Opioid Initiation Research Articles

Back Pain in the Era of Opioid Restriction and Implications for Neurosurgeons Based on Qualitative Findings From a Rural State.

Historically, back pain has been an inciting complaint for the initiation of opioids. Aggressive marketing of opioids to treat back pain coupled with the initiation of pain being treated as "the fifth vital sign" contributed to the emerging opioid crisis in the USA. West Virginia (WV) has long been considered the epicenter of the crisis. In 2018, the WV legislature passed a bill that placed prescribing limits on opioids. Our group set out to investigate the impacts of opioid prescribing restrictions through a sequential, mixed methods study evaluating prescription trends and stakeholder experiences. These stakeholder experiences generated emergent themes regarding the evolution of the opioid crisis up to and beyond the implementation of the bill, which is of relevance to neurosurgeons and back pain treatment. This study explores those findings for a neurosurgical audience. This study consisted of open-ended, semi-structured interviews with a purposive sample of 50 physicians, pharmacists, and patients in WV. Interviews were recorded and transcribed verbatim. Content analysis was utilized as the methodological orientation. Five theoretical domains relevant to the treatment of back pain emerged, describing the prevalence of opioid use, barriers to access care, the importance of opioids for function in resource-poor rural areas,disconnected and siloed care, and patient views on the impacts of pain care gaps and solutions. Spinal pain care in rural WV is complex due to identified challenges. Care siloing factors in suboptimal spinal pain care. Future work should define, implement, and assess the real-world effectiveness of treatment paradigms for the full spectrum of surgical and non-surgical back pain complaints. Neurosurgeons should be present in this arena.

Age-Related Risk of Serious Fall Events and Opioid Analgesic Use

Opioid analgesics may be associated with increased risk of falls, particularly among older adults. To quantify the age-related risk of serious fall events among adults prescribed opioids by opioid exposure, time from initiation, and daily dose. This population-based cohort study conducted in New South Wales, Australia, used data linking national pharmaceutical claims to national and state datasets, including information on sociodemographic characteristics, clinical characteristics, medicines use, health services utilization, and mortality (POPPY II study). It included adults (18 years or older) who initiated prescription opioid treatment, which was defined as no prior dispensing during the preceding 365 days, between January 1, 2005, and December 31, 2018. Data were analyzed from February to June 2023. Time-dependent periods of opioid exposure were evaluated from dispensing records. Serious fall events identified from emergency department, hospitalization, and mortality records. Negative binomial models were used to assess associations between time-dependent opioid exposure (overall, by time from initiation, and by dose), age, and risk of fall events. Models were adjusted for known fall risk factors, including other fall risk-increasing drugs, frailty risk, and prior serious fall events. The cohort comprised 3 212 369 individuals who initiated prescription opioid treatment (1 702 332 women [53%]; median [IQR] age at initiation, 49 [32-65] years). Overall, 506 573 serious fall events were identified, including 5210 fatal falls. During exposure to opioids, the risk of serious fall events was elevated among all age groups; compared with the group aged 18 to 44 years, this risk was highest among those 85 years or older (adjusted incident rate ratio, 6.35; 95% CI, 6.20-6.51). Across all age groups, the first 28 days following opioid initiation was a time of increased serious fall risk; this risk increased with age. Among individuals aged 18 to 84 years, associations were identified between higher daily opioid doses and serious fall events. The results of this cohort study suggest that prescription opioids were associated with increased risk of serious fall events among adults of all ages, with individuals 85 years or older at greatest risk. These risks should be considered when prescribing opioids, particularly for individuals with preexisting risk factors or when opioids are prescribed at higher doses. Targeted falls prevention efforts may be most effective within the first month following opioid initiation.

Opioid stewardship program implementation in rural and critical access hospitals in Arizona.

The objective of this study is to examine rural hospitals' status in implementing opioid stewardship program (OSP) elements and assess differences in implementation in emergency department (ED) and acute inpatient departments. Health administrator survey to identify the number and type of OSP elements that each hospital has implemented. Arizona critical access hospitals (CAHs). ED and acute inpatient department heads at 17 Arizona CAHs (total of 34 assessments). Implementation of 11 OSP elements, by department (ED vs inpatient) and prevention orientation (primary vs tertiary). The percentage of implemented elements ranged from 35 to 94 percent in EDs and 24 to 88 percent in acute care departments. Reviewing the prescription drug monitoring program database and offering alternatives to opioids were the most frequently implemented. Assessing opioid use disorder (OUD) and prescribing naloxone were among the least. The number of implemented elements tended to be uniform across departments. We found that CAHs implemented, on average, 67 percent of elements that prevent unnecessary opioid use and 54 percent of elements that treat OUD. Some OSP elements were in place in nearly every Arizona CAH, while others were present in only a quarter or a third of hospitals. To improve, more attention is needed to define and standardize OSPs. Equal priority should be given to preventing unnecessary opioid initiation and treating opioid misuse or OUD, as well as quality control strategies that provide an opportunity for continuous improvement.

First Response to Opioids Survey Tool (FROST): Pilot study of a brief screening tool to assess opioid use disorder risk.

Early work suggests the type of subjective experiences upon first opioid use may predict opioid use disorder (OUD) risk. This study developed and pilot-tested a brief survey to evaluate the "first response" to opioids. A cross-sectional survey research study. The survey was administered to a subsample for the second time to assess test-retest reliability. Outpatient. Convenience sample of adults treated for OUD at an opioid treatment program. A seven-question First Response to Opioids Survey Tool (FROST), developed based on the existing questionnaires and stakeholder-advisor feedback, was evaluated. Participants (N = 157) were 36.8 (standard deviation [SD] = 9.4) years old, with 79.6 percent identifying as Caucasian and 56.7 percent male. They reported opioid initiation at 20.6 (SD = 8.8) years old, with a prescription-based (78.3 percent), orally administered (66.2 percent), and illicitly procured (51.0 percent) opioids. Upon opioid initiation, positive-valence, euphoria-like subjective experiences of feeling "comfortable" (65.0 percent), "happy" (61.1 percent), "euphoria" (58.6 percent), and "energized" (44.6 percent) were common, and different (p < 0.05) from other types of subjective experiences. Among 64 individuals who answered a question about "drug-liking," 50 (78.1 percent) reported drug-liking. Among 31 respondents who completed the survey a second time, the test-retest consistency was 78.2 percent for subjective experience characteristics and 72 percent for drug-liking responses. Qualitative results corroborated quantitative findings. These results suggest that euphoria-type experiences and drug-liking upon opioid initiation are common among adults with OUD and FROST's promising psychometric properties. Future research should assess clinical utility of this brief survey, which could be applied at bedside and help identify those at risk for OUD, guide safer opioid prescribing, and reduce opioid-related harm.

Investigating the efficacy and safety of olanzapine prophylaxis for opioid-induced nausea and vomiting (JORTC-PAL20): a study protocol for an open-label, single-arm exploratory study

IntroductionIn opioid therapy for cancer pain, opioid-induced nausea and vomiting (OINV) occur in 20%–40% of patients during initial opioid treatment or increasing opioid doses. OINV result in failure to achieve...

Getting what you pay for: impact of copayments on physical therapy and opioid initiation, timing, and continuation for newly diagnosed low back pain

BACKGROUND CONTEXTPhysical therapy (PT) is an important component of low back pain (LBP) management. Despite established guidelines, heterogeneity in medical management remains common. PURPOSEWe sought to understand how copayments impact timing and utilization of PT in newly diagnosed LBP. STUDY DESIGN/SETTINGThe IBM Watson Health MarketScan claims database was used in a longitudinal setting. PATIENT SAMPLEAdult patients with LBP. OUTCOME MEASURESThe primary outcomes-of-interest were timing and overall utilization of PT services. Additional outcomes-of-interest included timing of opioid prescribing. METHODSActual and inferred copayments based on nonnonprimary care provider visit claims were used to evaluate the relationship between PT copayment and incidence of PT initiation. Multivariable regression models were used to evaluate factors influencing PT usage. RESULTSOverall, 2,467,389 patients were included. PT initiation, among those with at ≥1 PT service during the year after LBP diagnosis (30.6%), occurred at a median of 8 days postdiagnosis (IQR 1–55). Among those with at least one PT encounter, incidence of subsequent PT visits was significantly lower for those with high initial PT copayments. High initial PT copayments, while inversely correlated with PT utilization, were directly correlated with subsequent opioid use (0.77 prescriptions/patient [$0 PT copayment] versus 1.07 prescriptions/patient [$50–74 PT copayment]; 1.15 prescriptions/patient [$75+ PT copayment]). Among patients with known opioid and PT copayments, higher PT copayments were correlated with faster opioid use while higher opioid copayments were correlated with faster PT use (Spearman p<.05). For multivariable whole-cohort analyses, incidence of PT initiation among patients with inferred copayments in the 50–75th and 75–100th percentiles was significantly lower than those below the 50th percentile (HR=0.893 [95%CI 0.887–0.899] and HR=0.905 [95%CI 0.899–0.912], respectively). CONCLUSIONSHigher PT copayments correlated with reduced PT utilization; higher PT copayments and lower opioid copayments were independent contributors to delayed PT initiation and higher opioid use. In patients covered by plans charging high PT copayments, opioid use was significantly higher. Copays may impact long-term adherence to PT.

Pathways to opioid use and implications for prevention: voices of young adults in recovery

BackgroundOpioid use remains a major public health issue, especially among young adults. Despite investment in harm reduction and supply-side strategies such as reducing overprescribing and safe medication disposal, little is known about demand-side issues, such as reasons for use and pathways to opioid use. Adolescents and young adults who struggle with opioid use disorder (OUD) are multifaceted individuals with varied individual histories, experiences, challenges, skills, relationships, and lives.MethodsTo inform the development of prevention strategies that hold promise for addressing opioid use, this study employs brief structured surveys and semi-structured in-depth interviews with 30 young adults (ages 18–29; 19 female, 23 White, 16 from Suburban areas) in recovery from OUD. For survey data, we used descriptive statistics to summarize the means and variance of retrospectively reported risk and protective factors associated with opioid use. For in-depth interview data, we used a combination of thematic analysis and codebook approaches to generate common themes and experiences shared by participants.ResultsSurveys revealed that the most endorsed risk factors pertained to emotions (emotional neglect and emotional abuse) followed by sexual abuse, physical abuse, and physical neglect. Themes generated from qualitative analyses reveal challenging experiences during adolescence, such as unaddressed mental health, social, and emotional needs, which were often reported as reasons for opioid initiation and use. Through surveys and interviews, we also identified positive assets, such as skills and social relationships that were present for many participants during adolescence.ConclusionImplications include the need for universal prevention strategies that include emotion-focused interventions and supports alongside current harm reduction and environmental strategies to regulate prescriptions; the potential utility of more emotion-focused items being included on screening tools; and more voices of young people in recovery.

Nine recommendations for the emergency department for patients presenting with low back pain based on management and post-discharge outcomes in an Australian, tertiary emergency department.

To ascertain and develop recommendations for analgesic management, discharge planning and further healthcare utilisation of adults presenting to an Australian tertiary ED with radicular or low back pain (LBP). This prospective cohort study included adults presenting with non-specific LBP or radicular pain to an Australian tertiary ED. Participants with trauma/cancer-related pain, and those requiring hospital admission or surgical interventions were excluded. The primary outcome was pharmacological and non-pharmacological management delivered in ED, retrospectively collected via electronic medical records. The secondary outcomes include discharge management use, and changes made due to post-discharge healthcare utilisation, as observed by weekly telephone questionnaires over 4-weeks follow-up. Of the 100 participants recruited, 94 completed follow-up. In ED, pharmacological management was received by 85%, including opioids (62%) and non-steroidal anti-inflammatory drugs (NSAIDS, 63%). Non-pharmacological management was received by 73%, including patient education (71%) and exercise prescription (37%). In the first-week post-discharge, changes to initial discharge plan occurred in 50%, mostly carried out by GPs (76%). Over the follow-up period, 51% received additional investigations/referrals. Pharmacological use decreased by 38% and non-pharmacological use decreased by 10%. 16% of opioid-naïve patients continued using opioids 4-weeks post-discharge. ED presentations for LBP were more often treated pharmacologically than non-pharmacologically, with opioids commonly prescribed and NSAIDs potentially under-utilised. Post-discharge, additional investigations/referrals, discharge analgesia reductions and maintenance of non-pharmacological management were common. Opioid initiation as a result of LBP presentations, signifies a potential 'gateway' towards unintentional long-term use. Key study findings form our nine recommendations to inform ED LBP pain management.

Inpatient Use of Extended-Release (ER) Opioids for Vaso-Occlusive Crisis Associated with Increased Length of Stay for ER Opioid-Naïve Patients

Background: The intermittent acute pain syndrome associated with sickle cell disease (SCD) is a poorly understood phenomenon with complex pathophysiology. Given the broad spectrum of analgesic interventions, including immediate-release (IR) and extended-release (ER) opioids, healthcare providers are challenged with the task of safely and effectively escalating inpatient opioid regimens, especially in the setting of limited guidelines outlining the combination of different opioid formulations. Despite SCD being the most common genetic disorder in the United States, more research is required to improve physician expertise with appropriate and timely pain management of vaso-occlusive crisis. Methods: This study was a retrospective chart review (n=200) of patients with known SCD requiring hospitalization for acute pain secondary to vaso-occlusive crisis without an alternative etiology of pain symptoms. The review included a patient population aged 18-67 years old with 43.5% males and 56.5% females hospitalized from 2/1/2022 to 5/6/2022. The primary outcome measure was hospital length of stay (LOS) for adequate pain control compared against varying factors of inpatient opioid-prescribing practices, including initiation or continuation (if prescribed within 6 months prior to admission encounter per PDMP review) of an ER opioid formulation, degree of morphine milligram equivalents (MME) escalation from outpatient regimen, utilization of a sickle cell analgesic order set, and initiation of patient-controlled analgesia pump (PCA). A secondary outcome measure investigated was the quantitative comparison of highest daily prescribed MME in relation to the aforementioned inpatient variables. Data analysis was completed using Wilcoxon Rank Summary analysis, with a significant p-value set to &amp;lt; 0.05. Results: Among the primary outcome analysis, the only significant factor affecting LOS was the introduction of an ER opioid. The results show that within the patient cohort naïve to an outpatient ER opioid (n=105), ER opioid-incorporated inpatient analgesic regimens resulted in a significantly increased mean LOS compared to IR opioid monotherapy regimens, with an average of 8.8 inpatient days as compared to 5.3 days, respectively (p-value &amp;lt; 0.001). For the patients prescribed an outpatient ER opioid at baseline (n=95), the continuation of an inpatient ER opioid did not result in a significant change in mean LOS, calculated as 6.7 days vs. 6.0 days in the continued and non-continued groups, respectively (p-value = 0.716). Among the secondary outcome measures, utilization of a sickle cell order set and PCA did not significantly affect degree of MME escalation. Conclusions: Limited evidence-based recommendations for the treatment of acute pain episodes in SCD has resulted in widely varying opioid regimens prescribed by inpatient providers and has created clinical challenges regarding the optimization of pain management. This study investigated inpatient opioid regimens utilized in treatment of vaso-occlusive crisis and found that the initiation of ER opioids resulted in increased length of stay for ER opioid-naïve patients as compared to treatment with IR opioids alone. These results question the benefit of inpatient ER opioids in relation to the risk of opioid dependence and MME escalation.

Delayed Management of Sickle Cell Disease Vaso-Occlusive Episodes and the Impact on Prolonged Hospitalizations at a Single Academic Center

Introduction: Sickle Cell Disease (SCD) affects nearly 100,000 people in the United States (Centers for Disease Control and Prevention, 2023). Vaso-occlusive episode (VOE) is the most common reason for hospitalization in SCD. Many providers are unfamiliar with the pain management timing and dosages required to adequately treat these episodes (Jang et al., J Transl Med 2021). Nationally, areas with comprehensive sickle cell centers have shown decreased hospital utilization, fewer VOEs, and improved quality of life (Oyedeji et al. JAMA 2020). Even in areas without a comprehensive center, implementing individualized pain care plans for SCD has reduced admission rates of high-utilizing patients while not impacting their pain rating scores (Welch-Coltrane et al. Pain Medicine 2021). Our academic hospital, Oregon Health and Science University (OHSU), lacks a comprehensive SCD center and VOE treatment plans are not easily accessible for these patients. We conducted a retrospective analysis on a cohort of patients with SCD to investigate the factors influencing the length of emergency department (ED) and hospital stays for VOE. We aim to identify if implementing individualized pain plans via a standardized template within the electronic health record (EHR) for these patients will decrease hospital admission, length of stay and time to ED discharge. We also aim to integrate individualized pain plans into the EHR that would allow for direct exposure to the care team by creating plans that are easily accessible, reviewed, and routinely utilized for clinical decision-making. Methods: We performed a preliminary retrospective analysis of encounters (n=107) from 2008-2023 at OHSU, where the primary diagnosis was either a VOE or an equivalent diagnosis. Based on data demonstrating earlier maximum opioid doses leading to shortened hospital stays in frequent pain patients, we recorded the timing of the first opioid and morphine milliequivalents per hour in the first 24 hours (Payne et al. Pediatr Blood Cancer 2018). Additionally, we recorded the length of stay, admission rates, time to first IV fluid, and the type of IV fluid used. We performed a linear regression analysis on the collected data with the dependent variable as the length of stay across the independent variables of time to first opioid, time to first intravenous fluid, and morphine milliequivalents per hour during the first 24 hours after presentation. Results: Eighteen patients accounted for the 107 analyzed encounters. Thirteen patients (72%) had Hgb-SS disease, 2 (11%) had Hgb-SC disease, and 3 (17%) had Hgb-S-beta thalassemia. Sixty-two admissions (58%) were ED discharges, and 45 (42%) were ED to hospital admissions. The length of stay and time to the first opioid positively correlated with p=0.005 (Figure 1a). The length of stay and time to first intravenous fluid administration was also positively correlated with p=0.01. The length of stay and morphine milliequivalents per hour in the first 24 hours were negatively correlated with p&amp;lt;0.0001 (Figure 1b). Conclusions: Longer time to administration of opioids and intravenous fluids correlated with a longer length of stay in both the ED and the hospital. Additionally, lower morphine milliequivalents in the first 24 hours of presentation were associated with a prolonged hospital stay at our institution. We hypothesize that these three factors are secondary to delays in care and inappropriate initial treatment of VOE. To address these factors, we aim to implement standardized pain plans in the EHR of our institution. Implementation of individualized pain plans, particularly in the ED, has led to the earlier initiation of opioids (Della-Moretta et al. Ann Emerg Med 2020). We anticipate similar effectiveness for timely and appropriate fluid administration and adequate opioid dosing. We plan to continue retrospective analysis and compare this data to VOE encounters post-implementation. By implementing individualized plans that are integrated within the EHR and efficiently utilized by the care team, we hope to improve VOE management at our institution with decreased length of stay, less ED to hospital admissions, and improved patient satisfaction.

Characterizing prescription opioid, heroin, and fentanyl initiation trajectories: A qualitative study

We understand the current crisis of overdose deaths to be driven by widespread opioid use, characterized by distinct ‘waves’ of drug use. The first wave was driven by prescription opioids, the second by heroin, and the third by illicit, non-pharmaceutical fentanyl and fentanyl analogues (henceforth, fentanyl). The purpose of this study is to describe opioid initiation within each of the three waves from the perspective of people who use illicit opioids, with a focus on emerging pathways into fentanyl use. The authors recruited sixty people reporting past-30-day illicit opioid use in Dayton, Ohio. Participants completed a brief survey and a semi-structured in-depth qualitative interview, conducted from March to November 2020 with a total of 13 in-person and 47 virtual interviews. The qualitative interviews were transcribed in their entirety and analyzed thematically using NVivo 12. We noted supply-side changes as influencing trajectories in all three waves. However, we also noted differences in the experiences of prescription opioid and heroin initiation, with these trajectories influenced by pharmacological effects, pain management, curiosity, intergenerational use, pricing, and peers. In comparison, most participants were unaware that they were initiating fentanyl, and many reported overdosing with their first use of fentanyl. We identified a trajectory into fentanyl with limited to no prior heroin use among a few participants. The increased risk of overdose with initiation into fentanyl use further emphasizes the need for an expansion of naloxone distribution and the implementation of more comprehensive measures, such as overdose prevention centers, drug testing, and a safer supply. Further research on the dynamics of the ongoing overdose death crisis in the era of fentanyl and the 4th wave of the overdose crisis is critical in developing responsive prevention and intervention strategies.

Long-acting opioids as a trigger for palliative care consultation in pancreatic cancer.

252 Background: Pancreatic cancer is associated with significant symptom burden, a poor prognosis, and a poor quality of life. Early involvement of palliative care alongside standard disease modifying treatment in metastatic pancreatic cancer has been associated with improved quality of life and improved symptom burden. Receipt of opioids has been shown to improve overall survival in patients with pancreatic cancer, while escalating opioid usage has been associated with higher risk of death. Given this dichotomy in prognosis, the utilization of a long-acting opioid for cancer-related pain should warrant a palliative care consultation. Methods: This is a retrospective study conducted under an IRB-approved protocol of patients who were diagnosed with pancreatic cancer between January 1, 2021 and May 30, 2023, and who had been prescribed a long-acting opioid for cancer-related pain at our institution. Data collection including patient demographics, opioid doses, hospice utilization, date of death, and aggressive interventions at end-of-life were collected via chart review. Descriptive statistics were calculated using means and medians. Statistical methods included percentage calculations of baseline characteristics. Time from initiation of long-acting opioid to death was measured. Results: Of 51 patients surveyed, 50 met eligibility criteria for our study. The median age was 66 years (Range 42-90). Stage at diagnosis included 6 resectable, 6 borderline resectable, 12 locally advanced, and 26 metastatic. Ten were able to undergo a surgical resection. 28% of patients died within 90 days of starting a long-acting opioid. 36% died within 180 days of starting a long-acting opioid. Access to palliative care services was associated with increased utilization of medical cannabis (P=0.00001) and documentation of MOLST (Medical Orders for Life Sustaining Treatment) forms (p=0.049). Access to palliative care consultation (p=0.0007) as well as access to medical cannabis (p=0.00001) was more likely at academic main site as opposed to satellite hospitals. Conclusions: The initiation of long-acting opioids in patients with advanced pancreatic cancer should be considered as a trigger for palliative care involvement as it portends a poorer prognosis. Furthermore, even at a single institution, there were disparities in access to specialty palliative care resources. Further research needs to be conducted to optimize timing of palliative care referrals in a resource limited environment.

Changes in opioid agonist treatment initiation among people prescribed opioids for pain following voluntary and mandatory prescription drug monitoring program implementation: A time series analysis.

Prescription drug monitoring programs (PDMP) are increasingly used to identify people prescribed high-dose opioids. However, little is known about whether PDMPs impact opioid agonist treatment (OAT) uptake, the gold standard for opioid use disorder. This study examined the impact of PDMP implementation on OAT initiation among people prescribed opioids, in Victoria, Australia. De-identified electronic records from all 464 Victorian general practices included in the POLAR database were used. OAT initiation was defined as a new OAT prescription between 1 April 2017 and 31 December 2020, with no OAT prescriptions in the year prior. Interrupted time series analyses were used to compare outcomes before (April 2017 to March 2019) and after (April 2019 to December 2020) PDMP implementation. Binary logistic regression was used to examine differences in patients' characteristics associated with OAT initiation prior to and after PDMP implementation. In total, 1610 people initiated OAT, 946 before and 664 after PDMP implementation. No significant immediate (step) or longer-term (slope) changes in the rates of OAT initiation were identified following PDMP implementation, after adjusting for seasonality. A high opioid dose (>100 mg oral morphine equivalent) in the 6-months prior to OAT initiation was the only significant characteristic associated with reduced odds of OAT initiation post-PDMP implementation (odds ratio 0.29; 0.23-0.37). PDMP implementation did not have a significant impact on OAT initiation among people prescribed opioids. Findings suggest additional clinical initiatives that support OAT initiation are required to ensure PDMPs meet their intended target of reducing opioid-related harms.

Comparison of the Effects of OPRM1 A118G Polymorphism Using Different Opioids: A Prospective Study

Contextμ-opioid receptor gene (OPRM1) A118G polymorphism (rs1799971) causes loss of N-glycosylation sites at the extracellular domain of μ-opioid receptors. G-allele carriers show a limited response to morphine; however, studies investigating the impact of A118G polymorphism on the efficacy of opioids other than morphine are limited. ObjectiveTo compare the impact of A118G polymorphism on the efficacy of various opioids. MethodsThis prospective cohort study enrolled 222 in-patients administered one of the following opioid therapies for cancer pain as part of an opioid introduction or rotation strategy: tapentadol extended-release tablets, methadone tablets, hydromorphone controlled-release tablets, oxycodone controlled-release tablets, or transdermal fentanyl patches. The impact of A118G polymorphism on the difference in the Brief Pain Inventory-Short Form score on days three, seven, and 14 from baseline was compared among the groups. ResultsOverall, 81, 74, and 67 patients had the AA, AG, and GG genotypes, respectively, with an OPRM1 A118G G-allele variant frequency of 0.47. The reduction in the Brief Pain Inventory-Short Form score after opioid therapy initiation did not differ significantly among the patients with the three A118G genotypes treated with tapentadol (p = 0.84) or methadone (p = 0.97), whereas it was significantly smaller in G-allele carriers than that in AA homozygous patients treated with hydromorphone (p < 0.001), oxycodone (p = 0.031), or fentanyl (p < 0.001). ConclusionTapentadol and methadone may be more suitable than hydromorphone, oxycodone, and fentanyl for G-allele carriers due to their dual mechanism of action and low susceptibility to OPRM1 A118G polymorphism.

Incidence of opioid misuse by cigarette smoking status in the United States

BackgroundThe combination of opioid misuse and cigarette smoking contributes to increased morbidity and mortality compared to each substance use alone. We estimated the incidence of opioid misuse for persons who currently or formerly smoked versus never smoked. MethodsData came from the 2015–2020 National Surveys on Drug Use and Health cross-sectional surveys of US civilians aged 12+ (n = 315,661). Weighted opioid misuse incidence and average time between cigarette use initiation and opioid misuse initiation were calculated annually by smoking status. Logistic regression models tested time trends in incidence by smoking status. ResultsOverall, 0.75% of persons initiated opioid misuse per year; opioid misuse incidence was 1.35% for those who currently smoked cigarettes, 0.54% for those who formerly smoked, and 0.67% for those who never smoked. For persons who currently smoked and misused opioids (1.50%), 95.08% smoked prior to opioid use. The average time between smoking followed by opioid misuse was 12.93 years and for opioid misuse followed by smoking was 4.36 years. Persons who currently smoked were more likely to initiate opioid misuse than those who had never smoked (AOR = 1.81, 95% CI: 1.60, 2.06). There was a decrease in the opioid misuse incidence over time (AOR = 0.90; 95% CI: 0.85, 0.92), which did not differ by smoking status. ConclusionsPersons who currently smoked cigarettes, relative to those who never smoked, were more likely to initiate opioid misuse. As most individuals smoked before opioid misuse, it may be useful for primary prevention efforts to decrease opioid misuse initiation by focusing on smoking status.

Five-Year Trajectories of Prescription Opioid Use

There are known risks of using opioids for extended periods. However, less is known about the long-term trajectories of opioid use following initiation. To identify 5-year trajectories of prescription opioid use, and to examine the characteristics of each trajectory group. This population-based cohort study conducted in New South Wales, Australia, linked national pharmaceutical claims data to 10 national and state data sets to determine sociodemographic characteristics, clinical characteristics, drug use, and health services use. The cohort included adult residents (aged ≥18 years) of New South Wales who initiated a prescription opioid between July 1, 2003, and December 31, 2018. Statistical analyses were conducted from February to September 2022. Dispensing of a prescription opioid, with no evidence of opioid dispensing in the preceding 365 days, identified from pharmaceutical claims data. The main outcome was the trajectories of monthly opioid use over 60 months from opioid initiation. Group-based trajectory modeling was used to classify these trajectories. Linked health care data sets were used to examine characteristics of individuals in different trajectory groups. Among 3 474 490 individuals who initiated a prescription opioid (1 831 230 females [52.7%]; mean [SD] age, 49.7 [19.3] years), 5 trajectories of long-term opioid use were identified: very low use (75.4%), low use (16.6%), moderate decreasing to low use (2.6%), low increasing to moderate use (2.6%), and sustained use (2.8%). Compared with individuals in the very low use trajectory group, those in the sustained use trajectory group were older (age ≥65 years: 22.0% vs 58.4%); had more comorbidities, including cancer (4.1% vs 22.2%); had increased health services contact, including hospital admissions (36.9% vs 51.6%); had higher use of psychotropic (16.4% vs 42.4%) and other analgesic drugs (22.9% vs 47.3%) prior to opioid initiation, and were initiated on stronger opioids (20.0% vs 50.2%). Results of this cohort study suggest that most individuals commencing treatment with prescription opioids had relatively low and time-limited exposure to opioids over a 5-year period. The small proportion of individuals with sustained or increasing use was older with more comorbidities and use of psychotropic and other analgesic drugs, likely reflecting a higher prevalence of pain and treatment needs in these individuals.

Initiation of opioids increase risk of death in older adults with dementia

Initiation of opioids increase risk of death in older adults with dementia

Prescription opioid utilization patterns, and associated outcomes, among privately insured patients prescribed opioids to manage pain associated with osteoarthritis

Objective To describe utilization patterns, negative clinical outcomes and economic burden of patients diagnosed with osteoarthritis (OA) of the hip and/or knee who received a prescription for tramadol or non-tramadol opioids vs. non-opioid drugs. Methods Optum Healthcare Solutions, Inc. commercial claims data were used (1/2012--3/2017). Adults with ≥2 diagnoses of OA of the hip and/or knee, and ≥30 days supply of pain medications were identified during the three-year period from the date of first prescription (index date) after the first OA diagnosis. Drug utilization statistics in the follow-up period were summarized by initial treatment (i.e. tramadol, non-tramadol opioids, non-opioid drugs). Opioid initiators were matched to those initiated on non-opioid treatments using a propensity score model accounting for baseline characteristics. Matched pairs analysis compared outcomes for these cohorts. Results Of 62,715 total patients, 15,270 (24.3%) initiated treatment with opioids, including 3,513 (5.6%) on tramadol and 11,757 (18.7%) on non-tramadol opioids. Opioid initiators had more comorbidities, higher baseline healthcare costs, and were more likely to have OA of the hip. Among non-opioid initiators, 27.5% switched to tramadol and 63% switched to non-tramadol opioids. Among tramadol initiators, 71% switched to non-tramadol opioids. Patients initiated on opioids had 20.4% (p < .01) higher all-cause healthcare costs and higher percentages experiencing multiple negative clinical outcomes (all p < .01) compared to matched controls. Conclusions Most patients with OA of the hip and/or knee either initiate on or switch to opioids for long-term management of OA-related pain despite known risks. This highlights the need for new treatments that delay or prevent use of opioids.

Prescription Opioid Initiation for Neuropathy, Headache, and Low Back Pain: A US Population-based Medicare Study

Neuropathy, headache, and low back pain (LBP) are common conditions requiring pain management. Yet little is known regarding whether access to specialists impacts opioid prescribing. We aimed to identify factors associated with opioid initiation among opioid-naïve older adults and evaluate how access to particular specialists impacts prescribing. This retrospective cohort study used a 20% Medicare sample from 2010 to 2017. Opioid initiation was defined as a first opioid prescription filled within 12 months after a diagnosis encounter. Disease-related opioid initiation was defined as a first opioid prescription filled within 7 days following a disease-specific claim. Logistic regression using generalized estimating equations was used to determine the association of patient demographics, provider types, and regional physician specialty density with disease-related opioid initiation, accounting for within-region correlation. We found opioid initiation steadily declined from 2010 to 2017 (neuropathy: 26–19%, headache: 31–20%, LBP: 45–32%), as did disease-related opioid initiation (4–3%, 12–7%, 29–19%) and 5 to 10% of initial disease-related prescriptions resulted in chronic opioid use within 12 months of initiation. Certain specialist visits were associated with a lower likelihood of disease-related opioid initiation compared with primary care. Residence in high neurologist density regions had a lower likelihood of disease-related opioid initiation (headache odds ratio [OR] .76 [95% CI: .63–.92]) and LBP (OR .7 [95% CI: .61–.81]) and high podiatrist density regions for neuropathy (OR .56 [95% CI: .41–.78]). We found that specialist visits and greater access to specialists were associated with a lower likelihood of disease-related opioid initiation. These data could inform strategies to perpetuate reductions in opioid use for these common pain conditions. PerspectiveThis article presents how opioid initiation for opioid-naïve patients with newly diagnosed neuropathy, headache, and LBP varies across providers. Greater access to certain specialists decreased the likelihood of opioid initiation. Future work may consider interventions to support alternative treatments and better access to specialists in low-density regions.

Major adverse cardiovascular events and mortality with opioids versus NSAIDs initiation in patients with rheumatoid arthritis

ObjectiveAssess major adverse cardiovascular event (MACE) risk with opioids compared with non-steroidal anti-inflammatory drugs (NSAIDs) in patients with rheumatoid arthritis (RA)MethodsWe conducted a new-user active comparator cohort study among patients...