.

Information on the prevalence of common imaging findings among patients without back pain in spine imaging reports might affect pain medication prescribing for patients with back pain. Prior research on inserting this text suggested a small reduction in opioid prescribing. To evaluate the effect of epidemiologic information in spine imaging reports on non-opioid pain medication prescribing for primary care patients with back pain. Post hoc analysis of the Lumbar Imaging with Reporting of Epidemiology cluster-randomized trial. A total of 170,680 patients aged ≥ 18 years from four healthcare systems who received thoracolumbar, lumbar, or lumbosacral spine imaging from 2013 to 2016 and had not received a prescription for non-opioid pain medication in the preceding 120 days. Text of age- and modality-specific epidemiologic benchmarks indicating the prevalence of common findings in people without back pain inserted into thoracolumbar, lumbar, or lumbosacral spine imaging reports at intervention clinics. Primary outcomes: any non-opioid prescription within 90 days after index imaging, overall, and by sub-class (skeletal muscle relaxants, NSAIDs, gabapentinoids, tricyclic antidepressants, benzodiazepines, duloxetine). count of non-opioid prescriptions within 90 days, overall, and by sub-class. The intervention was not associated with the likelihood of patients receiving at least one prescription for new non-opioid pain-related medications, overall (adjusted OR, 1.02; 95% CI, 0.97-1.08) or by sub-class. The intervention was not associated with the number of prescriptions for any non-opioid medication (adjusted incidence rate ratio [IRR], 1.02; 95% CI, 0.99-1.04). However, the intervention was associated with more new prescriptions for NSAIDs (IRR, 1.12) and tricyclic antidepressants (IRR, 1.11). Inserting epidemiologic text in spine imaging reports had no effect on whether new non-opioid pain-related medications were prescribed but was associated with the number of new prescriptions for certain non-opioid sub-classes. ClinicalTrials.gov identifier: NCT02015455.

Understanding overdose incidents in Canadian federal custody

BackgroundWhile the community effects of the opioid-related drug crisis in Canada are well documented, limited detailed data is available on overdose trends among custodial populations. Given that this crisis has disproportionate impacts on justice involved persons, research is needed to understand the implications of this crisis within institutional settings. MethodsWe examined all overdose incidents that occurred between the 2012/2013 and 2018/2019 fiscal years in a federal correctional institution in Canada. An incident report search was conducted to identify overdose related incidents during this period. Information about the incident and characteristics of the victim was collected from incident reports, investigations, and victim case files. ResultsOver the period under examination, overdose incidents steadily increased (i.e., from 40 in 2012/2013, to 110 non-fatal incidents in 2018/2019), although there was considerable regional and institutional variation. The number of incidents involving opioids, particularly fentanyl, increased both in raw numbers and as a percentage of overall incidents (i.e., from 3% in 2012/2013 to 47% in 2017/2018, and 34% of non-fatal incidents in 2018/2019). Other substances continue to contribute to overdose incidents; in fact, non-opioid prescription medications (i.e., non-illicit medications such as anti-convulsant drugs and anti-depressants) remain the most common among intentional non-fatal incidents. Relative to the general in-custody population, victims of overdose incidents tended to be younger and were more likely to be serving a determinate sentence, be on a repeat federal sentence, and be serving time for robbery. Mental health conditions and histories of substance use were common. ConclusionThe effects of the overdose crisis are pronounced within certain Canadian federal institutions, illustrated by a growing number of fentanyl-related incidents. Institutional variation and variation in incidents (e.g., substance and intentionality) highlight diversity in drug activities among this custodial population and the need for multi-faceted responses that are reflective of local situations.

The Insurgence of Tramadol Abuse among the Most Active Population in Jirapa Municipality: A Study to Assess the Magnitude of the Abuse and Its Contributory Factors.

Background Tramadol has gained popularity among the drugs of the most active population especially the respondents in Ghana abuse especially farmers who nicknamed as “farm and buy cow.” It has recently become a public health concern, and stakeholders are worried about tramadol abuse and its implications on health in the Upper West Region. The study sought to measure the prevalence of tramadol/related substance abuse and the associated factors. Methods A community-based analytic cross-sectional study involving 420 respondents was conducted. The participants were selected using a multistage sampling technique. Semistructured questionnaire was used to generate the data. Results About 77.6% of the respondents abuse tramadol while 83.9% of the participants take at least one other related substance or drug. Participants with history of any substance abuse were 5 times more likely to abuse tramadol [AOR = 5.15; 95% CI (1.501-17.656); p = 0.009], compared to respondents with no history of any substance abuse. Respondents who take tramadol to enhance sex were 4 times more likely to abuse tramadol [AOR = 3.776; 95% CI (1.352-10.545); p = 0.011]. Formal sector employment was protective against tramadol abuse [AOR = 0.100; 95% CI (0.017-0.595); p = 0.011] compared to self-employment and the unemployed. In addition, use of nonopioid prescription drugs for posttraumatic/pain management reduced the risk of tramadol abuse [AOR = 0.237; 95% CI (0088-0.640); p = 0.004] compared to the posttraumatic/pain management dependence on prescription of only opioid like tramadol. Conclusion An infantile municipality like Jirapa is challenged with high level of tramadol and related substance which has serious repercussion on the health system in the Jirapa district. It is important that measures are taken by the stakeholders to stop tramadol and related substance and mitigate the impact of drug abuse in the district.

Low school belongingness and non-prescription opioid use among students in Ontario, Canada.

School belonging impacts a range of factors, including academic performance, school attendance, relationships with peers and teachers, mental and physical health, and drug and alcohol use. Previous studies have shown that a lack of belonging to one's school is associated with substance use. The objective of the study was to examine the association between low school belongingness and the use of opioids in students in grades 9 through 12 in Ontario, Canada. Data were gathered from 6418 participants in grades 9-12 who responded to the 2015 Ontario Student Drug Use and Health Survey (OSDUHS). Logistic regression analyses were used to model associations between low school belongingness and opioid use, adjusted for gender, grade, ethnicity, socio-economic status, and living situation. Overall, low school belongingness was associated with non-prescribed opioid use (OR = 1.11, 95% CI 1.05-1.17). Feeling unsafe at school (OR = 1.43, 95% CI 1.23-1.66) was associated with elevated odds of using non-medically prescribed opioids. Girls who felt that they were not a part of their school community were at elevated odds of using opioids (OR = 1.35, 95% CI 1.16-1.56); this association was not observed among boys. The findings suggest that low school belongingness may be associated with the use of non-prescribed opioids in students. These findings suggest that school-based interventions aimed at improving social cohesion and feelings of belongingness and safety may be beneficial in reducing the use of non-prescription opioids among adolescents.

A government mandated consent safely reduces opioid utilization for major pediatric genitourinary surgeries

IntroductionWe describe the effect of a state mandated opioid consent on opioid utilization and multimodal pain use for major pediatric genitourinary surgeries. MethodsAll patients who underwent an inpatient pediatric genitourinary surgery at the Children's Hospital of Pittsburgh between August 2015 and February 2020 were identified. Inpatient and outpatient multimodal pain control utilization were assessed. Delayed prescriptions or emergency department visits within 30 days were identified and when applicable referenced against National Surgical Quality Improvement Program data. ResultsAfter accounting for a 6-month transition period following policy implementation, 462 major pediatric genitourinary 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). 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) remained unchanged. Data agreed with National Surgical Quality Improvement Program data in 98.5% of cases. After excluding one surgeon who departed after the transition period, regional block utilization did not change from 61/115(53%) to 147/320(45.9%)(p = 0.425). ConclusionsA state mandated opioid consent safely reduced opioid utilization for most major pediatric genitourinary surgeries. Level of evidenceLevel III

Overdose deaths from nonprescribed prescription opioids, heroin, and other synthetic opioids in Medicare beneficiaries

ImportanceOpioid use disorder in the United States' Medicare population increased from 10 to 24 per 1000 from 2012 to 2018. Understanding the changes in the patterns of opioid overdose mortality over time holds broad clinical and public health relevance. ObjectiveTo examine trends and correlates of opioid overdose deaths from nonprescribed prescription opioids, heroin, and other synthetic opioids. Design, setting and participantsThe study used Medicare-National Death Index linked data from a 20% national sample to identify a retrospective cohort who died from opioid overdose in 2012–2016. The study analyzed data from December 2019 to March 2020. Main outcome and measuresWe examined type of opioid overdose deaths; percentage of opioid deaths without documented opioid prescriptions in the prior 6 months; and percentage of deaths from heroin or synthetic opioids among people on long-term prescription opioids whose prescribers reduced or subsequently discontinued their opioids. The study also calculated the proportion receiving medication for addiction treatment. The study included demographic characteristics and 15 chronic or potentially disabling conditions associated with overall opioid overdose deaths. ResultsAmong 6932 Medicare enrollees who died from opioid overdose in 2012–2016, the mean (SD) age was 52.9 (12.1) years, 45.4% were women, and 82.4% were white. The number of opioid overdose deaths increased from 1159 in 2012 to 1697 in 2016. In the adjusted analyses, opioid deaths occurring in 2016 were 2.6 times more likely to be due to heroin or other synthetic opioids than opioid deaths occurring in 2012. The prescription opioid deaths occurring without a documented opioid prescription in the 6 months before death increased from 6.8% in 2012 to 11.7% in 2016. Factors associated with such deaths, assessed in a stepwise logistic regression model, included metropolitan or rural residence and diagnosis of opioid use disorder. Among people with long-term opioid use whose prescription opioids were reduced in the 6 months before death, the percentage of deaths attributable to heroin and other synthetic opioids increased from 17% in 2012 to 47% in 2016. Factors associated with such deaths, assessed in a stepwise logistic regression model, included diagnosis of hepatitis and opioid use disorder. Less than 10% of these enrollees received medication for addiction treatment. ConclusionThere were substantial increases in patients' obtaining opioid analgesics from unlicensed sources and in overdose deaths from nonprescribed opioids during the study period (2012–2016). Increased access to pain management and opioid use disorder treatments is critical to reducing the opioid overdose deaths in the United States.

The prospective association between illicit drug use and nonprescription opioid use among vulnerable adolescents

In recent years, more than half of all drug overdose deaths in United States involved an opioid. To address this epidemic, antecedents to opioid misuse must be identified and empirically validated. The objective of the current investigation was to examine whether illicit drug use was prospectively associated with nonprescription opioid use among adolescents from a vulnerable population with a greater prevalence of substance abuse. A population-based cohort study of 1060 adolescents from 29 alternative high schools in southern California was conducted over a two-year period. A total of 929 adolescents (mean age 17.5 years, 49.9% female, 76.4% Hispanic) who had not experimented with nonprescription opioids at the baseline assessment were included in the analytic sample. The outcome was self-reported use of nonprescription opioids within two years. The predictors tested were illicit drug use, illicit drug use excluding marijuana, and the use of nonmedical marijuana. Covariates included age, sex, ethnicity, socioeconomic status, parental education, weekly income, sensation seeking, stress, anxiety, depression, and the use of alcohol and nicotine products. Multilevel, covariate-adjusted logistic regression models indicated that the odds of experimentation with nonprescription opioids was greater among adolescents who had used illicit drugs or illicit drugs excluding marijuana. Nonmedical marijuana use alone was a statistically significant predictor in unadjusted but not covariate-adjusted models. While prior studies have examined the progression from nicotine, alcohol, and marijuana use to nonprescription opioid use, the present findings emphasize the importance of illicit drug use as a detectable and empirically supported risk factor for future opioid misuse.

Validation of two methods for the quantitative analysis of cocaine and opioids in biological matrices using LCMSMS.

The proliferation of misuse of prescription and non-prescription opioids, in recent years, has caused an opioid epidemic in the United States. Forensic toxicology laboratories often encounter implications of abuse in both driving under the influence of drugs and death investigation cases. The Virginia Department of Forensic Science has seen over a 190% increase in the number of reported opioids in death investigation cases over the past several years. Traditionally, analyses are completed by individual drug class, which subsequently requires an individual case to be evaluated using multiple analytical techniques for comprehensive analysis. To ease the impact of increasing case submissions and case complexity, two liquid chromatography-tandem mass spectrometry (LCMSMS) methods for the quantitative analysis of opioids, cocaine, and cocaine metabolites in biological matrices have undergone a fit-for-purpose validation. The methods were compared to determine the advantages and disadvantages of each analytical technique. Two sample preparation techniques, protein precipitation and solid-phase extraction, were employed for quantitative validation. Validation aspects evaluated included accuracy and precision, sensitivity, linearity, matrix effects, recovery, carryover, interferences, dilution integrity, and post-extraction stability. The accuracy of the protein precipitation method ranged from 80±3% to 101±10%. The accuracy of the solid-phase extraction method ranged from 88±9% to 119±3%. Additionally, within-run and intermediate precision was within ±20% for both extraction techniques. Although ionization suppression was noted, it was determined to have minimal effect on the methods. The newly developed methods require less sample volume and combine four analytical techniques into one method, which significantly impacts laboratory productivity.

Trends in Pain Medication Prescriptions and Satisfaction Scores in Spine Surgery Patients at a Single Institution.

As the opioid crisis has gained national attention, there have been increasing efforts to decrease opioid usage. Simultaneously, patient satisfaction has been a crucial metric in the American health care system and has been closely linked to effective pain management in surgical patients. The purpose of this study was to examine rates of pain medication prescription and concurrent patient satisfaction in spine surgery patients. A total of 1729 patients undergoing spine surgery between June 25, 2017, and June 30, 2018, at a single institution by surgeons performing ≥20 surgeries per quarter, with medication data during hospitalization available, were assessed. Patients were evaluated for nonopioid pain medication prescription rates and morphine milligram equivalents (MME) of opioids used during hospitalization. Of the total cohort, 198 patients were evaluated for Press Ganey Satisfaction Survey responses. A χ2 test of independence was used to compare percentages, and 1-way analysis of variance was used to compare means across quarters. The mean total MME per patient hospitalization was 574.46, with no difference between quarters. However, mean MME per day decreased over time (P = .048), with highest mean 91.84 in Quarter 2 and lowest 77.50 in Quarter 4. Among all procedures, acetaminophen, nonsteroidal anti-inflammatory drugs, and steroid prescription rates increased, whereas benzodiazepine and γ-aminobutyric acid-analog prescriptions decreased. There were no significant differences between quarters for mean hospital ratings (P = .521) nor for responses to questions from the Press Ganey Satisfaction Survey regarding how often staff talk about pain (P = .164), how often staff talk about pain treatment (P = .595), or whether patients recommended the hospital (P = .096). There were also no differences between quarters for responses in all other patient satisfaction questions (P value range, .359-.988). Over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, whereas satisfaction scores remained unchanged. These findings indicate an increasing effort in reducing opioid use among providers and suggest the ability to do so without affecting overall satisfaction rates. 4. The opioid epidemic has highlighted the need to reduce opioid usage in orthopedic spine surgery. This study reviews the trends for inpatient management of post-op pain in orthopedic spine surgery patients in relation to patient satisfaction. There was a significant increase in non-opioid analgesic pain medications, and a reduction in opioids during the study period. During this time, patient satisfaction as measured by Press-Ganey surveys did not show a decrease. This demonstrates that treatment of post-operative pain in orthopedic spine surgery patients can be managed with less opioids, more multimodal analgesia, and patient satisfaction will not be affected.

Treatment of Opioid Dependence with Depot Buprenorphine (CAM2038) in Custodial Settings Is Safe, Effective and Cost-Effective

Background: Opioid agonist treatment (OAT) is effective but resource intensive to administer safely in custodial settings, leading to significant under-treatment of opioid dependence in these settings worldwide. Methods: This open-label trial compared depot buprenorphine, CAM2038 (weekly for 4 weeks then monthly) to oral methadone ( https://www.anzctr.org.au ACTRN12618000942257). Modelled treatment costs included a comparison group on sublingual buprenorphine-naloxone. Men and women, aged>18 years of various security classifications with a diagnosis of moderate to severe DSM-5 opioid use disorder and a custodial sentence of at least six months were recruited from correctional centres in New South Wales, Australia. Findings: Between November 2018 and July 2019, 67 patients not in OAT treatment at recruitment commenced depot buprenorphine. Sixty-two patients already stable on oral methadone treatment were recruited to the comparison arm. Patients treated with depot buprenorphine commonly reported at least one adverse event related to study drug (63/67, 94%), typically mild and transient. No diversion of depot buprenorphine was identified. Retention in depot buprenorphine treatment was 92%. Self-reported use of non-prescribed opioids (primarily buprenorphine-naloxone) and injecting drug use decreased significantly among depot buprenorphine patients by 16 weeks (p<0·0001). Monthly treatment costs were: $112AUD for injectable depot buprenorphine, $339AUD for oral methadone and $1,299AUD for sublingual buprenorphine-naloxone. Interpretation: The first published study to explore depot buprenorphine in custodial settings shows treatment retention, substance use and safety outcomes comparable to those observed in community settings and for other OAT used in custodial settings, without increased risk of diversion. Depot buprenorphine is a more efficient and less costly OAT delivery method requiring less health and custodial staff resources to administer. Enhanced access to depot buprenorphine should be considered for custodial settings worldwide. Trial Registration: (https://www.anzctr.org.au ACTRN12618000942257). Funding: NSW Health funded the study, and had input into design, data collection, analysis, interpretation and write-up. The JHFMHN provided clinical support for the study. Camurus AB provided CAM2038 for study participants with no right of veto of publication or dissemination of results. Declaration of Interests: AJD reports grants from Braeburn/Camurus AB, to conduct clinical studies with buprenorphine products and travel support to Hunter New England Local Health District, which employs AJD. He is an honorary investigator on an Indivior-funded study of buprenorphine products and has served on an advisory board for Mundipharma. PSH reports grants from Braeburn/Camurus AB, to conduct clinical studies with buprenorphine products and has served on advisory boards for Lundbeck, Indivior, AbbVie and Gilead. NL reports grants from Braeburn and Camurus AB to conduct sponsored, and investigator-led clinical studies with CAM2038. NL served on Advisory Boards for Mundipharma, Indivior and Chiesi Pharmaceuticals. MC was employed by the NSW Ministry of Health, sponsors of the study. All other authors declare no competing interests. Ethics Approval Statement: The trial was approved by JHFMHN and the Aboriginal Health and Medical Research Council (AHMRC) Human Research Ethics Committees (Protocol JH File No G561/17 & HREC/ 18/JH/3), as well as the CSNSW Ethics Committee. Participation was voluntary and written, informed consent was obtained from all participants prior to the conduct of any study procedure.

Clinician training level impacts prescribing practices for the conservative management of acute renal colic: a contemporary update.

Given the current and increasing awareness of the opioid crisis, this study aimed to characterise the types of analgesic prescription for conservatively managed renal colic. This was a retrospective cohort study of consecutive patients presenting to the Emergency Department (ED) in 2014-2019. Patients were included if they had radiographically confirmed obstructing calculus, managed conservatively without intervention, and were given a prescription for analgesia on discharge. Patient demographics were recorded and analysed. Opioid, non-opioid, and alpha-blocker medications were compared according to patient and disease parameters, and clinician training. Oral morphine equivalents (OMEs) were used to compare prescribed quantities. Subgroup analyses of stone size and location were performed. Our analysis included 1761 patients with confirmed renal colic: median age of 50years (16-96). Altogether, 88% of included patients were prescribed opioids on discharge, while only 68% were prescribed non-opioids (p < 0.001). Oxycodone immediate release was the most frequently prescribed analgesic. Logistic regression modelling controlling for patient and disease characteristics significantly predicted more non-opioid (p < 0.001) and alpha-blocker (p = 0.037) prescription with clinician training < 3years. Linear regression modelling demonstrated that clinicians training < 3years predicted lower OMEs per prescription compared to clinicians with ≥ 3 years of training (p = 0.001). Subgroup analyses supported similar predictions with training. Prescribing patterns are associated with different clinician experience levels. However, a substantial amount of opioids are still given overall on patient discharge regardless of the clinician experience. Educational interventions aimed at reducing the opioid prescription rate and quantities may be considered for clinicians of all training levels.

Ranking the Harm of Psychoactive Drugs Including Prescription Analgesics to Users and Others-A Perspective of German Addiction Medicine Experts.

Background: Over the past 15 years, comparative assessments of psychoactive substance harms to both users and others have been compiled by addiction experts. None of these rankings however have included synthetic cannabinoids or non-opioid prescription analgesics (NOAs, e.g., gabapentinoids) despite evidence of increasing recreational use. We present here an updated assessment by German addiction medicine experts, considering changing Western consumption trends–including those of NOAs.Methods: In an initial survey, 101 German addiction medicine physicians evaluated both physical and psychosocial harms (in 5 dimensions) of 33 psychoactive substances including opioids and NOAs, to both users and others. In a second survey, 36 addiction medicine physicians estimated the relative weight of each health and social harm dimension to determine the overall harm rank of an individual substance. We compared our ranking with the most recent European assessment from 2014.Results: Illicit drugs such as methamphetamine, heroin, cocaine and also alcohol were judged particularly harmful, and new psychoactive drugs (cathinones, synthetic cannabinoids) were ranked among the most harmful substances. Cannabis was ranked in the midrange, on par with benzodiazepines and ketamine—somewhat more favorable compared to the last European survey. Prescribed drugs including opioids (in contrast to the USA, Canada, and Australia) were judged less harmful. NOAs were at the bottom end of the ranking.Conclusion: In Germany, alcohol and illicit drugs (including new psychoactive substances) continue to rank among the most harmful addictive substances in contrast to prescribed agents including opioid analgesics and NOAs. Current laws are incongruent with these harm rankings. This study is the first of its kind to include comparative harm rankings of several novel abused substances, both licit/prescribed and illicit.

Trends in Acute Pain Management for Renal Colic in the Emergency Department at a Tertiary Care Academic Medical Center

Introduction: Renal colic secondary to kidney stone disease is a common reason for emergency department (ED) visits and often leads to patients receiving narcotic medications. The objective of this study was to describe longitudinal analgesia prescribing patterns for kidney stone patients acutely managed in the ED. Methods: This was a retrospective chart review of patients who presented to the ED between 2013 and 2018 and were subsequently diagnosed with a kidney stone. Encounters during which opioids and nonopioids were administered in the ED and prescribed at discharge were stratified by year, race, ethnicity, insurance status, gender, and location of ED (main academic campus and community-based campus). Patients were excluded if they required hospital admission or a stone-related procedure related to the ED encounter. Results: We reviewed 1620 total encounters for 1376 unique patients. Frequency of patients receiving opioids in the ED decreased from 81% in 2013 to 57% in 2018 (p < 0.001). During the same time period, nonopioid administration in the ED remained relatively unchanged (64% vs 67%). The proportion of patients prescribed opioids at discharge decreased from 77% to 59% (p < 0.001), while nonopioid prescriptions at discharge increased from 32% to 41% (p = 0.010). Frequency of administering both a narcotic and non-narcotic during the same ED encounter decreased over the 5-year period from 27% to 8% (p < 0.001). Conclusion: Opioids are being given less both during the ED encounter and at discharge for acute renal colic, while nonopioid prescribing is increasing. These trends may be due to increasing physician awareness to opioid addiction, or as a result of stricter legislation prohibiting opioid prescribing.

Effect of Opioid Limiting Legislation on Postoperative Opioid Utilization in Patients Treated for Ankle Fractures.

Background:The state of Ohio implemented legislation in August of 2017 limiting the quantity of opioids a provider could prescribe. The purpose of this study was to identify if implementation of legislation affected opioid and nonopioid utilization in patients operatively treated for ankle fractures in the initial 90-day postoperative period after controlling for injury severity and preoperative narcotic usage.Methods:A retrospective review of 144 patients treated for isolated ankle fractures in a pre-law group (January 2017–July 2017; n = 73) and post-law group (January 2018–July 2018; n = 71) was completed using electronic medical records and a legal prescriber database. Total number of opioid prescriptions, pills, milligrams of morphine equivalents (MMEs), and nonopioid prescriptions were recorded. Multiple regression analysis was run to identify predictors of opioid prescribing after controlling for law group, demographic, preoperative narcotic use, and injury severity characteristics.Results:Mean MME prescribed per patient significantly decreased from 817.2 MME pre-law to 380.9 post-law (P < .01). Mean number of opioid pills prescribed per patient decreased from 99.1 in the pre-law group and 55.3 in the post law group (P < .001), respectively. Multiple linear regression analysis to predict the mean number of opioid pills prescribed was statistically significant (R 2 = 0.33; P < .001), with law group adding significantly to the prediction (P < .001). The multiple linear regression analysis to predict MME per patient was found to be statistically significant (R 2 = 0.31; P < .001), with the law group contributing significantly (P < .001).Conclusion:The Ohio prescriber law successfully contributed to the decreased number of opioid pills and MME prescribed in the initial 90-day postoperative period after controlling for injury severity and preoperative narcotic usage. Policies on opioid prescriptions may serve as an important public health tool in the fight against the opioid epidemic.Level of Evidence:Level III, retrospective comparative series.

Race, Ethnicity, and Insurance: the Association with Opioid Use in a Pediatric Hospital Setting.

This study examined the association between race/ethnicity and health insurance payer type with pediatric opioid and non-opioid ordering in an inpatient hospital setting. Cross-sectional inpatient encounter data from June 2013 to June 2018 was retrieved from a pediatric children's hospital in Southern California (N = 55,944), and statistical analyses were performed to determine associations with opioid ordering. There was a significant main effect of race/ethnicity on opioid and non-opioid orders. Physicians ordered significantly fewer opioid medications, but a greater number of non-opioid medications, for non-Hispanic African American children than non-Hispanic Asian, Hispanic/Latinx, and non-Hispanic White pediatric patients. There was also a main effect of health insurance payer type on non-opioid orders. Patients with government-sponsored plans (e.g., Medi-Cal, Medicare) received fewer non-opioid prescriptions compared with patients with both HMO and PPO coverage. Additionally, there was a significant race/ethnicity by insurance interaction on opioid orders. Non-Hispanic White patients with "other" insurance coverage received the greatest number of opioid orders. In non-Hispanic African American patients, children with PPO coverage received fewer opioids than those with government-sponsored and HMO insurance. For non-Hispanic Asian patients, children with PPO were prescribed more opioids than those with government-sponsored and HMO coverage. Findings suggest that the relationship between race/ethnicity, insurance type, and physician decisions opioid prescribing is complex and multifaceted. Given that consistency in opioid prescribing should be seen regardless of patient background characteristics, future studies should continue to assess and monitor unequitable differences in care.

Neonatal opioid exposure: public health crisis and novel neuroinflammatory disease.

Substance use, specifically the use of prescription and non-prescription opioids among pregnant women, is a major public health issue and chief contributor to the opioid crisis. The prevalence of Neonatal Opioid Withdrawal Syndrome has risen 5-fold in the past decade, and is a well-recognized consequence of perinatal opioid exposure. By contrast, the long-term damage to the developing brain from opioid medications is just beginning to be recognized as a serious concern. Published data suggest that opioid exposure commencing in utero negatively affects the maturation of the neural-immune system, and trajectory of central nervous system development. Methadone induces peripheral immune hyper-reactivity, lasting structural and microstructural brain injury, and significant deficits in executive function and cognitive control in adult animals following in utero exposure. Thus, to address the cascading public health crisis stemming from the multitude of infants with in utero opioid exposure who will grow up with altered neurodevelopmental trajectories, rigorous preclinical, mechanistic studies are required. Such studies will define the long-term sequelae of prenatal opioid exposure in an effort to develop appropriate and targeted interventions. Specifically, the development of novel fluid, neuroimaging and biobehavioral biomarkers will be the most useful to aid in early identification and treatment of opioid exposed infants with the greatest risk of poor clinical outcomes. These studies will be essential to understand how in utero insults determine brain structure and function in adulthood, and what targeted interventions will be required to improve long-term outcomes in the countless children being born exposed to opioids each year.

Quality improvement initiative for pain management practices in primary care

In the context of both chronic pain and opioid crises, this large-system quality improvement project sought to increase use of evidence-based multimodal pain management strategies. Primary care providers (PCPs) in internal medicine and family medicine identified as above-median prescribers of 30-day opioid supplies were selected for intervention. PCPs received individualized email letters showing their opioid prescribing patterns relative to peers and urging them to view an internal pain/opioid educational video and related system guidelines. The median number of patients receiving 30-day opioid supplies from our target PCPs decreased over a 24-month period. For cohort patients identified at baseline and remaining in treatment over time, those receiving opioid prescriptions decreased, and those receiving nonopioid prescriptions increased. Percentages of PCPs prescribing nonopioids for cohort patients increased over the first year and nonpharmacologic referrals increased in range. Our evidence suggests that PCPs who are higher opioid prescribers will change their practices voluntarily when given feedback about their opioid prescribing patterns relative to their peers, as well as education regarding evidence-based pain management and opioid prescribing.

Opioid Prescribing and Use After Pediatric Umbilical Hernia Repair.

Opioid overuse is a concern in adult and pediatric populations. Physician education may improve appropriate opioid prescribing and patient instruction for use. Prescribing and use of opioids for pain control after pediatric umbilical hernia (UH) repair before and after surgeon education was evaluated. This is a substudy of a multi-institutional study assessing prescribing practice before and after surgeon education. This study further assessed patient prescription filling patterns and parent report of pain control. A retrospective study was performed evaluating children who underwent UH 6 months before and after an educational presentation on opioid use. Prescriptions, prescription fills, patient medication use, and pain control effectiveness were assessed. Adverse events were collected. There were 78 subjects in the pre-education and 99 in the post-education group. Opioid prescribed changed from 98.7% to 61.6% (P < .0001), and nonopioid prescriptions increased following education (P = .0063). The number of opioid prescriptions filled decreased (P = .0296). There were limited data on opioid doses used and quality of pain control, but the post-education group showed good pain control. There was no difference in adverse events. Surgeon education on the current opioid epidemic and strategies for opioid stewardship improves opioid prescribing and use without adversely impacting pain control or clinical outcome.

YouTube viewers’ comments on the opioid epidemic offer solutions to help chronic pain patients

Abstract Background Approximately 34.3 million people used prescription opioids for non-medical reasons globally in 2016. In addition, many of the 1.5 billion people worldwide who suffer from chronic pain use opioids. According to the United Nations Office on Drugs and Crime, 76% of overdose deaths are caused by prescription and non-prescription opioids. Opioid use disorder and addiction encompass many aspects; such as, economic forces, cultural forces and individual genetic makeup. Because of this complexity, policymakers will have to address chronic pain and social determinants of health. Understanding the public's perspectives on the opioid epidemic is critical for policymakers to create awareness and treatment programs to decrease opioid related deaths while treating pain. Methods This inductive, iterative approach to content analysis of secondary data collected 8,761 comments posted by viewers on ten videos regarding the opioid epidemic on CNN's YouTube Channel and ten videos on Fox News' YouTube channel posted between January 1, 2017 and December 31, 2018. Results After analyzing 8,761 comments, from 20 videos, results indicated 618 (7%) were pain patients, 926 (10.6%) of the comments indicated stigma, (54.5% social stigma and 30% structural stigma). 5,453 (62.2%) of the comments posted claims regarding the opioid epidemic and 1,881 (21.5%) offered solutions. Three of the major solutions offered include legalizing cannabis (608, 7%), developing alternative therapies (174, 1.9%), and kratom (105, 1.2%). Conclusions Reducing access to opioids is harming legitimate pain patients. Policymakers need to take the public's opinions into consideration when developing policies and programs that help reduce opioid overdose. These policies must ensure that the 1.5 billion chronic pain patients worldwide receive adequate pain control in order to have a good quality of life that allows them to be contributing members of society. Key messages Worldwide, 1.5 billion people suffer from chronic pain, many without access to adequate pain control. Solutions posted by viewers include cannabis, alternative therapies and kratom. Understanding the public’s perspectives will help policymakers create programs that improve quality of life for chronic pain patients that minimize social, internalized and structural stigma.

Toxicology and prescribed medication histories among people experiencing fatal illicit drug overdose in British Columbia, Canada

<h3>BACKGROUND:</h3> Since 2015, illicit drug overdose has been one of British Columbia’s most pressing public health issues. Our objective was to assess prescription history in the context of postmortem toxicology among people who had a fatal illicit drug overdose in BC. <h3>METHODS:</h3> Toxicology results from drug overdose deaths involving 1 or more illicit drugs, as identified by the BC Coroners Service in 2015–2017, were linked to the prescription drug histories of individuals as recorded in BC’s PharmaNet database for a descriptive analysis. Substances identified in toxicology were considered prescribed if the individual had an active dispensation for a matching medication within 60 days before overdose. <h3>RESULTS:</h3> There were 2872 deaths from illicit drug toxicity during the study period; 1789 (62.3%) were closed cases with toxicology results available. In 85.5% of cases, 1 or more opioids were found to be relevant to death. Prescribed opioids in the absence of nonprescribed opioids were detected in only 2.0% of cases, and 6.7% had a combination of prescribed and nonprescribed opioids. Among those with 1 or more nonprescribed opioids, 78.5% had fentanyl or fentanyl analogues detected. Medications used in opioid agonist therapy (methadone and buprenorphine) were found to be relevant to death in 7.4% of cases, with methadone (130 cases) much more common than buprenorphine (&lt; 5 cases). Stimulants were detected in 70.6% of cases. <h3>INTERPRETATION:</h3> Our data show a high prevalence of nonprescribed fentanyl and stimulants, and a low prevalence of prescribed opioids detected on toxicology in people who died from illicit drug overdose. These results suggest that strategies to address the current overdose crisis in Canada must do much more than target deprescribing of opioids.