Risk For Opioid Misuse Research Articles

Economic Evaluation Design within the HEAL Prevention Cooperative.

The rapid rise in opioid misuse, disorder, and opioid-involved deaths among older adolescents and young adults is an urgent public health problem. Prevention is a vital part of the nation’s response to the opioid crisis, yet preventive interventions for those at risk for opioid misuse and opioid use disorder are scarce. In 2019, the National Institutes of Health (NIH) launched the Preventing Opioid Use Disorder in Older Adolescents and Young Adults cooperative as part of its broader Helping to End Addiction Long-term (HEAL) Initiative (https://heal.nih.gov/). The HEAL Prevention Cooperative (HPC) includes ten research projects funded with the goal of developing effective prevention interventions across various settings (e.g., community, health care, juvenile justice, school) for older adolescent and young adults at risk for opioid misuse and opioid use disorder (OUD). An important component of the HPC is the inclusion of an economic evaluation by nine of these research projects that will provide information on the costs, cost-effectiveness, and sustainability of these interventions. The HPC economic evaluation is integrated into each research project’s overall design with start-up costs and ongoing delivery costs collected prospectively using an activity-based costing approach. The primary objectives of the economic evaluation are to estimate the intervention implementation costs to providers, estimate the cost-effectiveness of each intervention for reducing opioid misuse initiation and escalation among youth, and use simulation modeling to estimate the budget impact of broader implementation of the interventions within the various settings over multiple years. The HPC offers an extraordinary opportunity to generate economic evidence for substance use prevention programming, providing policy makers and providers with critical information on the investments needed to start-up prevention interventions, as well as the cost-effectiveness of these interventions relative to alternatives. These data will help demonstrate the valuable role that prevention can play in combating the opioid crisis.

SP1.1.4 Caveat Chirurgicus - Opioid use following surgery

Abstract Introduction Over the last 20-years there has been increasing opioid related deaths, in the context of a worldwide epidemic of misuse including addiction and overdose. Startlingly, opioid commencement is usually iatrogenic. Most published data is from the USA with little evidence from UK surgical practice. Methods Retrospective analysis of surgical unit opioid prescriptions. Data included opioids prescribed on discharge, 1, 3- and 6-months post-discharge usage and milligrams-of-morphine equivalence(mgEq) used to compare regimes. Results One hundred cases reviewed. 35% of patients were opioid naïve on admission and of these 20%, 5.71% and 8.57% remained on opioids at 1, 3- and 6-months post discharge respectively. Females more likely to remain on long-term opioids at 6 months at lower doses (42% v 30%). Only 6% of discharge summaries recommended GP follow-up and assessment of opioid requirements. Furthermore, none were prescribed a tapering dosage regime on-discharge. Patients receiving Acute Pain Team reviews, more likely to remain on long-term opioids, at lower doses (30.67mgEq, 29.25mgEq and 32.63mgEq at 1-, 3- and 6-months post-discharge) compared to those without (69.16mgEq, 74.25mgEq and 65.13mgEq). Only 11% of patients with pre-existing opioid prescriptions were reviewed by the acute pain team. Worryingly, no documented assessment of opioid misuse risk in patients. Conclusion Standardised assessments i.e., opioid Risk Assessment Tools and mgEq need to be documented and monitored in primary and tertiary care. Acute pain team services should be offered to more patients. Our study hopes to raise awareness of the need for effective opioid stewardship in surgical patients.

Identifying the risk of opioid misuse in a chronic pain population: the utility of the MMPI-2-RF personality psychopathology five (PSY-5-RF) and higher-order scales.

Prescription-related opioid misuse, especially in chronic pain populations, is an ongoing problem and is related to increased mortality. The purpose of this study was to assess the utility of two restructured scales of the MMPI-2-RF: the Personality Psychopathology Five (PSY-5-RF) and the Higher-Order Scales to determine which of their subscales may be beneficial for identifying the risk of opioid misuse in a chronic pain population. A sample of 136 patients with chronic disabling occupational musculoskeletal disorders completed the MMPI-2-RF and the Current Opioid Misuse Measure (COMM) upon admission to a functional restoration program. The PSY-5-RF and H-O subscales were correlated with the baseline COMM scores. Correlation analyses, ROC curve analyses, and multiple binary logistic regression models were developed to determine which subscales were most associated with elevated COMM scores. The results of the regression analyses suggest that Scale elevations on two of the PSY-5-RF Scales and two Higher-Order Scales of the MMPI-2-RF demonstrated significant associations with elevated COMM scores, thus exhibiting the utility of these subscales in identifying the risk of opioid misuse among chronic pain patients. These findings are clinically meaningful in underscoring the importance of identifying specific personality traits as potential predictors of opioid misuse, and identifying those at risk through careful screening. Clinical implications based on each of the PSY-5-RF and H-O scales significantly associated with elevated COMM scores are discussed.

The past and future use of perioperative opioids in gynecologic oncology patients after open surgery (535)

<b>Objectives:</b> As surgeons, it is our ethical imperative to minimize the harmful impact on patients and their communities through the prescription of perioperative opioid medication. This study reviews the perioperative opioid use in our gynecologic oncology surgical practice over the last decade. <b>Methods:</b> We undertook a chart review of adult gynecologic oncology patients who underwent open surgery from July 1, 2012, to August 26, 2021. Perioperative and patient characteristics were abstracted. Prospective phone surveys were completed from April through September 2021 in this patient population two to four weeks after surgery to assess self-reported opioid use post-hospital discharge. Quantities of oral and intravenous opioid medications are reported as oral morphine equivalents (OME). Data are presented as proportions or median results by year and compared using Chi-square tests or Wilcoxon rank-sum tests, respectively. <b>Results:</b> There were 1210 patients included in the chart review, and we completed 75 prospective surveys. From 2012 to 2021, the rate of non-steroidal anti-inflammatory drug use increased from 40.7% to 80% (p<0.01), and the use of epidurals and transversus abdominis plane (TAP) blocks increased from 46.5% to 93.9% (p<0.01, Figure 1a). The median length of hospital stay was decreased by 20% (5 to 4 days, p<0.01). The total amount of OME used per patient in the hospital decreased by 62.6% from 2012 to 2021 (412 OME in 2012 vs 154.3 OME in 2021, p<0.01). When divided by length of stay, the median OME used per day also decreased (84.7 OME in 2012 vs 42 OME in 2021, p<0.01). Opioid prescription sizes at the time of hospital discharge significantly decreased as well from 675 OME per patient in 2012 (equivalent to 90 doses of 5mg oxycodone tablets) to 150 OME per patient in 2021 (equivalent to 20 doses of 5mg oxycodone tablets, p<0.01, Figure 1b). From our prospective survey data, the actual amount of OME used by patients in 2021 after hospital discharge was a median of 22.5 OME (equivalent to 3 doses of 5mg oxycodone tablets per patient). There was a decrease in preoperative opioid use from 2012 to 2021 (41.9% in 2012 vs 28.7% in 2021, p=0.05). The refill rate for postoperative opioids did not significantly differ during this time period (18% in 2012 vs 10.4% in 2021, p=0.10). <b>Conclusions:</b> Patients in this study used fewer opioids in the perioperative period between 2012 and 2021, likely due to utilization of enhanced recovery after surgery pathways and increased awareness of the risks of opioid misuse. While our division reduced the median postoperative opioid prescription size from 2012 to 2021 by 77.7%, our findings suggest we could further reduce prescription sizes by an additional 85% and still adequately treat our patients' postoperative pain. Ongoing assessment of surgical patients' opioid medication needs and patterns of prescribing is essential for addressing our contributions to the opioid epidemic.

Opioid risk stratification in the community pharmacy: The utility of the Opioid Risk Tool

ObjectiveThe objective for this paper is to report on the utility of the Opioid Risk Tool (ORT) to identify patients at elevated risk for opioid misuse and deliver medication safety-related services to them. Patient characteristics based on ORT risk stratification are also described. MethodsData from patients screened from September 17, 2018 to May 12, 2021 were descriptively evaluated for distribution of ORT scores, characteristics of patients stratified by ORT score, and services delivered to patients based on ORT score. The ORT generates a score from 0 to 26, with scores of 0–3, 4–7, and 8 or higher representing low, moderate, and high risk of opioid use disorder, respectively. Based upon screening results, pharmacists provided patient-specific education and interventions. ResultsA total of 6,460 patients were evaluated. Low, moderate, and high ORT scores were found among 87.5, 8.2 and 3.9% of the patients receiving opioids, respectively. Males comprised 46.1% of the patients, and 27.7% of the patients had received a prior opioid prescription in the last 60 days. As a result of risk stratification, the pharmacist explained opioid use disorder to 18.8, 36.1, and 47.0% of patients with low, moderate and high ORT scores, respectively (p < .001). High ORT scores were significantly associated with the pharmacist introducing the patient to community support services (OR = 2.35), the pharmacist having contacted their provider (OR = 6.41), male gender (OR = 2.06), and having taken an opioid in the last 60 days (OR = 1.76). ConclusionsThe ORT is a useful tool for opioid risk stratification of patients receiving opioid medications in the community pharmacy setting. Such stratification allows the pharmacist to provide individualized services to patients based on their risk profile.

Cultural dimensions of individualism and collectivism and risk of opioid misuse: A test of Social Cognitive Theory.

Despite the critical role social and cultural contexts play in pain experience, limited theoretical and empirical attention has been devoted to the interplay between social, cognitive, cultural, and psychological factors in chronic pain management and the risk of opioid misuse. Using structural equation modeling, the present study tested the Social Cognitive Theory (SCT) of chronic pain management and risk of opioid misuse in the context of intraindividual cultural dimensions of individualism and collectivism among 316 ethnically diverse adults with chronic pain in the United States. Social cognitive predictors account for a significant amount of variance in pain dysfunction and risk of opioid misuse in adults with chronic pain. Satisfaction with pain support was positively associated with both greater pain acceptance and greater pain self-efficacy. Individualism was found to be positively associated with satisfaction with pain support, pain self-efficacy, and pain acceptance but negatively associated with the risk of opioid misuse. Collectivism was positively associated with the risk of opioid misuse. The study findings not only empirically support using SCT for adults with chronic pain, but also provide a more thorough conceptual framework that highlights the intracultural diversity and interplay among social, cognitive, and psychological factors that affect pain experience and the risk of opioid misuse among adults with chronic pain.

Association of Postsurgical Opioid Refills for Patients With Risk of Opioid Misuse and Chronic Opioid Use Among Family Members

The US health care system is experiencing a sharp increase in opioid-related adverse events and spending, and opioid overprescription may be a key factor in this crisis. Ambient opioid exposure within households is one of the known major dangers of overprescription. To quantify the association between the postsurgical initiation of prescription opioid use in opioid-naive patients and the subsequent prescription opioid misuse and chronic opioid use among opioid-naive family members. This cohort study was conducted using administrative data from the database of a US commercial insurance provider with more than 35 million covered individuals. Participants included pairs of patients who underwent surgery from January 1, 2008, to December 31, 2016, and their family members within the same household. Data were analyzed from January 1 to November 30, 2018. Duration of opioid exposure and refills of opioid prescriptions received by patients after surgery. Risk of opioid misuse and chronic opioid use in family members were calculated using inverse probability weighted Cox proportional hazards regression models. The final cohort included 843 531 pairs of patients and family members. Most pairs included female patients (445 456 [52.8%]) and male family members (442 992 [52.5%]), and a plurality of pairs included patients in the 45 to 54 years age group (249 369 [29.6%]) and family members in the 15 to 24 years age group (313 707 [37.2%]). A total of 3894 opioid misuse events (0.5%) and 7485 chronic opioid use events (0.9%) occurred in family members. In adjusted models, each additional opioid prescription refill for the patient was associated with a 19.2% (95% CI, 14.5%-24.0%) increase in hazard of opioid misuse in family members. The risk of opioid misuse appeared to increase only in households in which the patient obtained refills. Family members in households with any refill had a 32.9% (95% CI, 22.7%-43.8%) increased adjusted hazard of opioid misuse. When patients became chronic opioid users, the hazard ratio for opioid misuse among family members was 2.52 (95% CI, 1.68-3.80), and similar patterns were found for chronic opioid use. This cohort study found that opioid exposure was a household risk. Family members of a patient who received opioid prescription refills after surgery had an increased risk of opioid misuse and chronic opioid use.

Evaluation of a Program to Screen Patients in Community Pharmacies for Opioid Misuse and Accidental Overdose.

IntroductionCommunity pharmacies nationwide have adopted new strategies to combat the opioid epidemic. One strategy to prevent opioid misuse and accidental overdose is patient screening to identify those at risk. The purpose of our study was to determine whether such screening in community pharmacies led pharmacy personnel to intervene with patients at risk and to describe the proportion of patients they identified as at risk.MethodsWe implemented the Opioid and Naloxone Education (ONE) program in North Dakota to give community pharmacies and pharmacists training and tools to provide preventive screening for opioid misuse and accidental overdose before dispensing a prescribed opioid. Data were collected and analyzed from September 15, 2018, through May 15, 2021, to evaluate overall patient risk characteristics for opioid misuse and accidental overdose.ResultsOf 8,217 patients screened, 3.9% were identified as at high risk for opioid misuse, and 18.3% at risk for accidental overdose. Nearly 1 of 3 screenings (31.7%) indicated opioid medication use in the past 60 days. Pharmacists delivered 1 or more risk-factor–dependent interventions to 41.1% of patients in the study. Following screening, naloxone dispensing in pharmacies increased to 6 times the national average.ConclusionPharmacy-based patient screening for risk of opioid misuse and accidental overdose led to risk-dependent interventions targeted to individual patients. The tools and risk-dependent interventions applied in the ONE program increased patient awareness of opioid risks and ways to reduce risk. Future studies should examine long-term outcomes, including reduction in overdose, treatment of opioid use disorder, and reduced opioid-related acute care.

Interpersonal Violence, PTSD, and Substance Use Types among Women Receiving Substance Use Treatment

Objective: Many women receiving substance use treatment report histories of interpersonal violence (IV) victimization, including physical and sexual assault. IV is a risk factor for mental and behavioral health difficulties such as posttraumatic stress disorder (PTSD) and substance use disorder (SUD). Consistent with the self-medication hypothesis, PTSD may explain elevated SUD among IV survivors. Yet, few studies have investigated whether PTSD may have differential mediating effects for different substances, which has significant treatment implications. Methods: In 124 women (M age = 35.37, SD = 11.90) in substance use treatment, we examined PTSD symptoms as a mediator between IV and severity of different types of substance use, including alcohol, cannabis, cocaine, and opioid use. Participants completed self-report measures including the ASSIST, PCL-5, and LEC-5. Data were analyzed using path analysis in Mplus 8.3. Both dichotomous and continuous outcomes of problematic substance use outcomes were examined. Results: Most women (53.3%) reported problematic substance use with at least one substance, including opioids (39.7%), cocaine (13.0%), alcohol (9.6%), and cannabis (5.6%). Most (83.2%) of the sample reported at least one IV incident. On average, women reported clinically significant PTSD symptom severity. When problematic substance use was examined dichotomously, findings revealed significant indirect effects from IV exposure to opioid (β = 0.10, p = .010) and cocaine use (β = 0.07, p = .039) via elevated PTSD symptoms. There were no significant indirect effects for problematic alcohol (β = 0.03, p = .260) or cannabis use (β = 0.02, p = .562). When substance use was examined continuously, results revealed significant indirect effects from IV exposure to opioid (β = 0.09, p = .017), cocaine use (β = 0.09, p = .015), and alcohol use (β = 0.08, p = .020) via elevated PTSD symptoms. Indirect effects for cannabis use remained nonsignificant (β = 0.05, p = .100). Conclusions: IV survivors may be particularly at risk for opioid and cocaine misuse because of elevated PTSD symptoms. Treatments that integrate PTSD and SUD are needed to simultaneously target traumatic stress and substance use. Women with opioid and cocaine misuse may particularly benefit from trauma-focused exposure-based psychotherapy to reduce symptoms of PTSD, and thus, decrease opioid and cocaine misuse.

Opioid and Alcohol Misuse in Veterans with Chronic Pain: A Risk Screening Study

In United States military veterans, chronic pain represents a risk factor for opioid and alcohol misuse, yet few studies have examined interactions among chronic pain, opioid prescription, and opioid and alcohol misuse. Previous work found substantial risk of co-morbid alcohol and opioid misuse in a community sample of opioid-prescribed individuals with chronic pain, a finding expanded upon here. Specifically, 211 veterans assessed within a chronic pain treatment service for opioid-prescribed individuals completed self-report measures of opioid misuse, alcohol misuse, pain intensity, depression, pain catastrophizing, and post-traumatic stress symptoms (PTS). Based on the substance misuse measures, 32% (n = 68) were misusing neither opioids nor alcohol, 23% (n = 48) were misusing both opioids and alcohol, 40% (n = 84) were misusing opioids alone, and 5% (n = 11) were misusing alcohol alone. Group comparisons indicated that individuals not misusing either substance were less distressed in comparison to those who were misusing opioids alone or both substances. The latter groups differed in PTS. Overall, misuse frequencies mirrored previous work, with approximately 1 of 3 misusing opioids and approximately 1 of 5 misusing both substances. There is a need for increased focus on both polysubstance misuse and the development of integrated treatment. PerspectiveOpioid and alcohol misuse was examined in 211 Veterans prescribed opioids for chronic pain. In total, 32% were not misusing either, 23% were misusing both, 40% were misusing opioids, and 5% were misusing alcohol. Veterans not misusing either were generally less disabled and distressed compared to those misusing opioids or both.

Identifying High-Risk Comorbidities Associated with Opioid Use Patterns Using Electronic Health Record Prescription Data

Introduction: Opioid use disorders (OUDs) constitute a major public health issue, and we urgently need alternative methods for characterizing risk for OUD. Electronic health records (EHRs) are useful tools for understanding complex medical phenotypes but have been underutilized for OUD because of challenges related to underdiagnosis, binary diagnostic frameworks, and minimally characterized reference groups. As a first step in addressing these challenges, a new paradigm is warranted that characterizes risk for opioid prescription misuse on a continuous scale of severity, i.e., as a continuum. Methods: Across sites within the PsycheMERGE network, we extracted prescription opioid data and diagnoses that co-occur with OUD (including psychiatric and substance use disorders, pain-related diagnoses, HIV, and hepatitis C) for over 2.6 million patients across three health registries (Vanderbilt University Medical Center, Mass General Brigham, Geisinger) between 2005 and 2018. We defined three groups based on levels of opioid exposure: no prescriptions, minimal exposure, and chronic exposure and then compared the comorbidity profiles of these groups to the full registries and to those with OUD diagnostic codes. Results: Our results confirm that EHR data reflects known higher prevalence of substance use disorders, psychiatric disorders, medical, and pain diagnoses in patients with OUD diagnoses and chronic opioid use. Comorbidity profiles that distinguish opioid exposure are strikingly consistent across large health systems, indicating the phenotypes described in this new quantitative framework are robust to health systems differences. Conclusion: This work indicates that EHR prescription opioid data can serve as a platform to characterize complex risk markers for OUD using existing data.

Prevalence of Opioid Misuse Risk in Patients With Cancer.

Opioid misuse risk may be similar in individuals with chronic cancer and noncancer pain. However, risk screening is not uniformly used for patients with cancer, so its prevalence is unknown. The primary aim of this study was to estimate the level of risk for opioid misuse among patients with cancer. Secondary aims were to compare opioid misuse risk across cancer types and specialties and to explore psychosocial factors that may contribute to opioid misuse risk. Clinicians were trained to administer the Opioid Risk Tool during ambulatory visits. Data were retrieved from electronic health records and analyzed using descriptive statistics. Five percent of patients seen in the cancer center during the data collection period were screened for opioid misuse risk. Of the 226 patients screened, 163 were at low risk, 34 were at moderate risk, and 29 were at high risk for future opioid misuse. The most frequent cancer diagnoses for patients at moderate or high risk were lung (n = 15), breast (n = 16), gastrointestinal (n = 10), and genitourinary (n = 8). Of the 63 patients at moderate or high risk, 50 had a family history of substance misuse, 45 had a personal history of substance misuse, and 29 had a history of psychological disease.

Literature Review for Office-Based Anesthesia

Literature Review for Office-Based Anesthesia

Preventing Adolescent Opioid Misuse: Racial/Ethnic Differences in the Protective Effects of Extracurricular Activities

Participation in extracurricular activities has been largely shown to be protective against adolescent substance use. However, research has yet to examine whether extracurricular activities are specifically protective against adolescent opioid misuse and if these protective effects vary by race/ethnicity. This study focuses on a high-risk population for drug use (i.e., justice-involved adolescents [JIAs]) that is not often captured in population-based surveys. The goals of the current study were twofold: (a) determine the prevalence of opioid misuse for White, Black, and Latinx JIAs and (b) assess the influence of participation in extracurricular activities on opioid misuse risk among White, Black, and Latinx JIAs. Using data from the Florida Department of Juvenile Justice (n = 65,248), multivariate logistic regression models were estimated to determine which racial/ethnic groups experienced protective effects from participation in extracurricular activities. Results show that 2.3% of the sample met criteria for past-30-day opioid misuse and participation in extracurricular activities lowered the risk for opioid misuse by 36%. However, although involvement in extracurricular activities was protective for White and Latinx youth, Black youth received no such protective effect. This study provides evidence of a fairly strong protective effect (36% risk reduction) for extracurricular activities against opioid misuse, but our results caution against assuming that youth from all racial/ethnic backgrounds benefit similarly from extracurricular activities because Black adolescents may not experience the same protective benefit that White and Latinx youth receive. Programs should be aware that the protection extracurricular activities offer varies across racial/ethnic lines and tailoring may be warranted to see protective effects for Black youth.

Patterns and Trends in Receipt of Opioids Among Patients Receiving Treatment for Cancer in a Large Health System.

Given limited evidence on opioid prescribing among patients receiving treatment for cancer during the ongoing opioid epidemic, our objective was to assess predictors of and trends in opioid receipt during cancer treatment, including how patterns differ by type of cancer. Using cancer registry data, we identified patients with a first lifetime primary diagnosis of breast, colorectal, or lung cancer from 2013 to 2017 who underwent treatment within a large cancer center network. Cancer registry data were linked to electronic health record information on opioid prescriptions. We examined predictors of and trends in receipt of any opioid prescription within 12 months of cancer diagnosis. The percentage of patients receiving opioids varied by cancer type: breast cancer, 35% (1,996/5,649); colorectal, 37% (776/2,083); lung, 47% (1,259/2,654). In multivariable analysis, opioid use in the year before cancer diagnosis was the factor most strongly associated with receipt of opioids after cancer diagnosis, with 4.90 (95% CI, 4.10-5.86), 5.09 (95% CI, 3.88-6.69), and 3.31 (95% CI, 2.68-4.10) higher odds for breast, colorectal, and lung cancers, respectively. We did not observe a consistent decline in opioid prescribing over time, and trends differed by cancer type. Our findings suggest that prescription of opioids to patients with cancer varies by cancer type and other factors. In particular, patients are more likely to receive opioids after cancer diagnosis if they were previously exposed before diagnosis, suggesting that pain among patients with cancer may commonly include non-cancer-related pain. Heterogeneity and complexity among patients with cancer must be accounted for in developing policies and guidelines aimed at addressing pain management while minimizing the risk of opioid misuse.

Sex differences in the association of adverse childhood experiences on past 30-day opioid misuse among Florida justice-involved children

IntroductionOpioid misuse remains a chief public health concern in the United States, especially among justice-involved children and adolescents (JIC). Adverse childhood experiences (ACEs) are prevalent among JIC and are associated with a higher risk for opioid misuse. Justice involvement can be harsher for females, who tend to have higher ACE scores and experience more physiological and psychological risk factors than males. However, this study was the first to examine how sex may moderate the link between ACEs and opioid misuse. This study hypothesized that females will have higher odds of opioid misuse than males with equivalent ACEs. MethodsThe study team examined cross-sectional data on 79,960 JIC in the Florida Department of Juvenile Justice from 2007 to 2015. The study measured ACEs using 10 questions from the Positive Achievement Change Tool. Opioid misuse was reported by either self-disclosure, positive urinalysis, or other evidence of opioid consumption within the past 30 days. The team estimated logistic regression, marginal effects, and multiplicative interaction terms to test the hypotheses. ResultsJIC with an ACE score of 4 or higher were 2.59 times more likely to misuse opioids than JIC with lower ACE scores. Among JIC with 4 or more ACEs, females had significantly higher odds of opioid misuse than males. ConclusionReducing exposure to ACEs may decrease the risk for opioid misuse, particularly among females. These findings corroborate trauma-informed and sex-responsive prevention programs in the juvenile justice system.

Integration of Life Care Specialists Into Orthopaedic Trauma Care to Improve Postoperative Outcomes: A Pilot Study

Background AimThis pilot study assessed the feasibility and impact of integrating a Life Care Specialist (LCS) into orthopaedic trauma care. DesignThis was a prospective feasibility single group pilot study at a level 1 trauma center. MethodThe LCS is a paraprofessional behavior-based “pain coach” and delivered patient-centered opioid safety education, trained participants on nonpharmacologic pain management approaches, conducted opioid risk assessments, and coordinated care. Numeric Rating Scale pain scores were assessed on admission, at discharge, and at 2-week follow-up. Daily morphine milligram equivalents (MME) during hospitalization, opioid medication use at 2-weeks, and patient satisfaction were recorded. T test compared mean morphine milligram equivalents (MME) to historical orthopaedic trauma patient population's mean dosage at discharge from the study site. Generalized linear models assessed pain scores over time. ResultsTwenty-two percent of 121 total participants met criteria for moderate to severe risk of opioid misuse at initial hospitalization. On average, 2.8 LCS pain management interventions were utilized, most frequently progressive muscle relaxation (80%) and sound therapy (48%). Mean inpatient MME/day was 40.5, which was significantly lower than mean historical MME/day of 49.7 (p < .001). Pain scores improved over time from admission to 2-weeks postoperatively (p < .001). Nearly all participants agreed that the LCS was helpful in managing pain (99%). ConclusionsThe findings indicate feasibility to integrate LCS into orthopaedic trauma care, evident by participant engagement and satisfaction, and that LCS serve as valuable resources to assist with pain management and opioid education.

If we build it, will they come? Perspectives on pharmacy-based naloxone among family and friends of people who use opioids: a mixed methods study

BackgroundExpanding access to the opioid antagonist naloxone to reduce overdose mortality is a public health priority in the United States. Naloxone standing orders (NSOs) have been established in many states to increase naloxone dispensing at pharmacies, but increased pharmacy access does not ensure optimal uptake among those likely to witness an overdose. In a prior statewide purchase trial, we documented high levels of naloxone access at Massachusetts pharmacies under a statewide NSO. In this study, we characterize barriers to pharmacy-based naloxone uptake among potential opioid overdose “bystanders” (friends or family of people who use opioids) that may be amenable to intervention.MethodsEligible bystanders were Massachusetts residents ≥ 18 years of age, did not use illicit opioids in the past 30 days, and knew someone who currently uses illicit opioids. We used a sequential mixed methods approach, in which a series of semi-structured qualitative interviews (N = 22) were conducted April-July 2018, to inform the development of a subsequent quantitative survey (N = 260), conducted February-July 2020.ResultsMost survey participants (77%) reported ever obtaining naloxone but few (21%) attempted to purchase it at a pharmacy. Qualitative participants revealed that barriers to utilizing the NSO included low perceived risk of overdose, which was rooted in misconceptions regarding the risks of prescription opioid misuse, denial about their loved one’s drug use, and drug use stereotypes; inaccurate beliefs about the impact of naloxone on riskier opioid use; and concerns regarding anticipated stigma and confidentiality. Many participants had engaged in mutual support groups, which served as a source of free naloxone for half (50%) of those who had ever obtained naloxone.ConclusionsDespite high levels of pharmacy naloxone access in Massachusetts, few bystanders in our study had attempted to obtain naloxone under the NSO. Low perceived risk of overdose, misinformation, stigma, and confidentiality were important barriers to pharmacy naloxone uptake, all of which are amenable to intervention. Support groups provided a setting for addressing stigma and misinformation and provided a discreet and comfortable setting for naloxone access. Where these groups do not exist and for bystanders who do not participate in such groups, pharmacies are well-positioned to fill gaps in naloxone availability.

Understanding opioid use within a Southwestern American Indian Reservation Community: A qualitative study.

Morbidity and mortality due to nonprescription use of opioids has been well documented following the significant increase in the availability of prescription opioids in the early 2000s. The aim of this paper is to explore community beliefs about correlates of opioid risk, protective factors, and behavioral functions of opioid misuse among American Indian youth and young adults living on or near a reservation. Qualitative in-depth interviews were conducted with N = 18 youth and young adults who were enrolled in a parent research trial focused on American Indian youth suicide prevention. Participants were eligible if they endorsed the use of opioids themselves or by close friends or family members at any point during their trial participation. Major themes discussed include: (1) description of opioid use and those who use opioids; (2) acquisition; (3) initiation; (4) motivation to continue using; (5) consequences; and (6) possibilities for intervention. Family played an important role in the initiation of use, but was also highlighted as an important factor in treatment and recovery. A need for upstream prevention methods, including increased employment and after-school activities, was described. The insights gained through this work could help to inform treatment and prevention programs in the community. This work is timely due to the pressing urgency of the opioid epidemic nationally, and community capacity to address opioid use locally.

Young Adult Healthcare Exposure and Future Opioid Misuse: A Prospective Cohort Study

Outpatient opioid prescribing is associated with opioid misuse in young adults, but the longitudinal association between general healthcare exposure and opioid misuse has not been explored. The objective of this study is to examine the association between healthcare exposure in young adulthood and future opioid misuse. Data were drawn from the National Longitudinal Study of Adolescent to Adult Health (2001-2018) and analyzed in 2021. Healthcare exposure (i.e., inpatient hospitalization and visits to the clinic, emergency department, mental-health facility, or dentist) between individuals aged 18 and 26 years was the primary independent variable; only patients who did not report opioid misuse at baseline were included. Opioid misuse was defined as using prescription painkillers without a doctor's permission and was measured 17 years after exposure. Multivariable logistic regression was used to examine any associations with opioid misuse (ages 33-43 years). A total of 8,225 young adults with a mean baseline age of 21.8 (SE=0.12) years met inclusion criteria. Approximately 13.7% reported new opioid misuse at follow-up. Those reporting opioid misuse at follow-up were more likely to be White, lack a college education, or report depression. Those exposed to inpatient hospitalization, emergency departments, or mental-health facilities had an increased risk of future opioid misuse. In young adults reporting no opioid misuse at baseline, healthcare exposure was associated with an increased risk of opioid misuse later in adulthood in this large, national cohort. Physicians encounter this at-risk population daily, reinforcing the importance of responsible prescribing practices and the need for targeted screening, patient education, and intervention efforts in the healthcare setting.