Nonmedical Opioid Use Research Articles

Preoperative Patient Education and Smaller Prescription Quantity Reduce Opioid Use After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Results of a Prospective Study.

Most opioids prescribed postoperatively are unused. Leftover opioids are a major source of nonmedical opioid use among adolescents. Postoperative opioid use has also been associated with prescription quantity. Our purpose was to evaluate the effect of preoperative patient education and implementation of evidence-based prescribing guidelines on opioid use and pain level after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). AIS patients aged 10 to 17 years undergoing PSF were prospectively enrolled [postintervention cohort (POST-INT)]. Previous data on 77 patients showed median consumption of 29 doses of oxycodone after PSF [preintervention cohort (PRE-INT)]. All eligible patients during the study period were discharged with 30 doses of oxycodone and standard nonopioid analgesics. Only study participants received education on postoperative pain control. Demographics, radiographic/surgical data, pain level, and patient-reported outcomes were collected. Requests for opioid refills were documented. Forty-nine patients were enrolled. POST-INT was divided into low (L, ≤8 doses), average (AVE, 9-25), and high (H, >25) opioid use groups. Demographics, radiographic/surgical data, pain level, and patient-reported outcomes were similar between the groups. However, there was a difference in days of oxycodone use, doses consumed in the first week, and leftover doses ( P <0.001). Comparison to the PRE-INT L (≤16 doses), AVE (17 to 42), and high (H, >42) use groups showed that POST-INT L and AVE consumed less oxycodone (L: P =0.002; AVE: P <0.001). Also, the overall POST-INT cohort had fewer mean days of oxycodone use (5.6 vs. 8.9, P <0.001) and doses used in the first week (14 vs. 23, P <0.001) compared with the PRE-INT cohort. Subanalysis showed fewer study participants requested and received an opioid refill [3/49 patients (6%)] compared with eligible patients who declined to participate, withdrew, or missed enrollment [8/35 patients (23%)] ( P =0.045). Preoperative patient education and smaller prescription quantity successfully reduced opioid use while maintaining excellent pain control after PSF for AIS. Setting expectations regarding postoperative pain management is critical, as nonstudy participants were significantly more likely to request an opioid refill. Level II-therapeutic.

Tramadol misuse in treatment-seeking adolescents and young adults with problematic substance use – Prediction of treatment retention

Non-medical prescription use of opioids (NMPUO) is a public health concern worldwide. Recently, tramadol misuse is increasing, but the systematic research of misuse of this specific opioid is limited. This study set out to assess the relationship between tramadol use and completion of treatment for substance use among adolescents and adults ≤ 25 years in an outpatient clinical setting. A retrospective cohort study of treatment outcome, expressed as “completion” or “non-completion” of treatment, was conducted in treatment-seeking adolescents with problematic substance use (n = 335). Data was extracted from Ung-DOK interviews, a semi-structured assessment instrument designed for adolescents with substance abuse. The study included all treatment-seeking patients at an out-patient facility in 2014–2017. A total of 26% (n = 88) were tramadol users (life-time prevalence). Twenty percent (n = 66) of all treatments were non-completed. Tramadol users were significantly more likely than non-users to drop out of treatment (35% vs 15%, p < 0.001). In multivariate logistic regression, tramadol use and age 18 and above were factors significantly associated with non-completion. Tramadol use was statistically significantly associated with non-completion of treatment. Further research addressing treatment needs and treatment completion among tramadol users is needed.

Managing Cancer Pain in Patients With Opioid Use Disorder or Nonmedical Opioid Use

In this issue of JAMA Oncology, Fitzgerald Jones et al1 publish the results of a Delphi consensus panel on the management of pain in patients with advanced cancer in the context of opioid use disorder or nonmedical opioid use.

Conceptualizing the Socio-Built Environment: An Expanded Theoretical Framework to Promote a Better Understanding of Risk for Nonmedical Opioid Overdose Outcomes in Urban and Non-Urban Settings.

Nonmedical opioid (NMO) use has been linked to significant increases in rates of NMO morbidity and mortality in non-urban areas. While there has been a great deal of empirical evidence suggesting that physical features of built environments represent strong predictors of drug use and mental health outcomes in urban settings, there is a dearth of research assessing the physical, built environment features of non-urban settings in order to predict risk for NMO overdose outcomes. Likewise, there is strong extant literature suggesting that social characteristics of environments also predict NMO overdoses and other NMO use outcomes, but limited research that considers the combined effects of both physical and social characteristics of environments on NMO outcomes. As a result, important gaps in the scientific literature currently limit our understanding of how both physical and social features of environments shape risk for NMO overdose in rural and suburban settings and therefore limit our ability to intervene effectively. In order to foster a more holistic understanding of environmental features predicting the emerging epidemic of NMO overdose, this article presents a novel, expanded theoretical framework that conceptualizes "socio-built environments" as comprised of (a) environmental characteristics that are applicable to both non-urban and urban settings and (b) not only traditional features of environments as conceptualized by the extant built environment framework, but also social features of environments. This novel framework can help improve our ability to identify settings at highest risk for high rates of NMO overdose, in order to improve resource allocation, targeting, and implementation for interventions such as opioid treatment services, mental health services, and care and harm reduction services for people who use drugs.

Becoming our young people’s case managers: caregivers’ experiences, needs, and ideas for improving opioid use treatments for young people using opioids

BackgroundEvidence continues to show that young people, ages 15-24, remain at significant risk of harms from non-medical opioid use and opioid use disorder (OUD), with experts calling for widespread implementation of developmentally-appropriate interventions. These recommendations include the involvement of caregivers in the prevention, early intervention, and treatment of young people using opioids. However, little research has investigated caregivers’ experiences supporting young people, leaving critical gaps in understanding this role. The aim of this study is to explore caregivers’ experiences accessing opioid use treatments with young people and their needs and ideas for improving such treatments.MethodsThis study reports qualitative findings from Phase 1 of the Improving Treatment Together project, a multi-phase, multi-site community-based participatory study broadly aimed at co-designing opioid use treatments to improve the experiences and outcomes of young people using non-medical opioids. During Phase 1, a total of 27 caregivers (parents, guardians) participated in full-day workshops that were conducted in three communities in British Columbia, Canada. Following human-centred co-design methods, caregivers engaged in small and large group discussions of their experiences, needs, and ideas for improving opioid use treatments for young people. Discussions were audio-recorded, transcribed verbatim, and thematically analysed.ResultsAcross communities, caregivers’ main experiences were defined as ‘becoming our young people’s case managers’ and ‘enduring a never-ending rollercoaster’. To improve these experiences, two needs themes were identified – expanding organizational and system-level capacity and wider-spread understanding of opioid use as a health issue. Caregivers brainstormed a total of 378 individual ideas to meet these needs, several of which spanned multiple needs themes.ConclusionsCaregivers’ experiences, needs, and ideas reveal critical opportunities for improving the quality of interventions for opioid use among young people. This study represents a substantial contribution to the design and implementation of developmentally-appropriate and family-centred interventions for young people using opioids.

Comorbid Affective and Substance Use Disorders of Medicaid/Medicare Beneficiaries at an Opioid Treatment Program Serving Small Urban and Rural Communities.

ObjectivesIdentify rates and correlates of comorbid affective and substance use disorders among an understudied population, Medicaid/Medicare beneficiaries receiving care at an opioid treatment program serving patients from small urban and rural areas. Examine whether past-year non-medical opioid use status differentiates comorbidity status.MethodsA cross-sectional, venue-based design was used to recruit a convenience sample of patients treated with methadone for opioid use disorder. Measures were assessed across three domains: (1) demographic characteristics, (2) opioid use characteristics, and (3) comorbid disorders. Brief validated screeners categorized probable comorbid disorders. Bivariate analyses examined correlates of comorbid disorders and determined variable selection for multivariable analyses.ResultsIn this sample (N = 210; mean age = 38.5 years; female = 62.2%; Non-Hispanic White race/ethnicity = 86.1%), comorbid disorders were common. Rates were as follows: current anxiety (48.1%), depression (41.1%), and PTSD (33.7%), and past-year stimulant (27.6%), marijuana (19.0%), alcohol (14.9%), and sedative (7.6%). In bivariate analyses, past-year non-medical opioid use and a greater accumulation of opioid use consequences were associated with most disorders. When including demographic and opioid use characteristics in multivariable analyses, past-year non-medical opioid use was associated with anxiety, PTSD, stimulant use disorder, and sedative use disorder.ConclusionsFew studies have investigated comorbid disorders among this understudied population. This analysis highlights a high burden, especially for affective disorders. Our findings demonstrate that routine, ongoing assessment of non-medical opioid use may be a promising and feasible strategy to detect patients needing integrated care. Future research should investigate whether changes to assessment protocols at opioid treatment programs in small urban and rural settings facilitate care coordination.

Beyond the Basics: Evidence-Based Approaches to Managing Pain in Individuals with Serious Illness and Opioid Use Disorder (OUD) or Non-Medical Opioid Use (P04)

Beyond the Basics: Evidence-Based Approaches to Managing Pain in Individuals with Serious Illness and Opioid Use Disorder (OUD) or Non-Medical Opioid Use (P04)

Naloxone protection, social support, network characteristics, and overdose experiences among a cohort of people who use illicit opioids in New York City

BackgroundDespite increased availability of take-home naloxone, many people who use opioids do so in unprotected contexts, with no other person who might administer naloxone present, increasing the likelihood that an overdose will result in death. Thus, there is a social nature to being “protected” from overdose mortality, which highlights the importance of identifying background factors that promote access to protective social networks among people who use opioids.MethodsWe used respondent-driven sampling to recruit adults residing in New York City who reported recent (past 3-day) nonmedical opioid use (n = 575). Participants completed a baseline assessment that included past 30-day measures of substance use, overdose experiences, and number of “protected” opioid use events, defined as involving naloxone and the presence of another person who could administer it, as well as measures of network characteristics and social support. We used modified Poisson regression with robust variance to estimate unadjusted and adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs).Results66% of participants had ever been trained to administer naloxone, 18% had used it in the past three months, and 32% had experienced a recent overdose (past 30 days). During recent opioid use events, 64% reported never having naloxone and a person to administer present. This was more common among those: aged ≥ 50 years (PR: 1.18 (CI 1.03, 1.34); who identified as non-Hispanic Black (PR: 1.27 (CI 1.05, 1.53); experienced higher levels of stigma consciousness (PR: 1.13 (CI 1.00, 1.28); and with small social networks (< 5 persons) (APR: 1.14 (CI 0.98, 1.31). Having a recent overdose experience was associated with severe opioid use disorder (PR: 2.45 (CI 1.49, 4.04), suicidality (PR: 1.72 (CI 1.19, 2.49), depression (PR: 1.54 (CI 1.20, 1.98) and positive urinalysis result for benzodiazepines (PR: 1.56 (CI 1.23, 1.96), but not with network size.ConclusionsResults show considerable gaps in naloxone protection among people who use opioids, with more vulnerable and historically disadvantaged subpopulations less likely to be protected. Larger social networks of people who use opioids may be an important resource to curtail overdose mortality, but more effort is needed to harness the protective aspects of social networks.

Depression and Long-Term Prescription Opioid Use and Opioid Use Disorder: Implications for Pain Management in Cancer.

Opinion statementPreventing depression in cancer patients on long-term opioid therapy should begin with depression screening before opioid initiation and repeated screening during treatment. In weighing the high morbidity of depression and opioid use disorder in patients with chronic cancer pain against a dearth of evidence-based therapies studied in this population, patients and clinicians are left to choose among imperfect but necessary treatment options. When possible, we advise engaging psychiatric and pain/palliative specialists through collaborative care models and recommending mindfulness and psychotherapy to all patients with significant depression alongside cancer pain. Medications for depression should be reserved for moderate to severe symptoms. We recommend escitalopram/citalopram or sertraline among selective serotonin reuptake inhibitors (SSRIs), or the serotonin and norepinephrine reuptake inhibitors (SNRIs) duloxetine, venlafaxine, or desvenlafaxine if patients have a significant component of neuropathic pain or fibromyalgia. Tricyclic antidepressants (TCAs) (consider nortriptyline or desipramine, which have better anticholinergic profiles) should be considered for patients who do not respond to or tolerate SSRI/SNRIs. Existing evidence is inadequate to definitively recommend methylphenidate or novel agents, such as ketamine or psilocybin, as adjunctive treatments for cancer-related depression and pain. Physicians who treat patients with cancer pain should utilize universal precautions to limit the risk of non-medical opioid use (non-medical opioid use). Patients should be screened for non-medical opioid use behaviors at initial consultation and at regular intervals during treatment using a non-judgmental approach that reduces stigma. Co-management with an addiction specialist may be indicated for patients at high risk of non-medical opioid use and opioid use disorder. Buprenorphine and methadone are indicated for the treatment of opioid use disorder, and while they have not been systematically studied for treatment of opioid use disorder in patients with cancer pain, they do provide analgesia for cancer pain. While an interdisciplinary team approach to manage psychological stress may be beneficial, this may not be possible for patients treated outside of comprehensive cancer centers.

Polysubstance use poisoning deaths in Canada: an analysis of trends from 2014 to 2017 using mortality data

BackgroundOver the past decade, rates of drug poisoning deaths have increased dramatically in Canada. Current evidence suggests that the non-medical use of synthetic opioids, stimulants and patterns of polysubstance use are major factors contributing to this increase.MethodsCounts of substance poisoning deaths involving alcohol, opioids, other central nervous system (CNS) depressants, cocaine, and CNS stimulants excluding cocaine, were acquired from the Canadian Vital Statistics Death Database (CVSD) for the years 2014 to 2017. We used joinpoint regression analysis and the Cochrane-Armitage trend test for proportions to examine changes over time in crude mortality rates and proportions of poisoning deaths involving more than one substance.ResultsBetween 2014 and 2017, the rate of substance poisoning deaths in Canada almost doubled from 6.4 to 11.5 deaths per 100,000 population (Average Annual Percent Change, AAPC: 23%, p < 0.05). Our analysis shows this was due to increased unintentional poisoning deaths (AAPC: 26.6%, p < 0.05) and polysubstance deaths (AAPC: 23.0%, p < 0.05). The proportion of unintentional poisoning deaths involving polysubstance use increased significantly from 38% to 58% among males (p < 0.0001) and 40% to 55% among females (p < 0.0001). Polysubstance use poisonings involving opioids and CNS stimulants (excluding cocaine) increased substantially during the study period (males AAPC: 133.1%, p < 0.01; females AAPC: 118.1%, p < 0.05).ConclusionsIncreases in substance-related poisoning deaths between 2014 and 2017 were associated with polysubstance use. Increased co-use of stimulants with opioids is a key factor contributing to the epidemic of opioid deaths in Canada.

Worsening sleep quality across the lifespan and persistent sleep disturbances in persons with opioid use disorder.

Individuals with opioid use disorder (OUD) may experience worsening sleep quality over time, and a subset of individuals may have sleep disturbances that precede opioid use and do not resolve following abstinence. The purpose of the present study was to (1) collect retrospective reports of sleep across the lifespan and (2) identify characteristics associated with persistent sleep disturbance and changes in sleep quality in persons with OUD. Adults with OUD (n = 154) completed a cross-sectional study assessing current and past sleep disturbance, opioid use history, and chronic pain. Repeated-measures analysis of variance was used to examine changes in retrospectively reported sleep quality, and whether changes varied by screening positive for insomnia and/or chronic pain. Multivariate linear regression analyses were used to identify additional correlates of persistent sleep disturbance. Participants reported that their sleep quality declined over their lifespan. Changes in reported sleep over time varied based on whether the individual screened positive for co-occurring insomnia and/or chronic pain. In regression analyses, female sex (β = 0.16, P = .042), a greater number of treatment episodes (β = 0.20, P = .024), and positive screens for chronic pain (β = 0.19, P = .018) and insomnia (β=0.22, P = .013) were associated with self-reported persistent sleep disturbance. Only a portion of participants who screened positive for sleep disorders had received a formal diagnosis. OUD treatment providers should routinely screen for co-occurring sleep disturbance and chronic pain. Interventions that treat co-occurring OUD, sleep disturbance, and chronic pain are needed. Ellis JD, Mayo JL, Gamaldo CE, Finan PH, Huhn AS. Worsening sleep quality across the lifespan and persistent sleep disturbances in persons with opioid use disorder. J Clin Sleep Med. 2022;18(2):587-595.

Supportive environments during the substance use disorder epidemic in the rural United States: Provider support for interventions and expectations of interactions with providers

BackgroundHarm reduction interventions, including SSP (Syringe Services Programs) and MAT (Medications for Addiction Treatment) have demonstrated the potential to help stem the epidemic of opioid use disorder. However, for that potential to be realized, people must expect that healthcare providers will be supportive if they ever seek care for substance use. MethodsThis cross-sectional study investigated perceptions of provider support for SSP and MAT in the general population of 14 states selected specifically for 50 percent of the sample to include participants from rural counties with high rates of non-medical opioid use and injection. A survey of 3096 adults in 14 states and 675 counties within the Appalachian and Midwestern regions of the United States (collected between November of 2019 and May of 2020) examined the association between perceptions of provider support for harm reduction interventions, community members’ trust of community healthcare providers, and expectations for patient-provider interactions involving disclosure of non-medical drug use. Results and conclusionPath analysis supported the hypothesis that perceptions of provider support for harm reduction interventions predict positive expectations about patient-provider interactions and that trust in providers mediates this association. The model fit well among participants who reported past non-medical use of drugs and those who did not. In contrast to other research suggesting that trust in providers may be inconsequential during the initial stages of care, the current research suggests that trust may shape expectations about patient-provider interactions even before people use drugs. Communication of support for harm reduction interventions by providers may play an important role in promoting health care-seeking in populations that use drugs currently or who may use drugs in the future in high-risk rural areas of the United States.

Outcomes from the medication assisted treatment pilot program for adults with opioid use disorders in rural Colorado

BackgroundAs Colorado ranked among the top nationally in non-medical use of opioids, a pilot medication for opioid use disorder (MOUD) program was developed to increase the number of NPs and PAs providing MOUD in order to bring this evidence- based treatment to 2 counties showing disproportionally high opioid overdose deaths. Over the first 18 months, the MOUD Pilot Program led to 15 new health care providers receiving MOUD waiver training and 1005 patients receiving MOUD from the 3 participating organizations. Here we evaluate patient centered clinical and functional outcomes of the pilot MOUD program implemented in 2 rural counties severely affected by the opioid crisis.MethodsUnder state-funded law (Colorado Senate Bill 17–074), three rural agencies submitted de-identified patient-level data at baseline (N = 1005) and after 6 months of treatment (N = 190, 25%) between December 2017 and January 2020. The Addiction Severity Index, PhQ9 and GAD-7 with McNemar-Bowker, and Wilcoxon Signed Rank tests analysis were used to measure patient outcomes across after participation in the program. .ResultsPatients in treatment reported using less heroin (52.1% vs 20.4%), opioids (22.3% vs 11.0%), and alcohol (28.6% vs 13.1%, all P < 0.01). Patients reported improved health (53.4% vs. 68.2%, P = 0.04), less frequency of disability (8.69 vs. 6.51, P = 0.02), symptoms (29.8% vs 21.3%), pain (67.5% to 53.6), worry (45.3% vs 62.3%), anxiety (49.7% vs 23.2%), depression (54.1% vs 23.3%, all P < 0.02) after treatment.ConclusionsThis study shows decreased substance use, improved physical and mental health, and reduced symptoms after 6 months of MOUD. Although more research on retention and long-term effects is needed, data shows improved health outcomes after 6 months of MOUD. Lessons learned from implementing this pilot program informed program expansion into other rural areas in need to address some of Colorado’ major public health crises.

Cancer Pain and Opioid Use Disorder.

Opioid use disorder (OUD) is increasingly recognized and co-present in patients with cancer. Unfortunately, OUD is not addressed or treated adequately in oncology settings. In addition, patients with cancer-related pain treated with narcotic pain medications are at risk for nonmedical opioid use (NMOU). More than two-thirds of patients with advanced cancer have pain. Both OUD and NMOU need to be concomitantly addressed alongside cancer-related pain management to avoid complications such as overdose. We review the approach to identifying and treating OUD and NMOU in patients with cancer and cancer-related pain.

For Better or Worse: Self-reported Changes in Kratom and Other Substance Use as a Result of the COVID-19 Pandemic.

Background:Kratom is taken to self-treat pain and symptoms of psychiatric disorders, including substance-use disorders (SUDs) and opioid withdrawal. Before COVID-19, kratom use was increasing in the US, however, there are few published data on whether that trend continued during the COVID-19 pandemic, which could have affected kratom use in multiple ways.Aim:To examine COVID-19-related changes in kratom use and how these changes were experienced, relative to changes in other commonly used substances.Methods:Using Amazon Mechanical Turk, 2615 evaluable surveys were completed between September 2020 and March 2021. Responses from past-month and past-year kratom-using adults (N = 174) indicating changes for the better or worse were examined using generalized linear mixed effects models, and relevant open-text responses (n = 85) were thematically coded.Results:For kratom 33% (n = 58) reported a Covid-related increase and 24% (n = 42) reported a Covid-related decrease. Controlling for changes in amount used, alcohol (OR = 5.02), tobacco (OR = 4.72), and nonmedical opioid use (OR = 3.42) were all more likely to have changed for the worse, compared with kratom use. Relative to decreases in kratom use, decreases in alcohol (OR = 3.21) and tobacco (OR = 6.18) use were more likely to be changes for the better. Cannabis use was the only substance to display a probability lower than 50% of being a decrease for the better, and of the increases, cannabis use displayed the highest probability of being for the better.Conclusions:Increases in kratom and cannabis use were less likely than alcohol and tobacco to be reported as changes for the worse, and decreases in kratom and cannabis use were more likely than alcohol and tobacco to be reported as changes for the better. These findings indicate that people differently conceptualize their relationships with kratom and cannabis, compared to their relationships with alcohol and tobacco.

Kratom Use in the US: Both a Regional Phenomenon and a White Middle-Class Phenomenon? Evidence From NSDUH 2019 and an Online Convenience Sample.

Kratom products available in the United States are becoming increasingly diverse both in terms of content and in terms of how they are marketed. Prior survey research indicates that kratom has been primarily used in the US to self-treat anxiety, depression, pain, fatigue, and substance use disorder (SUD) symptoms. Kratom is also well-known for its use as a short- or long-term full opioid agonist substitute. Therefore, use may be greater in regions particularly impacted by addiction to prescription opioids. Use may also be greater in demographic groups targeted by media outlets (such as specific podcasts) in which kratom is touted. Here, we aimed to determine whether lifetime and past-year kratom use were associated with region of residence and with being young, White, post-secondary educated, and employed. To strengthen confidence in our findings, we analyzed data from two sources: our own crowdsourced online convenience sample and the 2019 National Survey on Drug Use and Health (NSDUH). In our sample (N = 2,615), 11.1% reported lifetime and 6.7% reported past-year kratom use, and the odds of kratom use were higher among people who were White, younger, at least high school educated, employed, and above the poverty line, as well as those reporting nonmedical opioid use, past-year SUD, or lifetime SUD treatment; residence was not a significant predictor. In NSDUH data, suburban residence and other demographic factors, concordant with those from the crowdsourced sample, were associated with kratom use. Taken together, the findings support a general “White middle-class suburban” profile of the modal kratom user, but more research is needed to understand it. In the interim, focus should be on our finding that lifetime nonmedical opioid use was associated with an up to five times greater likelihood of past-year kratom use, suggesting that drug-use history may presently be the strongest predictor of kratom use.

Latent trajectories of anxiety and depressive symptoms among adults in early treatment for nonmedical opioid use

BackgroundUnderstanding the course of anxiety and depressive symptoms in early opioid use disorder (OUD) treatment may inform efforts to promote positive early treatment response and reduce treatment attrition. MethodsPersons in treatment for nonmedical opioid use were identified from 86 addiction treatment facilities. Growth mixture modeling was used to identify trajectories of anxiety and depression symptoms during the first month of treatment among individuals who screened positive for depression (N = 3016) and/or anxiety (N = 2779) at intake. ResultsA three-class solution best fit the data for anxiety symptoms and included the following trajectories: (1) persistent moderate-to-severe anxiety symptoms, (2) remitting severe anxiety symptoms, and (3) persistent minimal-to-mild anxiety symptoms. Similarly, a three-class solution best fit the data for depressive symptoms and included trajectories characterized by (1) persistent moderate-to-severe depressive symptoms, (2) persistent moderate depressive symptoms, and (3) mild/remitting depressive symptoms. Persistent moderate-to-severe anxiety and depressive symptoms were predicted by female gender and heavy past-month benzodiazepine co-use. LimitationsFine grained-information about substance use was not collected. Results may not be generalizable to individuals receiving treatment outside of specialty addiction clinics. ConclusionsAnalysis of anxiety and depression symptom trajectories in early treatment suggest that a subset of individuals entering treatment for opioid use experienced persistent and significant anxiety and depressive symptoms, whereas others experience a remission of symptoms. Interventions designed to target individuals at the greatest risk, such as women and individuals reporting opioid/benzodiazepine co-use, may help improve mental health symptoms in early OUD treatment.

Nonmedical Opioid Use After Short-term Therapeutic Exposure in Children: A Systematic Review

Opioid-related harms continue to rise for children and youth. Analgesic prescribing decisions are challenging because the risk for future nonmedical opioid use or disorder is unclear. To synthesize research examining the association between short-term therapeutic opioid exposure and future nonmedical opioid use or opioid use disorder and associated risk factors. We searched 11 electronic databases. Two reviewers screened studies. Studies were included if: they were published in English or French, participants had short-term (≤14 days) or an unknown duration of therapeutic exposure to opioids before 18 years, and reported opioid use disorder or misuse. Data were extracted, and methodologic quality was assessed by 2 reviewers. Data were summarized narratively. We included 21 observational studies (49 944 602 participants). One study demonstrated that short-term therapeutic exposure may be associated with opioid abuse; 4 showed an association between medical and nonmedical opioid use without specifying duration of exposure. Other studies reported on prevalence or incidence of nonmedical use after medical exposure to opioids. Risk factors were contradictory and remain unclear. Most studies did not specify duration of exposure and were of low methodologic quality, and participants might not have been opioid naïve. Some studies suggest an association between lifetime therapeutic opioid use and nonmedical opioid use. Given the lack of clear evidence regarding short-term therapeutic exposure, health care providers should carefully evaluate pain management options and educate patients and caregivers about safe, judicious, and appropriate use of opioids and potential signs of misuse.

Associations of Lifetime Nonmedical Opioid, Methamphetamine, and Kratom Use within a Nationally Representative US Sample

ABSTRACT Co-use of non-medical opioids (NMO) and methamphetamine is increasing. So too is the use of the psychoactive botanical “kratom,” including among people with NMO and methamphetamine use histories. We assessed characteristics associated with respondent groups who reported lifetime methamphetamine and/or kratom use within a nationally representative US sample using 2019 National Survey on Drug Use and Health data from respondents reporting lifetime NMO use (diverted prescription opioids, heroin). Weighted prevalence estimates for demographic, mental health, and substance use outcomes were determined. Logistic regression examined associations between group membership and outcomes. Among this sample of respondents with lifetime NMO use, 67.6% (95% CI = 65.6–69.4%) reported only NMO use; 4.6% (3.9–5.4%) reported NMO+Kratom; 24.7% (22.7–26.7%) reported NMO+Methamphetamine; and 3.2% (2.5–3.9%) reported NMO+Methamphetamine+Kratom. Compared to those in the NMO-only group, the NMO+Kratom group was more likely to report past-year serious mental illness (SMI; OR = 2.27), suicidality (OR = 1.89), and past-month psychological distress (OR = 1.88). The NMO+Methamphetamine+Kratom group was more likely to report past-year SMI (OR = 2.65), past-month psychological distress (OR = 2.06), and unmet mental health needs (OR = 2.03); increased odds for drug injection, opioid withdrawal, and perceived treatment need also emerged. Risk factors were observed for all groups but were greatest among those reporting use of all three substances.

Closed-loop wearable naloxone injector system

Overdoses from non-medical use of opioids can lead to hypoxemic/hypercarbic respiratory failure, cardiac arrest, and death when left untreated. Opioid toxicity is readily reversed with naloxone, a competitive antagonist that can restore respiration. However, there remains a critical need for technologies to administer naloxone in the event of unwitnessed overdose events. We report a closed-loop wearable injector system that measures respiration and apneic motion associated with an opioid overdose event using a pair of on-body accelerometers, and administers naloxone subcutaneously upon detection of an apnea. Our proof-of-concept system has been evaluated in two environments: (i) an approved supervised injection facility (SIF) where people self-inject opioids under medical supervision and (ii) a hospital environment where we simulate opioid-induced apneas in healthy participants. In the SIF (n = 25), our system identified breathing rate and post-injection respiratory depression accurately when compared to a respiratory belt. In the hospital, our algorithm identified simulated apneic events and successfully injected participants with 1.2 mg of naloxone. Naloxone delivery was verified by intravenous blood draw post-injection for all participants. A closed-loop naloxone injector system has the potential to complement existing evidence-based harm reduction strategies and, in the absence of bystanders, help make opioid toxicity events functionally witnessed and in turn more likely to be successfully resuscitated.