Opiate Users Research Articles

Factors Associated With Sex-Related Pre-exposure Prophylaxis Adherence Among Men Who Have Sex With Men in New York City in HPTN 067.

HPTN 067 assessed the feasibility of daily and non-daily dosing of open-label emtricitabine/tenofovir disoproxil fumarate (FTC/TDF)-based pre-exposure prophylaxis (PrEP). Factors associated with sex-related PrEP adherence were assessed among men who have sex with men (MSM) randomized to one of 3 PrEP dosing arms in HPTN 067 in New York City. Sex-related PrEP adherence was defined per protocol as at least 1 PrEP tablet taken within 4 days pre-sex and at least 1 additional PrEP tablet taken within 24 hours post-sex, assessed via electronic drug monitoring and weekly interviews. Demographic data and behavioral measures were evaluated for association with sex-related PrEP adherence. Logistic regression for clustered data was used to estimate the unadjusted and adjusted odds ratios. Of 176 randomized MSM participants, 59% were Black, 10% White, 25% Hispanic, and 6% other; median age was 31 years. In the multivariable analyses, higher sex-related PrEP adherence was significantly associated with daily dosing arm, older age, employment, and higher PrEP adherence behavioral skills. Lower sex-related PrEP adherence was significantly associated with identifying as Black or Hispanic (compared with White), opiate use, and reporting "I forgot" as an adherence barrier. This analysis identified populations of MSM who might benefit from additional support to optimize PrEP adherence, including those who are younger, unemployed, or opiate users. MSM with lower PrEP behavioral skills may benefit from targeted interventions. Further study is needed to assess racial and ethnic disparities in PrEP adherence, which may reflect broader social and economic inequalities not captured in this study.

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45: Opiate use is associated with increased risk of treatment failure when using antimuscarinics for overactive bladder

To determine if opiate use affects treatment response to antimuscarinic medications for overactive bladder. We performed a retrospective nested cohort analysis of patients being treated with antimuscarinic medication for overactive bladder between January 2010 and December 2017. We included patients who were prescribed an antimuscarinic and subsequently had clear documentation of adherence and response to treatment. The primary outcome was reported treatment failure. Patients who were currently on opiates at the time of treatment were matched by age to controls without an opiate prescription within 1 year of antimuscarinic treatment at a ratio of 1:3. Differences between groups were evaluated using Wilcoxon Rank-Sum and Fisher’s exact test where appropriate. Logistic regression was used to control for confounders and identify predictors of the primary outcome. We identified 480 patients who met inclusion criteria. Opiate users were more likely to report constipation, have a remote history of urogynecologic surgery, a diagnosis of depression or anxiety, and to report treatment failure after taking antimuscarinic medication for overactive bladder (64.2% vs 48.1%, p=0.02). After controlling for confounders, opiate use was predictive of antimuscarinic treatment failure (aOR 1.9, 95% CI 1.17-3.06). Treatment failure was also correlated with active central nervous system disease, number of incontinence episodes per day, number of nighttime voids, and number of previously failed antimuscarinic medications. Opiate use is associated with an increased risk of treatment failure when using antimuscarinic medications for overactive bladder.

Opiate Exposure and Predictors of Increased Opiate Use After Ureteroscopy.

Objective: Kidney stone formers are at risk for opioid dependence. The aim of this study is to describe opiate exposure and determine predictors of prolonged opiate use among kidney stone formers after surgery. Materials and Methods: A retrospective review was performed among patients who underwent ureteroscopy for upper tract stone disease. Prescription data were ascertained from a statewide prescribing database. Demographic data and surgical factors were collected from the electronic medical record. Predictors of additional postsurgery prescriptions filled within 30 days and persistent opiate use 60 days after ureteroscopy were determined. Results: Among 208 patients, 127 (61%) had received preoperative opiate prescriptions within 30 days before surgery. Overall, 12% (n = 25) of patients required an additional opiate prescription within 30 days after ureteroscopy, and 7% (n = 14) of patients continued to use opiate medications more than 60 days postoperatively. Patients continuing to use opiates long-term were not chronic opiate users. For both outcomes, preoperative opiate exposure, including number of prescriptions, days prescribed, and unique providers had significant associations (all p < 0.05). Additionally, younger age (p = 0.049) was associated with obtaining an additional opiate prescription within 30 days. Lower BMI (p = 0.02) and higher ASA score (p = 0.03) were predictors of continued opiate use more than 60 days after ureteroscopy. Conclusions: The majority of stone formers have had opiate exposure before surgery, often from multiple providers. Approximately 1 in 8 stone formers who undergo ureteroscopy require additional opiate prescriptions within 30 days. A small but significant population receive opiates beyond the immediate postoperative period.

The Adolescent Domain Screening Inventory (ADSI) as a screen for assessing opiate use

Background: The terms epidemic and crisis appear almost daily in the media in relation to opiates. Barriers to treatment include the lack of early identification of substance use disorders. A review of the literature revealed no instruments specifically tested to identify opiate users for early intervention. One instrument that may serve this purpose is the Adolescent Domain Screening Inventory, or ADSI. Methods: This exploratory study is a secondary analysis and was conducted in 2018 on data collected in 2000; the study employed the use of an independent t-test and logistic regression through IBM SPSS 24 software. Results: The independent t-test showed a statistically significant difference between the ADSI scores for non-opiate users and opiate users (p < .001). The ADSI showed a 20% increase over the beginning block, and predicted 72.8% of opiate users in this sample. Conclusion: This study suggests that the ADSI may be a useful tool in identifying opiate users who are early in their use, in an effort to provide substance use intervention and treatment in a timely manner.

A Gas Chromatography-Triple Quadrupole Mass Spectrometry Assay for the Quantification of Opiates in Human Blood Samples.

A simplified protein precipitation method in combination with gas chromatography-triple quadrupole mass spectrometry (GC-MS-MS) analysis was developed and validated for the simultaneous determination of codeine, morphine, 6-acetylmorphine (6-MAM), hydrocodone and hydromorphone in human blood samples. A protein precipitation with 10% trichloroacetic acid followed by solid-phase extraction using a mixed-mode cartridge was used to separate the analyte from the blood samples. A BSTFA + 1% TMCS was used for derivatization of opiates prior to the analysis. Codeine-D3, morphine-D3, 6-acetylmorphine-D3 and hydrocodone-D6 were used as internal standards. The GC-MS-MS was operated under multiple-reaction monitoring mode using electron ionization technique. The transition ions used for quantitation were 371 → 234 for codeine, 429 → 146 for morphine, 399 → 287 for 6-MAM, 299 → 228 for hydrocodone and 357 → 314 for hydromorphone. The method was linear over the concentration range 2.5-1000 ng/mL for all analytes, except hydrocodone which was linear over 5-1000 ng/mL with a correlation coefficient (r2) = 0.99. The limit of detection was 1.0 ng/mL for all compounds except hydrocodone which was 2.5 ng/mL. The limit of quantitation was 2.5 ng/mL for all compounds except hydrocodone which was 5.0 ng/mL. The precision (% RSD) was within 1.26-14.81 and the accuracy (% Bias) was within -6.29-10.93% for all compounds. The method successfully analyzed morphine (305 ng/mL) and 6-acetylmorphine (6-MAM) (2.3 ng/mL) in a human blood sample received from an opiate user.

Endoscopic Ultrasound as a Useful Tool for Benign Common Bile Duct Dilation in Chronic Opiate Users

Endoscopic Ultrasound as a Useful Tool for Benign Common Bile Duct Dilation in Chronic Opiate Users

‘Heroin is the devil’: addiction, religion, and needle exchange in the rural United States

ABSTRACTLike many rural and suburban counties in the Midwestern United States, George County, Indiana is facing increased rates of heroin use, drug-related overdose, and hepatitis C. Following an outbreak of HIV in 2015 in a nearby county, the George County department of health launched an effort to open a needle exchange despite considerable opposition from the community, including ambivalent stances among current and former users of opiates. This article examines these conflicted perspectives noting their grounding in a moral approach to addiction and seeks to explain opposition to the needle exchange program by examining locals’ depictions of the religious and moral landscape of the county. This analysis is based on 29 qualitative interviews conducted with 20 people who have experience using heroin or prescription opioid painkillers and 13 other community members involved in local efforts to address addiction. Ethnographic observation of public events was undertaken. Examining the contours of the local moral economy and its links to religious spirituality and practice reveals that the moral model of addiction both mitigates and produces social exclusion and begets conflicted stances towards the presence of an initiative to open a modest needle exchange program. Interviewees expressed a variety of stances towards the initiative feeling that it might decrease the spread of disease, but may not be used effectively. Though it is situated on morally contested terrain, it may be a step towards social inclusion and empowerment for addicted individuals who stake their right to health and a place in the community.

International Comparison in Opiate Prescribing for New Users in Primary Care using Electronic Medical Record Data

IntroductionThe opioid epidemic in North America has, in part, been attributed to an increase in opiate use for non-cancer pain and the prescription of more potent molecules. In contrast, the United Kingdom appears unaffected by this crisis, possibly because of differences in primary care prescribing, or health system policies.&#x0D; ObjectiveTo determine if there are differences in opiate prescribing for new users in primary care in the United Kingdom, United States, and Canada.&#x0D; ApproachElectronic health record data from Quebec, Canada (MOXXI), the United States (Partners Health Care, Boston MA), and the United Kingdom (CPRD random sample of 600,000) were used to identify new users of opiates (no prior prescription in 2 years), at least 18 years old between 2006-2016. Cancer patients were excluded after harmonizing equivalent READ and ICD9/10 codes. Generic drug names in each jurisdiction were mapped to the WHO ATC classification, and characterized using morphine milligram equivalents (MME).&#x0D; ResultsOverall 655,877 new users were identified, of whom 78% of 58,286 (U.S.), 88% of 6,251 (Canada), and 96% of 600,000 (UK) were non-cancer patients. Mean age of new users was 49 (SD 16) in the US, 57 (SD 16) in Canada, and 52 (SD 19) in the UK. 57.6% (UK) to 67.3% (US) of new users were women. In the UK, 86.5% of patients were started on codeine (MME:0.15), compared to 43.9% in Canada and 8.5% in the U.S. In the U.S 65.0\% were started on oxycodone (MME:1.5), and 10.9% on hydrocodone (MME:1). In Canada, tramadol (18.2%; MME: 0.1) followed by oxycodone (13.2%) were the next most commonly prescribed drugs.&#x0D; Conclusion/ImplicationsSubstantial differences in opioid prescribing practices for non-cancer pain were observed between the UK and Canadian and United States sites. The predilection to start patients on more potent opiates in North America may be a contributing cause to the opiate epidemic.

Not all drugs are created equal: impaired future thinking in opiate, but not alcohol, users.

Episodic future thinking refers to the ability to travel forward in time to pre-experience an event. Although future thinking has been intimately linked with self and identity, to our knowledge, no prior research has compared episodic future thinking in populations with different substance use disorders. This study investigates whether there are differences in episodic future thinking between these alcohol and opiate users. The study recruited participants who were on the opiate substitution program (n = 31) and individuals who had been diagnosed with alcohol dependence (n = 21) from the Royal Prince Alfred Hospital Drug and Health Services. Healthy controls (n = 23) were recruited via Royal Prince Alfred Hospital databases and the general community. Past and future thinking was measured using four cue words. After each cue word, participants rated their phenomenological experience (e.g. emotion, reliving experience). Results indicated that alcohol-dependent individuals performed significantly higher in episodic future thinking compared to opiate users. These findings indicate that not all substance use disorder groups share similar episodic thinking capabilities. Our results suggest that the self-projection component of rehabilitation programs may have to be tailored to the different episodic construction abilities found in substance use disorder groups.

John Strang: global leader in tackling addiction

In an interview for BBC Newsnight in 1997, John Strang, the then newly appointed Director of the National Addiction Centre at King's College London, UK, first spoke publicly about “take-home naloxone” for opiate users. This was a major step in reducing deaths from heroin overdose, and Strang continued to fight for the widespread uptake of naloxone for 20 years, alongside advancing the research agenda in addiction medicine. Reflecting today, Strang says “It's taken two decades for this life-saving approach (take-home naloxone) to make a real global impact. It's difficult to understand how slow this process has been without stigma and discrimination being part of the explanation.”

Positive reinforcement targeting abstinence in substance misuse (PRAISe): Study protocol for a Cluster RCT & process evaluation of contingency management

There are approximately 256,000 heroin and other opiate users in England of whom 155,000 are in treatment for heroin (or opiate) addiction. The majority of people in treatment receive opiate substitution treatment (OST) (methadone and buprenorphine). However, OST suffers from high attrition and persistent heroin use even whilst in treatment. Contingency management (CM) is a psychological intervention based on the principles of operant conditioning. It is delivered as an adjunct to existing evidence based treatments to amplify patient benefit and involves the systematic application of positive reinforcement (financial or material incentives) to promote behaviours consistent with treatment goals. With an international evidence base for CM, NICE recommended that CM be implemented in UK drug treatment settings alongside OST to target attendance and the reduction of illicit drug use. While there was a growing evidence base for CM, there had been no examination of its delivery in UK NHS addiction services. The PRAISe trial evaluates the feasibility, acceptability, clinical and cost effectiveness of CM in UK addiction services. It is a cluster randomised controlled effectiveness trial of CM (praise and financial incentives) targeted at either abstinence from opiates or attendance at treatment sessions versus no CM among individuals receiving OST. The trial includes an economic evaluation which explores the relative costs and cost effectiveness of the two CM intervention strategies compared to TAU and an embedded process evaluation to identify contextual factors and causal mechanisms associated with variations in outcome. This study will inform UK drug treatment policy and practice.Trial registration ISRCTN 01591254.

Lower prevalence of gastroesophageal reflux disease in patients with noncardiac chest pain on opiates: a cross-sectional study.

Opiates can cause heartburn and spastic esophageal dysmotility but their role in noncardiac chest pain (NCCP) is not known. Our aim was to characterize opiate effects on esophageal function using esophageal pH monitoring and high-resolution manometry (HREM) in these patients.We performed a cross sectional study of opiate users with NCCP who underwent HREM and esophageal pH study from 2010 to 2017 using opiate nonusers as a comparison group. Demographic data, symptoms, opiate use, endoscopic findings, esophageal pH study parameters, and HREM data were abstracted.Thirty three patients with NCCP on opiates were compared to 144 opiate non-users. Compared to opiate nonusers, opiate users had lower total acid exposure (2.3% vs. 3%, P=0.012), lower upright acid exposure (1.2% vs. 3.1%, P=0.032) and lower DeMeester score (6.5 vs. 12.7, P=0.016). Opiate users also had higher lower esophageal sphincter integrated relaxation pressure (LES-IRP) (7.0 mm Hg [2.2, 11.7] vs. 3.7 mm Hg [1.1, 6.2] P=0.011) and greater mean distal contractile integral (DCI) (2575 mm.Hg.s.cm [1134, 4466] vs. 1409 mm.Hg.s.cm [796, 3003] P=0.03) than opiate non-users. The prevalence of hypertensive motility disorders (15.2% vs. 11.1%) and achalasia (12.1% vs. 2.1%) was higher in opiate users (P=0.039) but did not reach significance on multivariate analysis.In patients presenting with NCCP, opiate users had lower esophageal acid exposure compared to opiate nonusers. This might be due to higher LES pressures preventing reflux and higher DCI leading to more rapid acid esophageal clearance.

Characteristics and experiences of buprenorphine-naloxone use among polysubstance users

ABSTRACTBackground: With a rise in overdoses and medical emergencies related to opioids, buprenorphine-naloxone (bup-nx) is seen as a preferred treatment for opioid dependence. However, the research examining experiences with bup-nx among polysubstance users who may or may not be opioid dependent has been limited. Objectives: The purpose of the study was to examine use, characteristics of users, and experiences of bup-nx use among polysubstance users entering drug-free recovery programs. Methods: This study examined secondary data on 896 opioid or opiate user individuals (53.4% male) collected by drug-free, self-help-based residential recovery centers during intake. Results: One-quarter of users said bup-nx helped them with their substance use while 75% of bup-nx users reported that bup-nx either had no effect or a negative effect on their drug problems. Of the very few (4%-7%) obtaining bup-nx solely through a prescription, over 90% reported relief from withdrawal. However, over 80% of those who obtained bup-nx through illicit means reported using bup-nx until their preferred drug could be obtained and used it for its euphoriant effect. Three groups of opioid users were created including one group with no bup-nx use, one with lifetime but not recent bup-nx use, and one with recent (past 6 month) use. There were differences in substance use patterns and characteristics of bup-nx experiences between the different groups. Conclusions: Results suggest that the views of bup-nx by individuals in drug-free recovery centers are varied, with many seeing bup-nx as not unlike other opioids while others report bup-nx as self-medication.

Fatal and non-fatal overdose among opiate users in South Wales: A qualitative study of peer responses

BackgroundOverdose is a major cause of death among injecting drug users in Wales. Few studies, however, have explored the overdose responses of witnesses in this context. This study applies Rhodes’ concept of the ‘risk environment’ to examine how witnesses respond to opiate overdose. MethodIn depth, semi-structured interviews were conducted with fifty-five participants recruited from statutory and third sector drug treatment providers operating across South Wales and from two Welsh prisons. Eligibility was based on whether the person was, or had recently been, an opiate user and whether they had personally experienced or witnessed an overdose event. ResultsWitnesses were amenable to assisting overdosed peers. However, a number of micro- and macro-level factors impeded the successful implementation of harm reduction techniques in response to an overdose. At micro level, the social setting of injecting drug use, peer group drug use norms and difficulties in identifying an overdose were linked to ineffective response. Macro-level factors including laws governing the possession of drugs and harm reduction discourse were also found to limit the uptake of overdose response techniques. ConclusionFindings suggest a need to insert pragmatic solutions into overdose prevention programmes and training to counter the factors hindering effective responses to overdose. This includes simpler techniques and harnessing the support and knowledge of injecting drug users’ social networks. Although these will go some way to addressing specific micro-level barriers, we also emphasise the need for additional policy measures that can address the macro-environmental conditions that produce and maintain features of injecting drug users’ risk environments.

LEVELS OF PLASMA SOLUBLE CD14 IN HIV-INFECTED OPIATE USERS

Chronic immune activation is one of the main causes of HIV disease progression. Bacterial components passed to the bloodstream from the gut as a result of microbial translocation, are known to induce immune activation. Component of Gram-negative bacteria’s cell walls, the lipopolysaccharide (LPS), is considered to be the major marker of microbial translocation. Through the activation of myeloid cells (predominantly monocytes) LPS causes the secretion of soluble CD14, thus making it a marker of LPS bioactivity. Besides sCD14 was shown to correlate with immune status in HIVinfected patients and to be an independent predictor of disease progression. Hypothesis: opiates increase microbial translocation from the gut in HIV-infected patients that is manifested by a higher concentration of sCD14 in plasma. Aim: to estimate the influence of opiate use on the level of sCD14 in plasma of HIV-infected patients. Materials and methods. Longitudinal study of 351 HIV positive individuals. Concentration of sCD14, was evaluated at 3 time points: baseline, after 12 and 24 months. Following groups were studied: 1) current opiate users – opiate use within past 30 days; 2) opiate users, who denied consumption of opiates within past 30 days; 3) people claiming to never have used opiates. Results. In dynamic assessment sCD14 mean was significantly higher in current opiate users (2222,46±39,02 ng/ml) against patients who denied opiates within past 30 days (1930±597 ng/ml) and those, claiming to never have used opiates (1915±577 ng/ml) (p<0,001). Conclusion. Opiate use in the course of HIV disease leads to increase in LPS induced monocyte activation which therefore signifies more intensive microbial translocation.

Factors Associated with Sustained Remission among Chronic Opioid Users.

BackgroundChronic opioid use is a major public health problem with significant morbidity. The aim of this study was to investigate factors associated with sustained remission among a sample of Iranian chronic opioid users in Shiraz, Iran.MethodsThis was a cross-sectional study to evaluate sustained remission among chronic opiate users aged 20-60 years. Participants included two groups: 365 people who have been in sustained remission for the past year, and 187 persons who did not achieve remission for the past one year. Then, demographic and factors related to drug use pattern and previous treatments were compared between two groups. Pearson chi-square test was used for univariate analysis and backward stepwise logistic regression was used to estimate adjusted odds ratios (AORs).FindingsOur findings showed that sustained remission was associated with Narcotic Anonymous (NA) participation [AOR = 3.28, 95% confidence interval (CI): 2.19-4.89, P < 0.001], male gender (AOR = 2.53, 95% CI: 1.45-4.43, P = 0.001), younger age of onset (AOR = 1.63, 95% CI: 1.03-2.58, P = 0.037), higher total years of opioid use (AOR = 2.13, 95% CI: 1.42-3.19, P < 0.001), no history of imprisonment (AOR = 2.11, 95% CI: 1.16-3.85, P = 0.015), and family support (AOR = 2.58, 95% CI: 1.33-5.01, P = 0.005).ConclusionParticipation in self-help groups can be a suitable alternative in predicting sustained remission among chronic opiate users. Chronic opioid users should be encouraged by the physicians who are involved in the treatment of drug addiction to participate in NA programs.

Factors affecting the dose of methadone among patients receiving methadone maintenance therapy in Taiwan.

Methadone maintenance treatment (MMT) has been shown to be an effective therapeutic strategy for opioid users. This study aimed to investigate the predictive effect of clinically predominant sleep disturbance (CPSD) on the dose of methadone among opiate users receiving MMT during a follow-up period of 6 years in Taiwan. This retrospective study included 1,290 individuals with opioid dependence who visited our MMT clinic for the first time. Generalized estimating equations were used to analyze the effect of CPSD on the daily dose of methadone by controlling for the effects of demographic and MMT characteristics. A total of 469 (36.4%) participants were comorbid with CPSD. After controlling for the effects of demographic and MMT characteristics, the participants comorbid with CPSD had a higher dose of daily methadone than those without CPSD (estimate: 7.03, p < .001). Furthermore, younger age (estimate: -1.22, p < .001), older age at initial MMT (estimate: .44, p < .001), lower educational level (estimate: -.90, p = .003) and lower attendance rates (estimate: -.14, p = .033) are significantly related to higher doses of daily methadone. Our study provided a naturalistic observation of the cohort for long period, along with a large sample size which could reflect clinical practice in the real world. We reported that a higher daily dose of methadone was significantly associated with CPSD after controlling for the effects of other factors. CPSD should be routinely surveyed among heroin users receiving MMT. (Am J Addict 2018;27:225-230).

Hepatitis C (HCV) and the Risk of QTC Prolongation - An Exploratory Cohort Study Among Opiate Users in Substitution

Background: Prolongation of the QT interval is a known adverse event associated with certain pharmacotherapies, stress sensitivity, female gender, and low potassium level. It can potentially lead to fatal outcomes by inducing Torsade de pointes arrhythmia. Patients with opiate dependence are highly vulnerable to this condition due to the side effects of opioids and other accumulated risk factors. Methods: A convenience sample of 99 patients with opiate dependence receiving substitution treatment was recruited in an Inner-city substitution clinic in Germany. All patients were assessed with an ECG before and after taking opiate-agonist medication. Additional sociodemographic information and medical history were also collected. To determine the impact of different variables on QTc interval, a multiple variables linear regression with a stepwise selection was fitted. Findings: A concerning high prevalence of QT prolongation was observed among participants (32·3% before and 17·2% after medication intake). A significant finding in this study was the identification of Hepatitis C infection as an important risk factor in addition to baseline QTc prolongation, female gender, tobacco - dependence and QT-prolonging medications. Interpretation: The accumulation of risk factors for QT prolongation can have serious adverse consequences in patients with substance use disorder receiving opiate-agonist medications. Addressing these factors for example treatment of HCV infection needs to be considered as part of an integrated treatment program to prevent such consequences. Further research is required to explore the association of various factors with QTc prolongation, evaluate the impact of potential interventions on cardiac adverse events and also unravel the underlying mechanisms of QTc prolongation in this population. Funding: No grant funding. Declaration of Interest: Authors do not have any conflict of interests in regards to this study to disclose. Ethical Approval: The study design was approved by the ethics committee of the Ludwig Maximillian University (LMU) in Munich.

Opana ER (Oxymorphone)-Induced Thrombotic Microangiopathy: An Atypical Presentation in a Patient With Hepatitis C.

Oxymorphone is a semisynthetic extended release opiate used to treat moderate to severe chronic pain. The Food and Drug Administration approved the oral form of oxymorphone available as Opana and Opana ER (extended release) since 2006. The Food and Drug Administration and the Centers for Disease Control and Prevention issued warning against intravenous use of Opana ER. We are presenting a case report of a 37-year-old female with a history of active intravenous drug abuse who presented to our hospital with acute kidney injury. Urinalysis showed red blood cell sediments, many dysmorphic red blood cell casts along with nephrotic range proteinuria of 12 g/deal per day. Kidney biopsy showed microscopic thrombotic microangiopathy (TMA) involving glomeruli and vessels. Further workup was undertaken for TMA, and apart from mildly elevated lactate dehydrogenase of 380 (normal <243), active hepatitis C, and slightly low ADAMTS-13 (55%), there was no other laboratory evidence of TMA. On literature search, we found that intravenous injection of chronic Opana ER has been reported to cause TMA resulting in chronic kidney disease. Our patient also admitted to use of intravenous Opana ER abuse for the past 5 years. She had a normal platelet count and an absence of schistocytes, which makes it an atypical presentation of TMA resulting in chronic kidney disease in an opiate user. We strongly urge physicians to avoid prescribing opiates for chronic pain, especially Opana ER, which if injected intravenously for recreational purposes can lead to serious side effects like TMA. Treatment is mainly supportive and avoidance of drug in future.