Opioid Mortality Research Articles

P1253 Temporal Trend of Opioid Prescriptions Among Adults with Ulcerative Colitis: A Nationwide Cohort Study in Sweden 2008-2021

Abstract Background The rising opioid misuse and related mortality led the US government to declare opioid use as a public health emergency in 2017 [1]. Population-based studies on opioid use in Ulcerative Colitis (UC) are scarce [2]. The aim of this study was to describe the time trend of opioid use among adults with UC compared to the general population in Sweden. Methods We conducted a nationwide cohort study including individuals aged ≥18 years with a UC diagnosis, identified via two ICD-10 code K51 registrations in the National Patient Register. Each patient with UC was matched with up to 10 reference individuals without inflammatory bowel disease (IBD) by birth year, sex, calendar year, and place of residence. Observation started on January 1, 2008, at age 18, or the date when the UC diagnosis definition was fulfilled (whichever came last) and ended at emigration, death, or December 31, 2021 (whichever came first). Data on opioid dispensations were obtained from the Prescribed Drug Register. Opioid use per calendar year was defined as ≥1dispensed opioid prescription. We categorized codeine combinations, tramadol, and dextropropoxifen opioids as weak and oxycodone, morphine, hydromorphone, fentanyl, buprenorphine, tapentadol, and petidine as strong. Annual prevalence estimates of opioid use were calculated, and joinpoint analysis was performed to explore the trend and to estimate annual percent change (APC) of opioids. Results The cohort included 59,983 patients with UC (47.4% female) and 539,505 reference individuals. Cancer diagnoses within two years prior to the index date were observed in 1.1% of UC patients and 0.7% of reference individuals, while psychiatric disorders were identified in 3.8% and 3.6%, respectively. During the observation period, UC patients had a higher prevalence of opioid use compared to reference individuals. The Joinpoint analysis revealed three distinct periods (Figure 1): slightly increasing from 2008-2014, followed by decreasing trends during 2015-2018 (APC: -2.45) and 2019–2021 (APC: -5.20). As shown in Figure 2, the prevalence of any annual opioid use among UC patients declined from 15.5% in 2008 (compared to 9.5% for reference individuals) to 13.0% in 2021 (8.0% for reference individuals). Conversely, strong opioid use among UC patients increased from 3.0% to 9.0% over the study period, compared to a rise from 1.0% to 4.0% among reference individuals. Conclusion Opioid use among UC patients in Sweden showed a modestly decreasing trend since 2015 similar to that in the general population. The main limitation of this research was the inability to account for illegal opioid use, which is likely to underestimate the use of opioids among the reference group.

Opioid toxicity deaths in Indigenous people who experienced incarceration in Ontario, Canada 2015-2020: A whole population retrospective cohort study

While Indigenous people are overrepresented in Canada's prisons and in the toxic drug supply crisis, we lack data on the harms related to opioids for Indigenous people with experiences of incarceration. We aimed to examine opioid toxicity deaths in Indigenous peoples who experienced incarceration and to compare opioid toxicity mortality rates with rates for people with no incarceration. This retrospective cohort study linked correctional data for all people who were incarcerated in provincial correctional facilities and coronial data for all people who died from opioid toxicity in Ontario, Canada between 2015 and 2020. We calculated opioid mortality rates for Indigenous people who experienced incarceration and for people who did not experience incarceration using publicly available population data and calculated age-standardized mortality rates for Indigenous and non-Indigenous people who experienced incarceration compared with people who did not experience incarceration. Of 14,885 Indigenous people who experienced incarceration, 2% (N=242) died from opioid toxicity in custody or post-release, representing 2.9% of all opioid toxicity deaths in Ontario during this period. The crude opioid toxicity mortality rate per 100 person-years was 0.53 for Indigenous females and 0.36 for Indigenous males who experienced incarceration, compared with 0.0060 for females and 0.0132 for males who did not experience incarceration. Rates of opioid toxicity death were highest in the month post-release for Indigenous people who experienced incarceration, at 1.13 per 100 person-years. Standardized for age and compared with people with no incarceration, the mortality ratio was 81.0 (95% CI 62.1-100.0) for Indigenous females who experienced incarceration and 23.6 (95% CI 20.1-27.1) for Indigenous males who experienced incarceration. The SMRs for Indigenous and non-Indigenous females who experienced incarceration were not significantly different, at 81.0 compared with 76.4, and were significantly different for Indigenous and non-Indigenous males who experienced incarceration, at 23.6 compared with 28.5. This whole-population study identified a substantial and inequitable burden of opioid toxicity death for Indigenous people who experienced incarceration, similar to the burden for non-Indigenous people who experienced incarceration. The large burden is particularly concerning in the context of the overrepresentation of Indigenous people in correctional facilities. Focus is warranted to prevent substance use harms for Indigenous people, including through community- and custody-based interventions to support health. Canadian Institutes of Health Research through the Canadian Research Initiative in Substance Misuse (SMN-139150 and REN-181677).

Implementation strategies to support recovery support workers serving criminal legal involved people who use drugs

IntroductionRecovery support workers (RSWs) who provide social support interventions for people who use drugs (PWUD) often face challenges that can jeopardize the well-being, efficacy and sustainability of this essential workforce. To date, little has been reported on the types of implementation strategies used to support RSWs. We describe and evaluate a multifaceted implementation strategy package to support Reducing Opioid Mortality in Illinois (ROMI), a paired peer recovery coach and case manager (PRC-CM) intervention for PWUD with recent criminal-legal involvement in urban and rural settings. MethodsROMI utilized a remote, hub and spoke-administered multifaceted implementation strategy package to support PRCs-CMs to deliver evidence-based services to PWUD with criminal-legal involvement. The core strategies included: (a) comprehensive training; (b) individual clinical supervision; (c) group consultation; and (d) centralized technical assistance. We evaluated the implementation strategy package using a mixed-methods design including qualitative interviews with the intervention staff to explore their experiences with each strategy component, as well as a quantitative coding of topics discussed during supervision and group consultation meetings to estimate prioritization of issues and balance of topics between strategy type. ResultsBetween January 2019 and January 2024, the study interviewed 8 PRC-CMs and quantitatively coded 568 sessions (79 group consultations and 489 individual supervisory) for discussion themes. The hub-and-spoke model allowed for centralized access to highly skilled supervisory staff as well as knowledge sharing across geographically remote teams. The therapeutic space to process feelings and emotional support provided during individual supervision was noted to be an essential resource by PRC-CMs. Group consultation facilitated camaraderie, mutual support and continual learning through dynamic and responsive trainings. Frustrations around resource limitations and systemic barriers facing their clients remained a dominant concern for PRCs-CMs, and was incompletely addressed by the technical assistance strategy. ConclusionUnderstanding the practical components and individual strengths of the implementation strategies required to support the implementers of complex interventions such as social support and navigation for PWUD with criminal-legal involvement elucidates the organizational and professional capacities that may be required for real world implementation. Trial registrationNCT04925427

Community alcohol sales and opioid poisoning deaths: Alcohol serving space as a harm reduction opportunity

The concurrent use of opioids and alcohol is particularly dangerous for individuals. Alcohol is commonly seen in opioid overdose death toxicology reports and, concurrent use of alcohol and opioids is often reported by individuals across a diverse range of opioid use profiles. This study investigates whether there is a community-level relationship between alcohol sales and opioid-related overdose deaths to inform the situating of harm reduction efforts in spaces most likely to reduce substance-related harms. Using an ecological design, zip code-level data for New Hampshire were combined from the US Census Bureau’s American Community Survey (sociodemographics), the National Alcohol Beverage Control Association (alcohol retail sales), and the NH Office of the Chief Medical Examiner (zip code level opioid poisoning deaths) to investigate the relationship between alcohol sales and opioid-related poisoning deaths at a community level in a state with the third highest rate of opioid poisoning deaths for the year the current study represents. Using a spatial error regression model approach, opioid-related poisoning deaths were higher in zip codes with greater population density and on-premise alcohol sales and were lower in zip codes with greater off-premise alcohol sales and area disadvantage. The findings here co-locate higher levels of on-premise alcohol sales and opioid-related poisoning deaths at a community-level, mirroring individual-level findings on the danger of mixing these two substances. Results inform harm reduction approaches by identifying substance use spaces where overdose prevention messaging or policy change may be most effective.

Impact of California's naloxone co-prescription law on emergency department visits, 30-day mortality, and prescription patterns.

Opioid overdose is a public health epidemic adversely impacting individuals and communities. To combat this, California passed a law mandating that prescribers offer a naloxone prescription in certain circumstances. Our objective was to evaluate associations with California's naloxone prescription mandate and emergency department (ED) overdose visits/hospitalizations, opioid and naloxone prescribing, and 30-day mortality. This retrospective cohort study included data from January 1, 2018, to December 31, 2019, and included all Kaiser Permanente Southern California (KPSC) members aged >10 years across 15 KPSC EDs. Exposure was defined as presentation to the ED within the study period. The primary outcome was ED visits for opioid overdose pre- and post-implementation of California's naloxone prescription mandate. A total of 1.1 million ED visits (534K pre/576K post) were included in the study population. ED opioid overdose visits were 344 (6.4/10,000) pre-policy and 351 (6.1/10,000) post-policy implementation, while non-opioid overdose visits were 309 (5.8/10,000) pre-implementation and 411 (7.1/10,000) post-implementation. The unadjusted rate of visits with opioid prescriptions decreased significantly (14.9% pre to 13.5% post) after implementation. ED naloxone prescriptions increased substantially (104 pre vs. 6031 post). Primary adjusted interrupted time series analysis found no statistical difference between monthly opioid overdose visits pre versus post (odds ratio 1.02, 95% confidence interval [CI] 0.98‒1.07). Difference-in-differences analysis revealed no significant changes in hospitalization (coefficient [CE]=‒0.05, 95% CI=‒0.11 to 0.02) or 30-day mortality (CE=‒0.01, 95% CI=‒0.03 to 0.01). This study revealed that the implementation of California's naloxone prescription mandate was associated with significantly increased naloxone prescribing and decreased opioid prescribing, but no significant change in ED opioid overdose visits, hospitalizations, or 30-day mortality. This indicates that increasing naloxone prescribing alone may not be sufficient to lower opioid overdose rates.

Buprenorphine, oxycodone, hydrocodone, and methadone mortality in the United States (2010‒2017).

Opioid overdose survivors present to emergency departments (EDs) and many EDs have developed programs to initiate buprenorphine. The impact of the increasing use of buprenorphine in ED and by other providers is unknown while opioid mortality continues to rise. Public mortality data do not distinguish buprenorphine from other prescription opioids. Our objective was to determine when changes in overdose mortality trends occurred comparing deaths involving buprenorphine to oxycodone, hydrocodone, and methadone. This observational study utilized the drug-involved mortality database including US death certificates (2010‒2017) in which buprenorphine, oxycodone, hydrocodone, or methadone were contributing causes of death (determined through textual analysis). Population- and drug utilization-adjusted mortality rates were examined using disjointed linear regression. Buprenorphine-involved deaths were stratified by polysubstance involvement. The population-adjusted mortality rates for buprenorphine-involved deaths were lowest compared to other opioids; however, the change in rate for buprenorphine increased faster than oxycodone, hydrocodone, and methadone at 8.9% each quarter-year (95% confidence interval [CI]: 8.0, 9.8) from 2010 to mid-2016 when it stabilized. After adjusting for changes in dispensing over the study period, buprenorphine-involved mortality rates were increasing at 5.3% (95% CI: 4.6, 6.1) each quarter-year. In 2017, 94% buprenorphine-involved deaths had at least one other drug contributing to the cause of death. Given the low mortality, high proportions of polysubstance mortality, and the mixed agonist/antagonist mechanism of action, use of buprenorphine alone likely presents a lower risk for overdose than comparators. Mortality rose faster than dispensing, signaling need to ensure people understand buprenorphine risks, particularly polysubstance use, balanced against importance for treating opioid use disorders.

Trends in Pregnancy-Associated Opioid Toxicity and Mortality

ObjectivesTo examine trends in pregnancy-associated non-fatal and fatal opioid toxicity and all-cause mortality, and identify associated factors. ApproachWe conducted a population-based study of 1,555,370 pregnancies in Ontario, Canada, 2013-2022. We analyzed linked administrative datasets, including coroner data, and calculated pregnancy-associated (during pregnancy or within one-year post-pregnancy) non-fatal/fatal opioid toxicity and all-cause mortality ratios per 100,000 livebirths by year and timing (pregnancy, post-pregnancy). Poisson regression models analyzed trends in outcomes and generated adjusted relative risks (aRR) of opioid toxicity by socio-demographic and clinical factors. ResultsPregnancy-associated non-fatal opioid toxicity increased 220% between 2013 and 2020 (45.5-145.4/100,000 livebirths) before declining by 30% in 2021. Over the study period, fatal opioid toxicity increased 150% (6.8-17.5/100,000) and all-cause mortality increased 120% (32.8-71.2/100,000). Our methods did not identify any opioid toxicity deaths in pregnancy, and most non-fatal (66.6%) and fatal (88.9%) opioid toxicity and all-cause mortality (73.9%) occurred 43-365 days post-pregnancy. The percent of deaths attributed to opioids increased from 12.7% in 2015 to 25.0% in 2020. Substance use disorder (aRR 19.52, 95% CI 16.87-22.58), pre-pregnancy opioid toxicity (aRR 4.69, 3.81-5.78), mental illness (aRR 2.01, 1.75-2.29), high neighbourhood deprivation (aRR 1.45, 1.28-1.64), and social disadvantage (aRR 3.21, 2.77-3.71) were associated with elevated risk of opioid toxicity. ConclusionsPregnancy-associated opioid toxicity and mortality have increased substantially. In 2020, 1 in 4 pregnancy-associated deaths involved opioids. ImplicationsFindings highlight the need for comprehensive care and perinatal harm reduction services. System-level improvements to reduce poor outcomes must include complete data capture of all pregnancy-associated deaths.

Buprenorphine Induction in Trauma Patients With Opioid Use Disorder — A Single Center Experience?

IntroductionBuprenorphine is a Food and Drug Administration-approved therapy for opioid use disorder, with proven efficacy in treatment retention and reduction in opioid use and mortality. Low-dose buprenorphine initiation or microinduction is a novel means of initiation that may allow for an easier transition in patients. Trauma patients have high rates of opioid use disorder and patient directed discharges (PDD). We hypothesized that patients initiated on a buprenorphine microinduction program would have increased protocol completion and fewer PDD compared with patients initiated historically on a traditional induction. MethodsOur retrospective cohort study compared buprenorphine microinduction and traditional induction in trauma patients at an urban level one trauma center between December 2020 and June 2022. Patients aged 18-89 y with traumatic injuries who received buprenorphine were included. Our primary outcome was in-hospital protocol completion, defined as reaching 16 mg of buprenorphine within 24 h or a documented stable dose. Statistical analysis was performed using chi-square for categorical variables and two sample t-tests for continuous variables. ResultsNinety-eight patients were included, with 46 initiating with microinduction and 52 initiating with traditional induction. There was no difference in protocol completion, (P = 0.29) and 83% of subjects who started an induction protocol completed it. Those who completed a protocol were more likely to be discharged home (P = 0.0002), had less PDD (P = 0.001), and had an increased likelihood of attending outpatient addiction clinic follow-up (P = 0.038). ConclusionsRegardless of the protocol type, buprenorphine induction can be implemented in trauma patients with high protocol completion rates. In our population, those who complete a protocol had a higher likelihood of discharge home and postdischarge follow-up in addiction medicine clinic.

Simulating the effects of medicaid expansion on the opioid epidemic in North Carolina

Expanding Medicaid plays a large role in ensuring that people across the United States have access to health care services. Although North Carolina recently moved toward Medicaid expansion, the impact of expansion on overdoses and overdose mortality may vary based on the type of treatment (offering medications for opioid use disorder [MOUD] vs. offering inpatient medically managed withdrawal without linkage to further MOUD treatment or non–MOUD-based treatment) accessed by individuals newly eligible for treatment through expansion. Based on official North Carolina statistics and published peer-reviewed literature, we developed a simulation model that forecasts opioid overdose and mortality under different scenarios for type of treatment accessed (MOUD-based vs. non–MOUD-based) and Medicaid coverage levels. An optimistic scenario assuming 70 % of individuals newly eligible for treatment would enter treatment during the first year of expansion estimated that 332 (Simulation Interval: 246–412) overdose deaths would be averted. A scenario more in line with recent historical trends assuming 38 % of individuals newly eligible for treatment would enter treatment resulted in 213 (Simulation Interval: 157–263) averted overdose deaths. In all scenarios, MOUD-based treatment approaches increased the number of lives saved compared with approaches expanding opioid treatment through non–MOUD-based treatment. Our study emphasized the need to ensure access to MOUD-based treatment for individuals newly covered by the Medicaid expansion.

The size paradox: An analysis of tube thoracostomy in trauma

BackgroundDebate continues over chest tube (CT) size for traumatic hemothorax (HTX) and pneumothorax (PTX). We compared CT failure and opioid use between large-bore chest tubes (LB-CT) and small-bore chest tubes (SB-CT). MethodsA retrospective study comparing trauma patients with SB-CT (≤14Fr) or LB-CT (≥24Fr) was performed. CT failure includes HTX, PTX, or empyema requiring intervention. Secondary outcomes included opioid use (MME), mortality, and favorable discharge. ResultsOf 252 patients, 65.1 ​% had SB-CT. SB-CT were older with lower ISS. Failure rate was lower for SB-CT (9.2 vs 22.7 ​%, p ​= ​0.003), as was opioid use (332 vs 767, p ​< ​0.001). In adjusted analysis there was no difference in CT failure between SB-CT and LB-CT. Subgroup analysis found SB-CT had lower total MME (234 vs 342, p ​= ​0.018). ConclusionsThis study found no major differences in CT failure or opioid use by CT size, suggesting SB-CT are a safe, and effective alternative to LB-CT in trauma.

Impact of opioid overdoses on US life expectancy and years of life lost, by demographic group and stimulant co-involvement: a mortality data analysis from 2019 to 2022

The United States' opioid crisis is worsening, with the number of deaths reaching 81,806 in 2022 after more than tripling over the past decade. This study aimed to comprehensively characterize changes in burden of opioid overdose mortality in terms of life expectancy reduction and years of life lost between 2019 and 2022, including differential burden across demographic groups and the contribution of polysubstance use. Using life tables and counts for all-cause and opioid overdose deaths from the National Center for Health Statistics, we constructed cause-eliminated life tables to estimate mortality by age in the absence of opioid-related deaths. We calculated the loss in life expectancy at birth (LLE) and total years of life lost (YLL) due to opioid overdose deaths by state of residency, sex, racial/ethnic group, and co-involvement of cocaine and psychostimulants. Opioid-related deaths in the US led to an estimated 3.1 million years of life lost in 2022 (38 years per death), compared to 2.0 million years lost in 2019. Relative to a scenario with no opioid mortality, we estimate that opioid-related deaths reduced life expectancy nationally by 0.67 years in 2022 vs 0.52 years in 2019. This LLE worsened in all racial/ethnic groups during the study period: 0.76y-0.96y for white men, 0.36y-0.55y for white women, 0.59y-1.1y for Black men, 0.27y-0.53y for Black women, 0.31y-0.82y for Hispanic men, 0.19y-0.31y for Hispanic women, 0.62y-1.5y for American Indian/Alaska Native (AI/AN) men, 0.43y-1y for AI/AN women, 0.09y-0.2y for Asian men, and 0.08y-0.13y for Asian women. Nearly all states experienced an increase in years of life lost (YLL) per capita from 2019 to 2022, with YLL more than doubling in 16 states. Cocaine or psychostimulants with abuse potential (incl. methamphetamines) were involved in half of all deaths and years of life lost in 2022, with substantial variation in the predominant drug class by state and racial/ethnic group. The burden of opioid-related mortality increased dramatically in the US between 2019 and 2022, coinciding with the period of the COVID-19 pandemic and the associated disruptions to social, economic, and health systems. Opioid overdose deaths are an important contributor to decreasing US life expectancy, and Black, Hispanic, and Native Americans now experience mortality burdens approaching or exceeding white Americans. None.

Recreational cannabis dispensary access effects on prescription opioid use and mortality

While opioid prescribing rates have fallen since 2012, opioid mortality in the United States (US) climbed to record highs in 2022, per CDC reports. In the last decade, evidence emerged that recreational cannabis legislation (RCL) may help mitigate adverse opioid-related outcomes. Yet, the empirical evidence on the relationship between RCL and opioid misuse as a whole is inconsistent and possibly spurious, given common estimation methods. Studies reporting beneficial associations between RCL and opioid mortality tend to avoid the mechanism of change, often assuming mortality benefits stem from substituting cannabis for opioids. We test this relationship using prescription opioid quantities and access to recreational cannabis in the US state of Oregon. Our approach uses within-state variation in distance to recreational dispensary access generated by RCL and prior volumes of legal opioid use to assess the impact of dispensary access on prescription opioids. Results suggest that communities located closer to recreational dispensaries are associated with lower rates of prescription opioids per capita. We also show that reasonable bounds to our primary specification suggest communities located within a mile from a recreational dispensary have prescription opioid rates per capita that are 1.0–3.9 percent lower than surrounding communities. Despite the reduction, we find no evidence that reducing barriers to cannabis access and subsequent declines in prescription opioids are associated with meaningful changes in opioid mortality.

Cannabis Co-Use Among Black Individuals with Chronic Pain Who Use Opioids: Associations with Other Substance Use and Pain Related Outcomes

Abstract: Background Black individuals with chronic musculoskeletal (MSK) pain tend to experience worse pain and opioid use-related outcomes, including other substance co-use, compared with non-Hispanic White individuals. Co-using cannabis with opioids could instigate a cascade of pain-related vulnerabilities and poor outcomes. Here, we test associations between cannabis/opioid co-use and pain-related outcomes among Black individuals with chronic MSK pain. Methods Black adults with chronic MSK pain who use opioids ( N =401; 51.62% female, Mage =35.90, SD =11.03) completed online measures of pain intensity/interference, emotional distress, opioid dependence, and risky use of other substances. Results Compared with opioid use alone, opioid and cannabis co-use was associated with elevated anxiety and depression symptoms, opioid dependence, and risky substance use, but not pain. Conclusions Black individuals with chronic MSK pain who co-use opioids and cannabis warrant targeted interventions that address their needs. Tailored interventions could help address disparities in pain-related outcomes and opioid morbidity and mortality rates.

Opioid Use, Mortality Risks and Crime: Insights from a Rapid Reduction in Heroin Supply

Abstract In 2001, a large and sustained supply shock halted a heroin epidemic in Australia. We use drug offenses to identify individual opioid users and examine how the shock affected their mortality risks and criminal activity over the next eight years. Initially, gains from fewer overdoses are offset by drug substitution and more crime, including homicides. Most adverse effects dissipate over time, while persistent mortality reductions save the lives of around one in 48 individuals in our sample. Our results demonstrate that reducing the supply of illicit opioids can lead to meaningful longer-term improvements, even when the short-term effects are ambiguous.

Discontinuation of medication treatment for opioid use disorder after a successful course: The discontinuation phase of the CTN-0100 (RDD) trial

Introduction and backgroundBuprenorphine, and extended-release naltrexone, are effective in decreasing opioid use, morbidity and mortality. The available evidence suggests that these medications should be used for long term treatment; however, patients often ask how long they need to be on medication, and whether it would be safe to discontinue. There are sparse data to guide us. The CTN-0100 trial will address this gap in our knowledge by studying participants who have decided to discontinue buprenorphine and extended-release naltrexone for OUD. Research design and methodsThe trial is a multicenter, randomized, non-blinded study. Participants are stable adult volunteers, on sublingual buprenorphine, extended-release buprenorphine, or extended-release naltrexone, expressing an interest in discontinuing medication. Participants on buprenorphine must be stable for at least 1 year and participants on extended-release naltrexone must be stable for at least 6 months. Participants are engaged in the study for up to 96 weeks, including a flexible taper period, and are then transitioned to follow-up within the trial. All participants are randomly assigned to the study Medical Management (MM) or to MM plus Connections (CHESS health) digital smartphone application aimed at recovery and abstinence (MMD). Sublingual Buprenorphine participants are also randomized (2 × 2 design) to a taper using either sublingual or extended-release buprenorphine. Discussion/conclusionIt is hoped that this trial will provide a rich source of data on management of patients discontinuing medication for opioid use disorder (MOUD) to inform future research and practice. The trial will shed light on which strategies are most likely to lead to long-term success (absence of relapse), and what participant characteristics distinguish those who can safely discontinue MOUD from those who remain at risk of relapse should they discontinue.ClinicalTrials.gov Identifier: NCT04464980

The association between naloxone claims and proportion of independent versus chain pharmacies: A longitudinal analysis of naloxone claims in the United States

BackgroundExpanding access to naloxone through pharmacies is an important policy goal. Our objective was to characterize national county-level naloxone dispensing of chain versus independent pharmacies. MethodsThe primary exposure in our longitudinal analysis was the proportion of chain pharmacies in a county, identified through the U.S. Department of Homeland Security 2010 Infrastructure Foundation-Level Data. We defined counties as having “higher proportion” of chain pharmacies if at least 50% of pharmacies were large national chains. The primary outcome was quarter-year (2016Q1-2019Q2) rate of pharmacy naloxone claims per 100,000 persons from Symphony Health at the county level. We compared the naloxone dispensing rate between county types using 2-sample t tests. We estimated the association between county-level chain pharmacy proportion and rate of naloxone claims using a linear model with year-quarter fixed effects. ResultsNearly one-third of counties (n = 946) were higher proportion. Higher proportion counties had a significantly higher rate of naloxone claims across the study period, in 4 of 6 urban-rural classifications, and in counties with and without naloxone access laws (NALs). The linear model confirmed that higher proportion counties had a significantly higher rate of naloxone claims, adjusting for urban-rural designation, income, population characteristics, opioid mortality rate, coprescribing laws, and NALs. ConclusionIn this national study, we found an association between naloxone dispensing rates and the county-level proportion of chain (vs. independent) pharmacies. Incentivizing naloxone dispensing through educational, regulatory, or legal efforts may improve naloxone availability and dispensing rates—particularly in counties with proportionately high numbers of independent pharmacies.

Association Between Opioid-Related Mortality and History of Surgical Procedure: A Population-Based Case-Control Study.

This study examined whether there is an association between opioid-related mortality and surgical procedures. A case-control study design using deceased controls compared individuals with and without opioid death and their exposure to common surgeries in the preceding 4 years. This population-based study used linked death and hospitalization databases in Canada (excluding Quebec) from January 01, 2008 to December 31, 2017. Cases of opioid death were identified and matched to 5 controls who died of other causes by age (±4 years), sex, province of death, and date of death (±1 year). Patients with HIV infection and alcohol-related deaths were excluded from the control group. Logistic regression was used to determine if there was an association between having surgery and death from an opioid-related cause by estimating the crude and adjusted odds ratios (ORs) with the corresponding 95% confidence interval (CI). Covariates included sociodemographic characteristics, comorbidities, and the number of days of hospitalization in the previous 4 years. We identified 11,865 cases and matched them with 59,345 controls. About 11.2% of cases and 12.5% of controls had surgery in the 4 years before their death, corresponding to a crude OR of 0.89 (95% CI: 0.83-0.94). After adjustment, opioid mortality was associated with surgical procedure with OR of 1.26 (95% CI: 1.17-1.36). After adjusting for comorbidities, patients with opioid mortality were more likely to undergo surgical intervention within 4 years before their death. Clinicians should enhance screening for opioid use and risk factors when considering postoperative opioid prescribing.

United States marijuana legalization and opioid mortality trends before and during the first year of the COVID-19 pandemic.

To determine if marijuana legalization was associated with reduced opioid mortality. The United States (US) opioid mortality trend during the 2010-2019 decade was compared in states and District of Columbia (jurisdictions) that had implemented marijuana legalization with states that had not. Acceleration of opioid mortality during 2020, the first year of the coronavirus disease 2019 (COVID-19) pandemic, was also compared in recreational and medicinal-only legalizing jurisdictions. Joinpoint methodology was applied to the Centers for Disease Control and Prevention WONDER data. Trends in legalizing jurisdictions were cumulative aggregates. The overall opioid and fentanyl death rates and the percentage of opioid deaths due to fentanyl increased more during 2010-2019 in jurisdictions that legalized marijuana than in those that did not (pairwise comparison p = 0.007, 0.05, and 0.006, respectively). By 2019, the all-opioid and fentanyl death rates were 44 and 50 percent greater in the legalizing than in the nonlegalizing jurisdictions, respectively. When the COVID-19 pandemic hit in 2020, jurisdictions that implemented recreational marijuana legalization before 2019 had significantly greater increases in both overall opioid and fentanyl death rates than jurisdictions with medicinal-only legalization. For all-opioids, the mean (95 percent confidence interval) 2019-to-2020 increases were 46.5 percent (36.6, 56.3 percent) and 29.1 percent (20.2, 37.9 percent), respectively (p = 0.02). For fentanyl, they were 115.6 percent (80.2, 151.6 percent) and 55.4 percent (31.6, 79.2 percent), respectively (p = 0.01). During the past decade, marijuana legalization in the US was associated at the jurisdiction level with a greater acceleration in opioid death rate. An even greater increase in opioid mortality occurred in recreational-legalizing jurisdictions with the onset of the COVID-19 pandemic. Marijuana legalization is correlated with worsening of the US opioid epidemic.

Patterns of opioid use in New Zealand older adults, 2007-2018.

Opioid use has increased globally, dramatically increasing opioid overdose, dependence, abuse and mortality. Limited research is available on opioid use patterns in older adults in New Zealand and internationally. This study aims to address this gap by determining the incidence and prevalence of opioid use among older adults (age ≥65 years) in New Zealand from 2007 to 2018. This was a population-based retrospective cohort study conducted using New Zealand national administrative healthcare databases. The annual opioid use incidence (2008-2018) and prevalence (2007-2018) in older adults were determined and stratified by sex, age, and opioid type and strength. We used descriptive statistics to summarise the patterns of opioid dispensing. Data analysis was conducted using MS Excel, and data linking was performed using SQL software. A total of 820,349 older adults were initiated on opioids during the study period. The overall incidence of opioid use in older adults showed a steady increase from 2008 to 2015; similarly, the prevalence steadily increased from 2007 to 2015, and thereafter, both rates fluctuated. A slight decrease in both prevalence and incidence rates was observed in 2018. Codeine and tramadol were the most commonly dispensed opioids during the study period. Females had a higher incidence and prevalence of all opioids than males. The incidence and prevalence of opioid dispensing increased in New Zealand older adults over time. Monitoring the trends of opioid use in older adults is critical to enable clinicians and policymakers to deliver early interventions to prevent future opioid-related adverse events.

Recreational and Medical Cannabis Legalization and Opioid Prescriptions and Mortality

While some have argued that cannabis legalization has helped to reduce opioid-related morbidity and mortality in the US, evidence has been mixed. Moreover, existing studies did not account for biases that could arise when policy effects vary over time or across states or when multiple policies are assessed at the same time, as in the case of recreational and medical cannabis legalization. To quantify changes in opioid prescriptions and opioid overdose deaths associated with recreational and medical cannabis legalization in the US. This quasiexperimental, generalized difference-in-differences analysis used annual state-level data between January 2006 and December 2020 to compare states that legalized recreational or medical cannabis vs those that did not. Recreational and medical cannabis law implementation (proxied by recreational and medical cannabis dispensary openings) between 2006 and 2020 across US states. Opioid prescription rates per 100 persons and opioid overdose deaths per 100 000 population based on data from the US Centers for Disease Control and Prevention. Between 2006 and 2020, 13 states legalized recreational cannabis and 23 states legalized medical cannabis. There was no statistically significant association of recreational or medical cannabis laws with opioid prescriptions or overall opioid overdose mortality across the 15-year study period, although the results also suggested a potential reduction in synthetic opioid deaths associated with recreational cannabis laws (4.9 fewer deaths per 100 000 population; 95% CI, -9.49 to -0.30; P = .04). Sensitivity analyses excluding state economic indicators, accounting for additional opioid laws and using alternative ways to code treatment dates yielded substantively similar results, suggesting the absence of statistically significant associations between cannabis laws and the outcomes of interest during the full study period. The results of this study suggest that, after accounting for biases due to possible heterogeneous effects and simultaneous assessment of recreational and medical cannabis legalization, the implementation of recreational or medical cannabis laws was not associated with opioid prescriptions or opioid mortality, with the exception of a possible reduction in synthetic opioid deaths associated with recreational cannabis law implementation.