Opioid Injection Research Articles

Transition from injecting opioids to smoking fentanyl in San Francisco, California

BackgroundThe introduction of illicitly made fentanyl in the United States has slowly replaced heroin. New illicit drugs are often associated with changes in frequency and modes of administration. We assessed changes in injection frequency and smoking fentanyl in the new era of fentanyl availability in San Francisco. MethodsWe used targeted sampling to recruit 395 people who inject drugs (PWID) into an observational cohort study in San Francisco 2018–2020. We assessed changes in injection frequency, opioid injection frequency and fentanyl smoking frequency in four six-month periods. We also conducted qualitative interviews with PWID asking about motivations for injecting and smoking opioids. ResultsThe median number of past-month injections steadily decreased by semi-annual calendar year from 92 injections in July to December 2018 to 17 injections in January to June 2020. The rate of opioid injections reduced by half (Adjusted Incidence Rate Ratio = 0.41; 95 % Confidence Interval = 0.25, 0.70; p < 0.01). The number of days smoking fentanyl was associated with fewer number of injections (X2(2) = 11.0; p < 0.01). Qualitative interviews revealed that PWID’s motivation for switching from injecting tar heroin to smoking fentanyl was related to difficulties accessing veins. After switching to smoking fentanyl, they noticed many benefits including how the drug felt, improved health, fewer financial constraints, and reduced stigma. ConclusionBetween 2018 and 2020, there was a shift from injecting tar heroin to smoking fentanyl in San Francisco. Reductions in injection of illicit drugs may offer public health benefit if it reduces risk of blood-borne viruses, abscesses and soft-tissue infections, and infective endocarditis.

Prevalence of Hepatitis C Virus Infection Identified From Nontargeted Screening Among Adult Visitors in an Academic Appalachian Regional Emergency Department.

BackgroundWe describe the initial results of an adult academic emergency department (ED) nontargeted hepatitis C virus (HCV) screening program serving Appalachia, which is disproportionately affected by the opioid epidemic.MethodsThe study was a retrospective screening study of ED systematic, nontargeted, opt-out HCV testing outcomes from July 2018 through September 2020. Eligibility requirements for “nontargeted” HCV testing included age ≥18 years, verbally able to communicate, receiving bloodwork already as part of routine clinical care, and not opting out of testing. For eligible individuals who did not opt out of testing, an HCV antibody (Ab) test was performed. Reactive Ab tests were confirmed with reflexive HCV RNA testing. The primary study outcome was the characterization of HCV Ab and RNA prevalence.ResultsThere were 75 722 unique adult visitors during the period studied. Of these, 54 931 individuals were verbally engaged regarding testing and did not opt out. A total of 34 848 individuals received HCV Ab testing, with 3665 patients (10.5%) having reactive results. RNA confirmatory testing was reflexively performed in all Ab-positive patients, with 1601 (50.3%) positive. The majority of HCV Ab– and RNA-positive patients were young, born after 1965, and were more likely to be White, male, Medicaid insured, and report a history of injection drug use.ConclusionsED nontargeted, opt-out testing can identify a high prevalence of HCV infection among adult visitors. HCV infection was disproportionately high among younger, White individuals, likely reflecting the escalating syndemic of opioid injection and HCV transmission in Appalachia.

Excipient-Induced Pulmonary Vascular Disease: An Underrecognized and Deadly Complication of Opioid Addiction.

Despite widespread public health concern regarding opioid misuse and overuse, there is a paucity of literature on the acute and chronic pulmonary vascular and cardiac implications of excipient lung disease. This case series describes the clinical presentation of five adult patients who experienced profound pulmonary hypertension and right heart failure in the setting of confirmed or suspected crushed opioid injection at a single academic center between 2012 and 2019. The clinical characteristics and right heart catheterization data presented in these cases demonstrate the acute intravascular effects of the intravenous injection of crushed opioids and potential for hemodynamic collapse. Moreover, these cases suggest that survivors of acute excipient lung disease may develop chronic pulmonary vascular disease. Further studies are needed to explore the epidemiology and outcomes of oral opioid-induced intravascular excipient lung disease to increase awareness of this life-threatening complication among health care professionals and guide treatment and prevention measures.

Erector spinae plane blockade in the complex of anesthesia support of aldosteroma surgery

BACKGROUND: The only radical method of treatment of hormonally active adrenal tumors is retroperitoneoscopic adrenalectomy. The modern approach dictates the principles of multimodal analgesia, and avoidance of narcotic analgesics. On the other hand, early activation of such patients in the postoperative period entails a more pronounced postoperative pain syndrome. The relevance of these problems makes us think about better tactics of perioperative management of such patients.&#x0D; AIM: Feasibility of ESP blockade as a component of analgesia during retroperitoneoscopic surgeries for aldosteroma.&#x0D; MATERIALS AND METHODS: A randomized study was conducted in 41 patients who underwent retroperitoneoscopic adrenalectomy for aldosteroma. The patients were divided into 2 groups. In the 1st group the operation was carried out under combined anesthesia with Desflurane inhalation and perioperative analgesia by systemic injection of opioids; in the 2nd group the operation was carried out under combined anesthesia with Desflurane inhalation in combination with fascial blockade of the rectifying spine muscle at the operation site by 0.35% Ropivacaine solution.&#x0D; RESULTS: The use of ESP blockade as an analgesic component of combined anesthesia is indicated for retroperitoneoscopic surgeries for aldosteroma. Firstly, its implementation excludes the use of opioids during anesthesia, which allows to implement the principles of accelerated rehabilitation surgery (ERAS). Secondly, low-flow Desflurane inhalation combined with ESP blockade provides adequate anesthesia during unilateral adrenalectomy for aldosteroma. Thirdly, the analgesic effect of ESP blockade extends to the early postoperative period.&#x0D; CONCLUSIONS:&#x0D; The use of ESP block in combination with low flow Desflurane inhalation can be considered as the anesthesia method of choice for retroperitoneoscopic adrenalectomy for aldosteroma.&#x0D; This technology allows to implement ERAS principles.&#x0D; The use of ESP block reduces the number of postoperative complications associated with the use of narcotic analgesics.

PIN24 Cost-Effectiveness of Syringe Service Programs and Medications for Opioid Use Disorder in Reducing the Risk of Hepatitis C Among Opioid Injection Drug Users in the United States

The overall prevalence of hepatitis C (HCV) among injection drug users (IDUs) in the United States is estimated at about 53%. Harm-reduction strategies like syringe service programs (SSP) and medications for opioid use disorder (MOUD) are effective in reducing HCV acquisition risk, and a combination of both provides an additive effect. This research aims to evaluate the cost-effectiveness of SSP alone, MOUD alone, and SSP+MOUD combination in preventing HCV cases among opioid IDUs in the United States.

Fentanyl, but not Morphine, Increases Cortical Electroencephalographic (EEG) Delta Power during Wakefulness in C57BL/6J (B6) Mice

Cortical EEG signals comprise differing oscillations that represent lower-level traits characteristic of higher-level behavioral phenotypes such as sleep and wakefulness (Physiology 32:60, 2017). Opioid-induced changes in neurobehavioral function also are reflected in altered EEG frequency and amplitude. These EEG features have the potential to provide insights regarding the desired actions and undesired side effects of opioids. In rat, morphine (Anesthesiology 103:779, 2005) and fentanyl (Sci Rep 9:14122, 2019) increase EEG slow waves. Studies of mice provide the additional opportunity to use mutated or transgenic animals with features potentially relevant to respiratory depression or addiction. This study is testing the hypothesis that subcutaneous injection of fentanyl and morphine causes dose-dependent EEG changes in wild-type mice. Experiments were conducted in accordance with the FASEB Statement of Principles for the use of Animals in Research and Education. Adult male B6 mice (n = 4) were implanted with telemeters (DSI HD-X02) for wireless recording of cortical EEG and neck muscle electromyogram. The recordings were used to quantify the effects of opioids on sleep and wakefulness. These studies demonstrated dose-dependent sleep disruption by both opioids (see companion abstract by Zebadua Unzaga et al.). EEG data were digitized by DSI Ponemah software and analyzed using public domain software for creating multi-tapered EEG spectrograms (J Vis Exp 153:e60333, 2019). Analyses were based on EEG data from the first 30 min after opioid injection, when all mice were awake. EEG power was expressed as percent change relative to saline (vehicle control) for six frequency bands: delta (0.5 to 4 Hz), theta (4 to 8 Hz), alpha (8 to 13 Hz), sigma (12 to 15 Hz), beta (13 to 30 Hz), and gamma (30 to 60 Hz). Increasing half log doses (mg/kg) ranged from 0.001 to 3 for fentanyl and 0.01 to 30 for morphine. Repeated measures ANOVA with the Geisser-Greenhouse correction showed a significant dose main-effect of fentanyl on EEG delta power (F(1.857, 5.571) = 7.454, p = 0.0276) and alpha power (F(1.705, 5.116) = 6.316, p = 0.0439). For fentanyl (3 mg/kg) compared to saline, Cohen's d = 2.9 for delta power. By contrast, for morphine there was a significant main effect of dose only for EEG sigma power (F(2.162, 6.486) = 6.557, p = 0.0265). Comparing morphine (30 mg/kg) to saline, the Cohen's d = 1.1 for sigma power. Although both fentanyl and morphine are full mu-opioid receptor agonists, they significantly altered EEG power at different frequency bands. Fentanyl, but not morphine, blocks alpha-1 adrenergic receptor subtypes and vesicular reuptake of several monoamine transmitters (J Pharmacol Exp Ther 343:376, 2020). These results support the interpretation that the differential effects of fentanyl and morphine on EEG power may be due, in part, to non-mu-opioid receptor of fentanyl.

Аналіз випадків смертельних отруєнь наркотичними та психотропними речовинами в Україні за результатами епідемічних, клінічних, судово-медичних і лабораторних досліджень (2015–2019 рр.)

Актуальність. На сьогодні в Україні гострі отруєння наркотичними та психотропними речовинами є вкрай актуальною медико-соціальною проблемою, далекою від вирішення. Мета дослідження — аналіз випадків смертельних отруєнь наркотичними та психотропними речовинами, спрямований на пошук заходів з підвищення ефективності системи охорони здоров’я з надання медичної допомоги при гострих побутових отруєннях. Матеріали та методи. Досліджено медичні дані пацієнтів з діагнозом «гостре наркотичне отруєння» (Міжнародна класифікація хвороб 10-го перегляду: Т40.0–Т40.3); дані Державної служби статистики України та Центру медичної статистики Міністерства охорони здоров’я України; звіти бюро судово-медичних експертиз. Лабораторні дослідження здійснено за допомогою імунохроматографічного аналізу і хромато-мас-спектрометрії (прилад — Aligent 6850/5973N, колонка — HP-5MS). Використана програма Statistica 12.6 (Windows 10/7). Результати. За 2015–2019 рр. в лабораторії Київського токсикологічного центру було виявлено більше 40 груп речовин, що призвели до гострих отруєнь, а кількість позитивних тестів зросла в 2,3 раза. Лідерами в структурі наркотиків визначені метадон, героїн і морфін. За 2014–2018 рр. в Україні зареєстровано 1365 смертей внаслідок отруєнь наркотичними та психотропними речовинами, зокрема у 2018 році — 399 випадків, 90,5 % становили чоловіки (361 випадок) та 9,5 % — жінки (38 випадків). Серед 355 випадків смертей отруєння опіоїдами становили 153 (кодеїн та морфін — 54 випадки (43,1 %), метадон — 76 випадків (21,4 %), опій — 15 випадків (4,2 %), синтетичні опіоїди — 8 випадків (2,3 %)). Серед 144 випадків смертей від отруєнь іншими наркотиками 31 (21,5 %) — отруєння психодислептиками (галюциногенами), 2 (1,4 %) — отруєння кокаїном та 5 (3,5 %) — отруєння психостимуляторами. Кількість смертей у 2018 році порівняно з даними 2017 року зросла в 1,5 раза, отруєння метадоном — у 2,5 раза, а отруєння неідентифікованими наркотиками — у 3 рази. В Україні у 2018 році частота смертей, пов’язаних зі вживанням наркотичних та психотропних речовин, та отруєнь ними серед населення віком від 15 до 64 років становила 10 осіб на кожен 1 000 000 населення. Висновки. Результати досліджень, здійснених різними державними установами в період 2014–2019 рр., свідчать про загрозливу динаміку збільшення як числа випадків отруєнь наркотичними та психотропними речовинами, так і збільшення їх різноманіття, наслідком чого є прогресивне зростання показників летальності і смертності, переважно серед населення чоловічої статі віком 25–44 років.

Multimodal Analgesia Decreases Postoperative Opioid Consumption in Living Liver Donation.

ObjectiveTo evaluate the effects of multimodal analgesia on postoperative opioid consumption and perioperative pain management in patients undergoing living liver donation.MethodsA retrospective study was conducted of 129 patients who underwent living liver donation between 2006 and 2015. Patients were separated into 2 cohorts, pre–multimodal analgesia and multimodal analgesia, to allow intergroup analysis. All patients received an intrathecal opioid injection and underwent donor hepatectomy. Primary outcome data compared opioid consumption in oral morphine equivalents for postoperative days (PODs) 0 to 4 between the cohorts. Secondary outcomes compared yearly averaged cumulative opioid consumption on PODs 0 to 4 in oral morphine equivalents; yearly averaged numeric rating scale pain scores; hospital length of stay; and percentage of patients receiving intravenous ketorolac, ketamine, or transversus abdominis plane blocks.ResultsFor PODs 0 to 4, a 50% reduction in overall opioids administered postoperatively (359 mg vs 179 mg; P<.01) was observed in the multimodal analgesia cohort, whereas no significant difference was found in year-to-year average postoperative pain scores (4.5 vs 3.6). The proportion of patients receiving ketorolac increased to more than 90% by 2013. More than 40% of all patients in the multimodal analgesia group received a perioperative regimen of acetaminophen, gabapentin, ketamine, and transverse abdominal plane blocks (0% in pre–multimodal analgesia). Mean hospital length of stay was reduced from 7.7 to 6.6 days (P<.01).ConclusionImplementation of multimodal analgesia to manage perioperative pain in living liver donation resulted in a 50% reduction of postoperative opioid consumption. Clinically satisfactory average pain scores were maintained for PODs 0 to 4.

Intravenous Lignocaine-Fentanyl Versus Epidural Ropivacaine-Fentanyl for Postoperative Analgesia After Major Abdominal Oncosurgery: A Pilot Prospective Randomised Study.

ObjectiveEpidural injection of local anaesthetics and intravenous opioid injection are two common analgesic strategies following major abdominal oncosurgery. However, epidural local anaesthetics may cause haemodynamic instability while opioid injection is associated with sedation and postoperative ileus. Intravenous lignocaine is also used for postoperative analgesia, and combined use of opioids plus lignocaine can reduce the doses and adverse effects of the individual drugs. This study therefore compared the analgesic efficacy of intravenous lignocaine–fentanyl (IV) to epidural ropivacaine–fentanyl (EPI) after major abdominal oncosurgery.MethodsSixty patients were randomised to IV and EPI groups. Patients in the IV group received preoperative intravenous bolus injections of lignocaine 1.5 mg kg−1 and fentanyl 0.5 μg kg−1, intraoperative infusions of lignocaine 1 mg kg−1 h−1 and fentanyl 0.5 μg kg−1 h−1, and postoperative infusions of lignocaine 0.5 mg kg−1 h−1 and fentanyl 0.25 μg kg−1 h−1. In the EPI group, patients received a 6-ml epidural bolus injection of ropivacaine 0.2% plus fentanyl 2 μg mL−1, intraoperative infusion of 5 mL·h−1 fentanyl and postoperative ropivacaine 0.1% plus fentanyl 1 μg mL−1 infusion at 5 mL h−1. All patients also received postoperative patient-controlled IV fentanyl as rescue analgesia. Patient-controlled fentanyl consumption was documented as the primary outcome for postoperative analgesic efficacy. Results were compared by Mann–Whitney U-test and Student’s t-test using Statistical Package for Social Science (SPSS) software.ResultsMedian (min–max) rescue fentanyl requirement in the first 24 h postsurgery was comparable between IV and EPI groups [780 (340–2520) μg vs. 820 (140–2260) μg; p=0.6], as was postoperative pain score (p>0.05). The incidence of intraoperative hypotension requiring bolus mephenteramine injection was significantly higher in the EPI group than the IV group (36% vs. 17%; p<0.001).ConclusionIntravenous lignocaine–fentanyl and epidural ropivacaine–fentanyl have comparable postoperative analgesic efficacies after major open abdominal oncosurgery.

Prevalence and Medication Treatment of Opioid Use Disorder Among Primary Care Patients with Hepatitis C and HIV.

Hepatitis C and HIV are associated with opioid use disorders (OUD) and injection drug use. Medications for OUD can prevent the spread of HCV and HIV. To describe the prevalence of documented OUD, as well as receipt of office-based medication treatment, among primary care patients with HCV or HIV. Retrospective observational cohort study using electronic health record and insurance data. Adults ≥ 18years with ≥ 2 visits to primary care during the study (2014-2016) at 6 healthcare systems across five states (CO, CA, OR, WA, and MN). The primary outcome was the diagnosis of OUD; the secondary outcome was OUD treatment with buprenorphine or oral/injectable naltrexone. Prevalence of OUD and OUD treatment was calculated across four groups: HCV only; HIV only; HCV and HIV; and neither HCV nor HIV. In addition, adjusted odds ratios (AOR) of OUD treatment associated with HCV and HIV (separately) were estimated, adjusting for age, gender, race/ethnicity, and site. The sample included 1,368,604 persons, of whom 10,042 had HCV, 5821 HIV, and 422 both. The prevalence of diagnosed OUD varied across groups: 11.9% (95% CI: 11.3%, 12.5%) for those with HCV; 1.6% (1.3%, 2.0%) for those with HIV; 8.8% (6.2%, 11.9%) for those with both; and 0.92% (0.91%, 0.94%) among those with neither. Among those with diagnosed OUD, the prevalence of OUD medication treatment was 20.9%, 16.0%, 10.8%, and 22.3%, for those with HCV, HIV, both, and neither, respectively. HCV was not associated with OUD treatment (AOR = 1.03; 0.88, 1.21), whereas patients with HIV had a lower probability of OUD treatment (AOR = 0.43; 0.26, 0.72). Among patients receiving primary care, those diagnosed with HCV and HIV were more likely to have documented OUD than those without. Patients with HIV were less likely to have documented medication treatment for OUD.

Cost-effectiveness of syringe service programs, medications for opioid use disorder, and combination programs in hepatitis C harm reduction among opioid injection drug users: a public payer perspective using a decision tree.

BACKGROUND: The hepatitis C virus (HCV) prevalence rate among injection drug users (IDUs) in North America is 55.2%, with 1.41 million individuals estimated to be HCV-antibody positive. Studies have shown the effectiveness of syringe service programs (SSPs) alone, medications for opioid use disorder (MOUD) alone, or SSP+MOUD combination in reducing HCV transmission among opioid IDUs. OBJECTIVE: To evaluate the cost-effectiveness of SSP alone, MOUD alone, and SSP + MOUD combination in preventing HCV cases among opioid IDUs in the United States. METHODS: We used a decision tree analysis model based on published literature and publicly available data. Effectiveness was presented as the number of HCV cases avoided per 100 opioid IDUs. A micro-costing approach was undertaken and included both direct medical and nonmedical costs. Cost-effectiveness was assessed from a public payer perspective over a 1-year time horizon. It was expressed as an incremental cost-effectiveness ratio (ICER) and an incremental cost savings per HCV case avoided per 100 opioid IDUs compared with cost savings with "no intervention." Costs were standardized to 2019 U.S. dollars. RESULTS: The incremental cost savings per HCV case avoided per 100 opioid IDUs compared with no intervention were as follows: SSP + MOUD combination = $347,573; SSP alone = $363,821; MOUD alone = $317,428. The ICER for the combined strategy was $4,699 compared with the ICER for the SSP group. Sensitivity analysis showed that the results of the base-case cost-effectiveness analysis were sensitive to variations in the probabilities of injection-risk behavior for the SSP and SSP + MOUD combination groups, probability of no HCV with no intervention, and costs of MOUD and HCV antiviral medications. CONCLUSIONS: The SSP + MOUD combination and SSP alone strategies dominate MOUD alone and no intervention strategies. SSP had the largest incremental cost savings per HCV case avoided per 100 opioid IDUs compared with the no intervention strategy. Public payers adopting the SSP + MOUD combination harm-reduction strategy instead of SSP alone would have to pay an additional $4,699 to avoid an additional HCV case among opioid IDUs. Although these harm-reduction programs will provide benefits in a 1-year time frame, the largest benefit may become evident in the years ahead. DISCLOSURES: This research had no external funding. The authors declare no financial interests in this article. Ijioma is a Health Economics and Outcomes Research (HEOR) postdoctoral Fellow with Virginia Commonwealth University and Indivior. Indivior is a pharmaceutical manufacturer of opioid addiction treatment drugs but was not involved in the design, analysis, or write-up of the manuscript.

Modern anesthesia in obstetrics as a component of the concept of safe anesthesia

Background. Anesthesia should be selected individually for each labor. Systemic analgesia of labor includes suggestive analgesia, narcotic analgesics, local infiltration and regional blockade, inhalation analgesia. It should be noted that there is no analgesic, sedative or local anesthetic that does not penetrate the placenta, affecting the fetus in any way.&#x0D; Objective. To describe modern anesthesia in obstetrics.&#x0D; Materials and methods. Analysis of literature sources on this issue.&#x0D; Results and discussion. Three groups of antispasmodics are used for analgesia: neurotropic (atropine, scopolamine), myotropic (papaverine, drotaverine) and neuromyotropic (baralgin). The main non-steroidal anti-inflammatory drugs used for this purpose include metamizole sodium, ketorolac tromethamine, diclofenac sodium. Inhalation autoanalgesia with nitrous oxide (N2O) is effective only in 30-50 % of women. When the concentration of N2O exceeds 50 %, the sedative effect increases and oxygenation decreases, which leads to the loss of consciousness and protective laryngeal reflexes. Such analgesia is indicated for low-risk patients who have refused from regional anesthesia. Epidural anesthesia (EDA) is the gold standard of labor anesthesia. The advantages of EDA include the option to change the degree of analgesia, the ability to continue pain relief until the end of labor and the minimal impact on the condition of both child and mother. Before manipulation, be sure to determine the platelet count and heart rate of the fetus. It is recommended to start EDA in the latent stage of labor. In patients with uterine scarring, early EDA is a mandatory component of medical care. The woman’s wish is the main indication for EDA. Indications for early catheterization of the epidural space include the presence of twins, preeclampsia, obesity, respiratory tract with special features. Headache is the most common complication of EDA. The use of pencil-point spinal needles minimizes the frequency of this complication. Adequate analgesia for uncomplicated labor should be performed with minimal concentrations of anesthetics with the least possible motor block. Local anesthetics (lidocaine, bupivacaine (Longocaine, “Yuria-Pharm”), ropivacaine) are used for EDA). Combined spinal-epidural anesthesia provides a rapid effect and long-term analgesia. For this purpose, 0.25 % Longocaine heavy (“Yuria-Pharm”) 2 mg and fentanyl 20 μg are administered intrathecally, followed by 0.225 % Longocaine 10 mg and fentanyl 20 μg epidurally. The technique of epidural dural puncture is a modification of combined spinal-epidural anesthesia. This technique improves the caudal spread of analgesia compared to the epidural technique without the side effects seen with spinal-epidural anesthesia. The ideal local anesthetic should be safe for both mother and fetus, provide sufficient analgesia with minimal motor block, and not affect labor process. A single spinal injection of opioids may be effective, but it should be limited in time. The use of systemic opioids during labor increases the need for resuscitation of newborns and worsens the condition of their acid-base balance compared to basic regional anesthesia. Catheter techniques can be used in case of the increased labor duration. Nalbuphine (“Yuria-Pharm”), which eliminates the side effects of regional anesthesia, can also be successfully used. Analgesic effect of paracetamol (Infulgan, “Yuria-Pharm”) in case of intravenous administration exceeds the analgetic effect of tramadol, and the effect on the newborn condition according to the Apgar scale does not differ (Meenakshi et al., 2015). Paracetamol (Infulgan) is moderately effective for perineal pain on the first day after delivery. The possibility of use during lactation is an another advantage of paracetamol.&#x0D; Conclusions. 1. Pain during labor is an extremely stressful factor, so women should have access to quality analgesia and anesthesia. 2. There is no analgesic, sedative or local anesthetic that does not penetrate the placenta, affecting the fetus. 3. EDA is the gold standard of labor anesthesia. 4. Combined spinal-epidural anesthesia provides rapid effect and long-term analgesia. 5. The use of systemic opioids during labor increases the need for resuscitation of newborns and worsens the condition of their acid-base balance. 6. Nalbuphine and Infulgan have been used successfully for labor pain relief.

Between Rights and Rhetoric: Assessing the Government of Canada’s Public Health Policy on Opioid Injection Drug Use (2015-2019)

Until 2015 Canadian public health policy on opioids was criticized for being rhetorical, lacking clear definition, and falling foremost on the side of enforcement. This article examines how the 2015 election of a new federal government introduced an alternative approach to opioid injection drug use, framing opioids as public health and human rights issue within Canadian policy. This article assesses the government’s commitment to a human rights approach to opioids and problematizes ambiguities in its approach. It raises questions about the politicized nature of the government’s strategy and whether Canada’s response remains caught between rights and rhetoric.

Plasma histamine concentrations in horses administered sodium penicillin, guaifenesin–xylazine–ketamine and isoflurane with morphine or butorphanol

ObjectiveVarious drugs administered to horses undergoing surgical procedures can release histamine. Histamine concentrations were evaluated in horses prepared for surgery and administered butorphanol or morphine intraoperative infusions. Study designProspective studies with one randomized. AnimalsA total of 44 client-owned horses. MethodsIn one study, anesthesia was induced with xylazine followed by ketamine–diazepam. Anesthesia was maintained with guaifenesin–xylazine–ketamine (GXK) during surgical preparation. For surgery, isoflurane was administered with intravenous (IV) morphine (group M: 0.15 mg kg–1 and 0.1 mg kg–1 hour–1; 15 horses) or butorphanol (group B: 0.05 mg kg–1 and 0.01 mg kg–1 hour–1; 15 horses). Histamine and morphine concentrations were measured using enzyme-linked immunoassay before opioid injection (time 0), and after 1, 2, 5, 30, 60 and 90 minutes. In a subsequent study, plasma histamine concentrations were measured in 14 horses before drug administration (baseline), 15 minutes after IV sodium penicillin and 15 minutes after starting GXK IV infusion. Statistical comparison was performed using anova for repeated measures. Pearson correlation compared morphine and histamine concentrations. Data are presented as mean ± standard deviation. Significance was assumed when p ≤ 0.05. ResultsWith histamine, differences occurred between baseline (3.2 ± 2.4 ng mL–1) and GXK (5.2 ± 7.1 ng mL–1) and between baseline and time 0 in group B (11.9 ± 13.4 ng mL–1) and group M (11.1 ± 12.4 ng mL–1). No differences occurred between baseline and after penicillin or between groups M and B. Morphine concentrations were higher at 1 minute following injection (8.1 ± 5.1 ng mL–1) than at 30 minutes (4.9 ± 3.1 ng mL–1) and 60 minutes (4.0 ± 2.5 ng mL–1). Histamine correlated with morphine at 2, 30 and 60 minutes. Conclusions and clinical relevanceGXK increased histamine concentration, but concentrations were similar with morphine and butorphanol.

Stigmatize the use, not the user? Attitudes on opioid use, drug injection, treatment, and overdose prevention in rural communities.

Stigma is a known barrier to treating substance use disorders and dramatically diminishes the quality of life of people who use drugs (PWUD) nonmedically. Stigma against PWUD may be especially pronounced in rural areas due to their decreased anonymity and residents' limited access, or resistance, to "neutralizing" information on factors associated with drug use. Stigma often manifests in the attitudes of professionals whom stigmatized individuals regularly interact with and often materially impact. We analyzed interviews conducted between July 2018 and February 2019 with professional stakeholders in rural southern Illinois who interact with PWUD, specifically those who use opioids nonmedically or who inject drugs (n=30). We further analyzed interview data from a complementary PWUD sample (n=22). Interviews addressed perspectives around nonmedical drug use and treatment/harm reduction, with analysis centered around the Framework Integrating Normative Influences on Stigma and its focus on micro, meso and macro level stigmatization processes. Stakeholder participants included professionals from local law enforcement, courts, healthcare organizations, emergency management services, and faith-based and social services organizations. Most stakeholders, particularly law enforcement, negatively perceived PWUD and nonmedical drug use in general, questioned the character, agency and extrinsic value of PWUD, and used labels (e.g. "addict," "abuser," etc.) that may be regarded as stigmatizing. Further, most respondents, including PWUD, characterized their communities as largely unaware or dismissive of the bio-medical and sociocultural explanations for opioid use, drug injection and towards harm reduction services (e.g., syringe exchanges) and naloxone, which were frequently framed as undeserved usages of taxpayer funds. In conclusion, rural stigma against PWUD manifested and was framed as a substantial issue, notably activating at micro, meso and macro levels. Stigma prevention efforts in these communities should aim to improve public knowledge on the intricate factors contributing to opioid use and drug injection and harm reduction programming's moral and fiscal value.

Frequent Cannabis Use Is Negatively Associated with Frequency of Injection Drug Use Among People Who Inject Drugs in a Canadian Setting.

Objectives: High levels of morbidity and mortality associated with injection drug use continue to represent a significant public health challenge in many settings worldwide. Previous studies have shown an association between cannabis use and decreased risk of some drug-related harms. We sought to evaluate the association between high-intensity cannabis use and the frequency of injection drug use among people who inject drugs (PWID). Methods: The data for this analysis were collected from three prospective cohorts of PWID in Vancouver, Canada, between September 2005 and May 2018. Generalized linear mixed-effects models were used to analyze the association between daily cannabis use and the frequency of injecting illegal drugs (i.e., self-reported average number of injections per month). Results: Among the 2,619 active PWID, the frequency of injection drug use was significantly lower among people who use cannabis daily compared with people who use it less than daily (adjusted odds ratio [AOR]=0.84, 95% confidence interval [CI]: 0.73-0.95). Sub-analyses indicated that this effect was restricted to the frequency of illegal opioid injection (AOR=0.78, 95% CI: 0.68-0.90); the association between daily cannabis use and the frequency of illegal stimulant injection was not significant (AOR=1.08, 95% CI 0.93-1.25). Discussion: The findings from these prospective cohorts suggest that people who use cannabis daily were less likely to report daily injection of illegal drugs compared with people who use it less than daily. These results suggest the potential value of conducting experimental research to test whether controlled administration of cannabinoids impacts the frequency of illegal opioid injection among PWID.

42 Advanced Fibrosis Is Unlikely in the Majority of Patients from an Appalachian Emergency Department’s Non-Targeted Hepatitis C Virus Screening

We have previously demonstrated a high prevalence of Hepatitis C Virus (HCV), particularly among young, publicly insured patients, reflecting the escalating syndemic of opioid injection and HCV transmission. We aim to describe the degree of hepatic fibrosis among patients with evidence of HCV infection identified from an adult academic emergency department (ED) non-targeted HCV screening program. The study was a retrospective cohort analysis of ED systematic, non-targeted, opt-out HCV testing outcomes from July 2018 through January 2019. To assess the degree of liver disease as evidenced by fibrosis, Fibrosis-4 (FIB4) and aspartate transaminase to platelet ratio (APRI) scores were calculated from available AST, ALT and Platelet lab values pulled from the electronic medical record, collected on the same day as the initial ED visit. The absence or presence of advanced fibrosis or cirrhosis was determined using validated cut-offs: FIB4 < 1.45, APRI < 1; FIB4 > 3.25, APRI > 2 respectively. As previously reported there were 21,359 unique adult visitors during the time period studied. Of these, 16,700 individuals were verbally engaged and did not opt out of testing. A total of 11,635 individuals received HCV Ab testing with 1,459 patients (12.5%) having reactive results. Newly identified information shows that 1,241 (85%) of these patients had concomitant labs as part of routine ED care sufficient to calculate a FIB4 and APRI score. Data indicate that advanced fibrosis or cirrhosis was not likely in the majority of patients (FIB4 56%, 707/1241 patients; APRI 72.6%, 901/1241 patients). Those with available FIB4 and APRI were more likely to be born after 1965 (857/1241 patients, 69.1%), of whom 90.9% (779) had government insurance or were uninsured (Medicaid 85.6%, 667 patients; Medicare 8.5%, 66 patients; Uninsured 5.9%, 46 patients). Of these, advanced fibrosis or cirrhosis was not likely in the majority of patients : medicaid (FIB4 64.9%, 433/667 patients; APRI 67.2%, 462/667 patients), medicare ( FIB4 57.6%, 38/66 patents; APRI 71% 47/66 patients), uninsured (FIB4 69.6%, 32/46 patients; APRI 71.7%, 33/46 patients). ED non-targeted, opt-out testing identified a high prevalence of HCV infection among adult visitors in whom the majority do not have evidence of advanced fibrosis or cirrhosis. The majority of those patients were young and insured. For a curable disease that carries severe morbidity and mortality, along with known financial costs of inaction, our program has demonstrated that the ED may be a prime location to identify and treat viremic HCV patients.

Responding to Outbreaks of Human Immunodeficiency Virus Among Persons Who Inject Drugs-United States, 2016-2019: Perspectives on Recent Experience and Lessons Learned.

In 2015, a large human immunodeficiency virus (HIV) outbreak occurred among persons who inject drugs (PWID) in Indiana. During 2016-2019, additional outbreaks among PWID occurred across the United States. Based on information disseminated by responding health departments and Centers for Disease Control and Prevention (CDC) involvement, we offer perspectives about characteristics of and public health responses to 6 such outbreaks. Across outbreaks, injection of opioids (including fentanyl) or methamphetamine predominated; many PWID concurrently used opioids and methamphetamine or cocaine. Commonalities included homelessness or unstable housing, previous incarceration, and hepatitis C virus exposure. All outbreaks occurred in metropolitan areas, including some with substantial harm reduction and medical programs targeted to PWID. Health departments experienced challenges locating case patients and contacts, linking and retaining persons in care, building support to strengthen harm-reduction programs, and leveraging resources. Expanding the concept of vulnerability to HIV outbreaks and other lessons learned can be considered for preventing, detecting, and responding to future outbreaks among PWID.

Opioid initiation and injection transition in rural northern New England: A mixed-methods approach

BackgroundIn rural northern New England, located in the northeastern United States, the overdose epidemic has accelerated with the introduction of fentanyl. Opioid initiation and transition to opioid injection have been studied in urban settings. Little is known about opioid initiation and transition to injection drug use in rural northern New England. MethodsThis mixed-methods study characterized opioid use and drug injection in 11 rural counties in Massachusetts, Vermont, and New Hampshire between 2018 and 2019. People who use drugs completed audio computer-assisted self-interview surveys on substance use and risk behaviors (n = 589) and shared personal narratives through in-depth interviews (n = 22). The objective of the current study is to describe initiation of opioid use and drug injection in rural northern New England. ResultsMedian age of first injection was 22 years (interquartile range 18–28 years). Key themes from in-depth interviews that led to initiating drug injection included normalization of drug use in families and communities, experiencing trauma, and abrupt discontinuation of an opioid prescription. Other factors that led to a transition to injecting included lower cost, increased effect/ rush, greater availability of heroin/ fentanyl, and faster relief of withdrawal symptoms with injection. ConclusionsTrauma, normalization of drug use, over-prescribing of opioids, and abrupt discontinuation challenge people who use drugs in rural northern New England communities. Inadequate opioid tapering may increase transition to non-prescribed drug use. The extent and severity of traumatic experiences described highlights the importance of enhancing trauma-informed care in rural areas.

Frequent Cannabis Use and Cessation of Injection of Opioids, Vancouver, Canada, 2005-2018.

Objectives. To evaluate the impact of frequent cannabis use on injection cessation and injection relapse among people who inject drugs (PWID).Methods. Three prospective cohorts of PWID from Vancouver, Canada, provided the data for these analyses. We used extended Cox regression analysis with time-updated covariates to analyze the association between cannabis use and injection cessation and injection relapse.Results. Between 2005 and 2018, at-least-daily cannabis use was associated with swifter rates of injection cessation (adjusted hazard ratio [AHR] = 1.16; 95% confidence interval [CI] = 1.03, 1.30). A subanalysis revealed that this association was only significant for opioid injection cessation (AHR = 1.26; 95% CI = 1.12, 1.41). At-least-daily cannabis use was not significantly associated with injection relapse (AHR = 1.08; 95% CI = 0.95, 1.23).Conclusions. We observed that at-least-daily cannabis use was associated with a 16% increase in the hazard rate of injection cessation, and this effect was restricted to the cessation of injection opioids. This finding is encouraging given the uncertainty surrounding the impact of cannabis policies on PWID during the ongoing opioid overdose crisis in many settings in the United States and Canada.