Pharmaceutical Opioids Research Articles

Clinical outcomes and health care costs among people entering a safer opioid supply program in Ontario.

Background:London InterCommunity Health Centre (LIHC) launched a safer opioid supply (SOS) program in 2016, where clients are prescribed pharmaceutical opioids and provided with comprehensive health and social supports. We sought to evaluate the impact of this program on health services utilization and health care costs.Methods:We conducted an interrupted time series analysis of London, Ontario, residents who received a diagnosis of opioid use disorder (OUD) and who entered the SOS program between January 2016 and March 2019, and a comparison group of individuals matched on demographic and clinical characteristics who were not exposed to the program. Primary outcomes were emergency department (ED) visits, hospital admissions, admissions for infections and health care costs. We used autoregressive integrated moving average (ARIMA) models to evaluate the impact of SOS initiation and compared outcome rates in the year before and after cohort entry.Results:In the time series analysis, rates of ED visits (−14 visits/100, 95% confidence interval [CI] −26 to −2; p = 0.02), hospital admissions (−5 admissions/100, 95% CI −9 to −2; p = 0.005) and health care costs not related to primary care or outpatient medications (−$922/person, 95% CI −$1577 to −$268; p = 0.008) declined significantly after entry into the SOS program (n = 82), with no significant change in rates of infections (−1.6 infections/100, 95% CI −4.0 to 0.8; p = 0.2). In the year after cohort entry, the rate of ED visits (rate ratio [RR] 0.69, 95% CI 0.53 to 0.90), hospital admissions (RR 0.46, 95% CI 0.29 to 0.74), admissions for incident infections (RR 0.51, 95% CI 0.27 to 0.96) and total health care costs not related to primary care or outpatient medications ($15 635 v. $7310/person-year; p = 0.002) declined significantly among SOS clients compared with the year before. We observed no significant change in any of the primary outcomes among unexposed individuals (n = 303).Interpretation:Although additional research is needed, this preliminary evidence indicates that SOS programs can play an important role in the expansion of treatment and harm-reduction options available to assist people who use drugs and who are at high risk of drug poisoning.

Opioid agonist treatment for people who are dependent on pharmaceutical opioids.

There are ongoing concerns regarding pharmaceutical opioid-related harms, including overdose and dependence, with an associated increase in treatment demand. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin. OBJECTIVES: To assess the effects of maintenance opioid agonist pharmacotherapy for the treatment of pharmaceutical opioid dependence. We updated our searches of the following databases to January 2022: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, four other databases, and two trial registers. We checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). We included RCTs with adults and adolescents examining maintenance opioid agonist treatments that made the following two comparisons. 1. Full opioid agonists (methadone, morphine, oxycodone, levo-alpha-acetylmethadol (LAAM), or codeine) versus different full opioid agonists or partial opioid agonists (buprenorphine) for maintenance treatment. 2. Full or partial opioid agonist maintenance versus non-opioid agonist treatments (detoxification, opioid antagonist, or psychological treatment without opioid agonist treatment). We used standard Cochrane methods. We identified eight RCTs that met inclusion criteria (709 participants). We found four studies that compared methadone and buprenorphine maintenance treatment, and four studies that compared buprenorphine maintenance to either buprenorphine taper (in addition to psychological treatment) or a non-opioid maintenance treatment comparison. We found low-certainty evidence from three studies of a difference between methadone and buprenorphine in favour of methadone on self-reported opioid use at end of treatment (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.28 to 0.86; 165 participants), and low-certainty evidence from four studies finding a difference in favour of methadone for retention in treatment (RR 1.21, 95% CI 1.02 to 1.43; 379 participants). We found low-certainty evidence from three studies showing no difference between methadone and buprenorphine on substance use measured with urine drug screens at end of treatment (RR 0.81, 95% CI 0.57 to 1.17; 206 participants), and moderate-certainty evidence from one study of no difference in days of self-reported opioid use (mean difference 1.41 days, 95% CI 3.37 lower to 0.55 days higher; 129 participants). There was low-certainty evidence from three studies of no difference between methadone and buprenorphine on adverse events (RR 1.13, 95% CI 0.66 to 1.93; 206 participants). We found low-certainty evidence from four studies favouring maintenance buprenorphine treatment over non-opioid treatments in terms of fewer opioid positive urine drug tests at end of treatment (RR 0.66, 95% CI 0.52 to 0.84; 270 participants), and very low-certainty evidence from four studies finding no difference on self-reported opioid use in the past 30 days at end of treatment (RR 0.63, 95% CI 0.39 to 1.01; 276 participants). There was low-certainty evidence from three studies of no difference in the number of days of unsanctioned opioid use (standardised mean difference (SMD) -0.19, 95% CI -0.47 to 0.09; 205 participants). There was moderate-certainty evidence from four studies favouring buprenorphine maintenance over non-opioid treatments on retention in treatment (RR 3.02, 95% CI 1.73 to 5.27; 333 participants). There was moderate-certainty evidence from three studies of no difference in adverse effects between buprenorphine maintenance and non-opioid treatments (RR 0.50, 95% CI 0.07 to 3.48; 252 participants). The main weaknesses in the quality of the data was the use of open-label study designs, and difference in follow-up rates between treatment arms. There is very low- to moderate-certainty evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. Methadone or buprenorphine did not differ on some outcomes, although on the outcomes of retention and self-reported substance use some results favoured methadone. Maintenance treatment with buprenorphine appears more effective than non-opioid treatments. Due to the overall very low- to moderate-certainty evidence and small sample sizes, there is the possibility that the further research may change these findings.

Tramadol and Codeine Stacking/Boosting Dose Exposure Induced Neurotoxic Behaviors, Oxidative Stress, Mitochondrial Dysfunction, and Neurotoxic Genes in Adolescent Mice

In spite of the increasing epidemic of pharmaceutical opioids (codeine and tramadol) misuse and abuse among the adolescents, little is known about the neurotoxic consequences of the widespread practice of tramadol and codeine abuse involving increasing multiple doses across days, referred to as stacking and boosting. Hence, in this study, we replicated stacking and boosting doses of tramadol, codeine alone, or in combination on spontaneous motor activity and cognitive function in adolescent mice and adduced a plausible mechanism of possible neurotoxicity. Ninety-six adolescent mice were randomly distributed into 4 groups (n = 24 per group) and treated thrice daily for 9days with vehicle, tramadol (20, 40, or 80mg/kg), codeine (40, 80, or 160mg/kg), or their combinations. Exposure of mice to tramadol induced hyperactivity and stereotypic behavior while codeine exposure caused hypoactivity and nootropic effect but tramadol-codeine cocktail led to marked reduction in spontaneous motor activity and cognitive function. In addition, tramadol, codeine, and their cocktail caused marked induction of nitroso-oxidative stress and inhibition of mitochondrial complex I activity in the prefrontal cortex (PFC) and midbrain (MB). Real-time PCR expression profiling of genes encoding neurotoxicity (RT) showed that tramadol exposure upregulate 57 and downregulate 16 neurotoxic genes, codeine upregulate 45 and downregulate 25 neurotoxic genes while tramadol-codeine cocktail upregulate 52 and downregulate 20 neurotoxic genes in the PFC. Findings from this study demonstrate that the exposure of adolescents mice to multiple and increasing doses of tramadol, codeine, or their cocktail lead to spontaneous motor coordination deficits indicative of neurotoxicity through induction of oxidative stress, inhibition of mitochondrial complex I activity and upregulation of neurotoxicity encoding genes in mice.

“They say it’s fentanyl, but they honestly look like Perc 30s”: Initiation and use of counterfeit fentanyl pills

BackgroundWorsening of the overdose crisis in the USA has been linked to the continuing proliferation of non-pharmaceutical fentanyl (NPF). The recent wave of NPF spread in the USA has been fueled by an increased presence of counterfeit pills that contain NPF. This qualitative study aims to characterize the motivation and practices of counterfeit NPF pill initiation and use among individuals using illicit opioids in Arizona.MethodsBetween October 2020 and May 2021, semi-structured interviews were conducted with 22 individuals meeting the following eligibility criteria: (1) 18 years or older; (2) residence in Arizona; and (3) use of illicit opioids in the past 30 days and/or opioid use disorder treatment in the past 12 months. Participants were recruited through referrals by a harm reduction organization, craigslist ads, and referrals by other participants. Interviews were conducted virtually via Zoom. Qualitative interviews were transcribed and analyzed thematically using NVivo.ResultsOut of 22 participants, 64% were male, and 45% were ethnic minorities. Age ranged between 25 and 51 years old. Participants noted significant recent increases in the availability of counterfeit NPF pills (“blues,” “dirty oxys”) that were most commonly used by smoking. The majority indicated first trying NPF pills in the past year, and the first use often occurred in situations of reduced access to heroin or pharmaceutical opioids. Participant decisions to switch over to more frequent NPF pill use or to maintain some levels of heroin use were shaped by local drug availability trends and personal experiences with NPF effects. They were also influenced by conflicting views of social acceptability of pharmaceutical-like drugs, perceived harms of NPF in terms of overdose risks and increased difficulty of quitting, and perceived benefits of switching to the non-injection route of opioid administration (e.g., from injecting heroin to smoking NPF pills).ConclusionOur findings highlight the need for the implementation of novel policy, treatment, and harm reduction approaches to address the growing unpredictability of drug supply and NPF pill-specific risks, attitudes, and behaviors.

Retrospective analysis of patterns of opioid overdose and interventions delivered at a tertiary hospital emergency department: impact of COVID-19

BackgroundOpioid-related overdoses cause substantial numbers of preventable deaths. Naloxone is an opioid antagonist available in take-home naloxone (THN) kits as a lifesaving measure for opioid overdose. As the emergency department (ED) is a primary point of contact for patients with high-risk opioid use, evidence-based recommendations from the Society of Hospital Pharmacists of Australia THN practice guidelines include the provision of THN, accompanied by psychosocial interventions. However, implementation of these guidelines in practice is unknown. This study investigated ED opioid-related overdose presentations, concordance of post-overdose interventions with the THN practice guidelines, and the impact, if any, of the SARS-CoV-2 (COVID-19) pandemic on case presentations.MethodsA single-centre retrospective audit was conducted at a major tertiary hospital of patients presenting with overdoses involving opioids and non-opioids between March to August 2019 and March to August 2020. Patient presentations and interventions delivered by the paramedics, ED and upon discharge from the ED were collated from medical records and analysed using descriptive statistics, chi square and independent T-tests.ResultsThe majority (66.2%) of patients presented to hospital with mixed drug overdoses involving opioids and non-opioids. Pharmaceutical opioids were implicated in a greater proportion (72.1%) of overdoses than illicit opioids. Fewer patients presented in March to August 2020 as compared with 2019 (26 vs. 42), and mixed drug overdoses were more frequent in 2020 than 2019 (80.8% vs. 57.1%). Referral to outpatient psychology (22.0%) and drug and alcohol services (20.3%) were amongst the most common post-discharge interventions. Naloxone was provided to 28 patients (41.2%) by the paramedics and/or ED. No patients received THN upon discharge.ConclusionsThis study highlights opportunities to improve ED provision of THN and other interventions post-opioid overdose. Large-scale multi-centre studies are required to ascertain the capacity of EDs to provide THN and the impact of COVID-19 on opioid overdose presentations.

How do people who use drugs receiving Opioid Medication Therapy perceive their treatment ? A multicentre study

BackgroundThe resurgence of heroin use and the misuse of pharmaceutical opioids are some of the reasons for a worldwide increase in opioid dependence. Opioid Medication Therapies (OMT) have amply demonstrated their efficacy. From a medical point of view, the main objectives of OMT concern medical and social outcomes, centred on risk reduction and the cessation of opioid use. But patient points of view can differ and few studies have explored opioid-dependent patient viewpoints on their OMT. This variable seems important to consider in a patient-centred approach. The aim of our study was to explore points of view of people who use drugs (PWUD) treated with OMT, in a large multicentre sample.MethodA cross-sectional multicentre study explored the points of view of PWUD with Opioid Use Disorder following OMT. Data regarding the patients’ points of view were collected using a self-administered questionnaire developed by the scientific committee of the study. A descriptive analysis and an exploratory factor analysis were performed to explore the structure of items exploring patient viewpoints.Results263 opioid dependent PWUD were included, a majority were men consuming heroin prior to being prescribed OMT. 68% were on methadone, 32% were on buprenorphine. Most PWUD identified a positive impact on their lives, with 92.8% agreeing or strongly agreeing that OMT had changed a lot of things in their lives. The exploratory factor analysis identified three factors: (F1) items related to points of views concerning the objectives and efficacy of OMT; (F2) items related to the legitimacy of OMT as a treatment compared to a drug, (F3) items related to experiences and relationships with OMT.ConclusionPatient viewpoints on efficacy were correlated with the pharmacological benefits of OMT and with the associated psychosocial measures. The implications of OMT in relationships, such as the feeling of being judged, concerned a majority. Points of view were ambivalent concerning the role of OMT as a treatment or as a drug. Involving patient points of view in therapeutic strategies decisions could help enhance positive views among PWUD on OMT and help PWUD towards their recovery.Trial registration: OPAL study was registered: (NCT01847729).

Immunomodulatory effects of pharmaceutical opioids and antipyretic analgesics: Mechanisms and relevance to infection.

Understanding how pharmaceutical opioids and antipyretic analgesics interact with the immune system potentially has major clinical implications for management of patients with infectious diseases and surgical and critical care patients. An electronic search was carried out on MEDLINE, EMBASE, PsycINFO, CENTRAL and the Cochrane library to identify reports describing the immunomodulatory effects of opioid analgesics and antipyretic analgesics, and their effects in infectious diseases. In adaptive immunity, nonsteroidal anti-inflammatory drugs have divergent effects: augmenting cell-mediated immunity but inhibiting humoral immunity. Nonsteroidal anti-inflammatory drugs have demonstrated a beneficial role in Mycobacterium tuberculosis infection and histoplasmosis in animals, and may be plausible adjuvants to antimicrobial agents in these diseases. There is a need to evaluate these findings rigorously in human clinical trials. There is preliminary evidence demonstrating antiviral effects of indomethacin in SARS CoV-2 in vitro; however, uncertainty regarding its clinical benefit in humans needs to be resolved in large clinical trials. Certain opioid analgesics are associated with immunosuppressive effects, with a developing understanding that fentanyl, morphine, methadone and buprenorphine suppress innate immunity, whilst having diverse effects on adaptive immunity. Morphine suppresses key cells of the innate immunity and is associated with greater risk of infection in the postsurgical setting. Efforts are needed to achieve adequate analgesia whilst avoiding suppression of the innate immunity in the immediate postoperative period caused by certain opioids, particularly in cancer surgery.

Overdose and take-home naloxone in emergency settings: A pilot study examining feasibility of delivering brief interventions addressing overdose prevention with 'take-home naloxone' in emergency departments.

Although most unintentional opioid deaths in Australia are attributed to pharmaceutical opioids, take-home naloxone (THN) programmes have to date predominantly targeted people using illicit opioids in drug treatment and harm reduction settings. We sought to examine the feasibility of delivering THN brief interventions (THN-BIs) with intranasal naloxone in EDs. This pilot feasibility study was conducted across three major metropolitan EDs in Sydney and Melbourne. ED staff were surveyed about their perspectives regarding THN before completing a 30-min training programme in THN-BI delivery. Patients presenting with opioid overdose or considered high risk for future overdose were eligible to receive the THN-BI. Staff survey responses were compared between hospitals and provider types using one-way analysis of variances. Patient demographic and clinical characteristics were extracted from medical records and compared between hospitals and overdose type using Fisher's exact test and one-way analysis of variances. One hundred and twenty-two ED staff completed the survey. One hundred and ten (90.2%) agreed that EDs should provide THN-BIs, whereas 23 (19.2%) identified time constraints and 17 (12.9%) felt uncomfortable discussing overdose with patients. Fifty-seven patients received the THN-BI, with the majority (n= 50, 87.7%) having presented following opioid overdose. The median age was 44 years and 40 (71.4%) were men. Two-thirds of the overdoses (n= 31, 66.0%) were attributed to heroin with one-third (n= 16, 34%) being attributed to pharmaceutical opioids. ED-based delivery of THN-BIs can reach a wide range of individuals at-risk of overdose. The present study supports the feasibility of THN interventions in EDs and underscores the importance of addressing implementation barriers including staff training.

Symposium

Prescription opioid misuse is widely rampant and increasing worldwide. Similar rising trends with reports of patients suffering from prescription opioid dependence are being reported from India. Unregulated prescription of opioids as pain-killers in the US contributed to onset of the ‘epidemic’ of prescription opioid misuse. Pain is a multidimensional and complex experience that has physical, social, spiritual and psychological aspects. Ensuring availability of opioids for treatment of chronic pain conditions is crucial. WHO estimates that 20 million people required end-of-life palliative care, of whom 78 % lived in low and middle income countries. India ranks among the lowest, with only 0.22% citizens having access to opioids for pain relief. While ensuring availability of prescription opioids for pain relief is crucial, it needs close monitoring and regulation as epidemic of prescription opioid misuse was fuelled by illicit marketing of pharmaceutical opioids. Enforcing stricter control has shown plateauing of the misuse and consequences in the US. However, various pros and cons are associated with strict control of opioids like shift to more illicit opioid use (like heroin, fentanyl from illicit drug market) and harmful routes of administration like injecting or insufflating. Stricter enforcement of control of pharmaceutical opioids (licit and illicit marketing) with regular monitoring of the outcomes is necessary, also simultaneous ensuring increased availability and accessibility of treatment for opioid dependent individuals. So the debate on prescription opioid control is ongoing and calls for further discussion in how to regulate the control as well as ensure availability to those who are in genuine need of the same.

Public health strategies to combat opioid epidemic in the United States: A systematic review

Abstract Background The opioid epidemic in the United States is a national public health crisis. Driven by an increase in availability of pharmaceutical opioids and by an increase in their consumption, specifically, for pain treatment, more so in the past twenty years, it has led to an economic cost of prescription opioid abuse, overdose, and dependence in the United States estimated to be 78.5 billion USD. The purpose of this systematic review was to identify and evaluate public health strategies that contribute towards combatting the opioid crisis. Methods Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, a search was conducted of the PubMed database for articles in English language that analyzed the most effective ways to regulate health markets to decrease the opioid crisis in the United States. Results The initial search yielded 2397 titles, of which 15 full-text articles were ultimately selected for inclusion in this systematic review. The review identified four categories in overcoming this epidemic nationwide, including required improvement in patient utilization of and access to safe and effective treatment options for opioid abuse and overdose, addressing the stigma correlated with opioid use, considering appropriate use of abuse deterrent formulations (ADF) along with patient education, and improving prescribing practices via utilization of drug monitoring programs, CDC opioid prescribing guidelines and provider continuing education. Conclusions Attempts to combat the opioid epidemic have been made, and the state and federal governments have only recently started to understand the magnitude of the seriousness of this public health crisis. While the methods with promising improvement of the situation have been identified, implementing them has shown to be a challenge. Continued application is needed, while considering possible new steps that could help reinforce their utilization further. Key messages Attempts to combat the opioid epidemic have been made, and the state and federal governments have only recently started to understand the magnitude of the seriousness of this public health crisis. The methods with promising improvement of the opioid crisis situation have been identified, however utilizing and implementing the existing public health strategies has shown to be a challenge.

Commentary on McCoy et al.: More pieces of the mosaic describing outcomes of the Australian up-scheduling of over-the-counter codeine to prescription only.

Data from the Australian Institute of Health and Welfare (AIHW) about trends in treatment and non-medical use of codeine and other opioids supports other recent studies indicating there has been no unintended harm from the February 2018 upscheduling of over-the-counter codeine to prescription only. Understanding the trends in non-medical use of pharmaceutical drugs and its consequences relies upon triangulating signals from different data sources to provide a mosaic overview [1]. McCoy et al.’s recent work forms an integral part of the picture in understanding outcomes from a major Australian opioid policy decision: the removal of codeine sales without a prescription [2]. The study examined those who regularly used codeine prior to the re-scheduling change and found reductions in codeine use, no increase in use of other opioids and reduced levels of opioid dependence following codeine re-scheduling. Small increases in general practitioner visits but a reduction in emergency department visits for opioids was also observed, alongside no change in mental health symptoms and an overall reduction in pain. These findings are consistent with work demonstrating a reduction in intentional poisonings with codeine [3], an analysis of population-level opioid supply showing no evidence of substitution to other opioids [4] and a study that found decreased codeine deaths, emergency department presentations and poisonings [5]. Collectively, these data sources provide a coherent picture indicating this policy change did not appear to have unintended harms. This may be linked to the substantial investment and implementation efforts that occurred at the time to raise awareness and support referral for pain management and alcohol and other drug treatment [6]. We write to describe the effects of up-scheduling using several sources provided by the AIHW, which represent a final piece of the puzzle. The National Drug Strategy Household Survey is conducted every 3 years. In 2016, past 12-month non-medical use of pharmaceuticals was the second leading category of drug misuse (4.8% of adults aged 14 or more years) after cannabis [7]. Non-medical use of painkillers/opioids was reported by 3.6% of the population: 29% misused painkillers/opioids at least weekly and 10.7% reported not being able to stop or cut back. Of those reporting misuse of painkillers/opioids, 74.8 and 40.6% reported non-medical use of OTC or prescription codeine, respectively. The prevalence of OTC codeine product misuse was highest in youths aged 14–19 years; 89% of those misusing painkillers/opioids reported this in the previous 12 months. In the 2019 survey, with codeine no longer available without a prescription, the proportion of people using codeine for non-medical purposes halved from 3.0% in 2016 to 1.5% [8]. The proportion of people who had recently misused pharmaceuticals decreased from 4.8% in 2016 to 4.2% in 2019. This included a decrease in the proportion of those recently misusing pain-killers/opioids from 3.6 to 2.7% during this period: of these, there was a statistically significant decrease in the proportion who had misused codeine, from 87.95% in 2016 to 60.7% in 2019. AIHW reports on episodes of care for clients seeking treatment from publicly funded Australian drug treatment services [9, 10] including reporting on trends where codeine was a drug of concern (Fig. 1). The number of codeine-related combined principal and additional drugs of concern closed episodes more than halved (51.1%), from 2711 in the last full financial year when codeine was available OTC (2016–17) to 1326 in the most recent year (2019–20). AIHW also reports standardized data concerning opioid agonist treatment with methadone or buprenorphine for the treatment of opioid use disorder [11]. From 2014 to 2020 heroin and pharmaceutical opioids accounted for 60–65% and 35–40% of the opioid of dependence, respectively (where reported). In the last calendar year (2017), when codeine was available OTC without a prescription, it accounted for 2095 cases (17.5% of all pharmaceutical opioids of dependence reported). This increased to 2332 (19%) in 2018, the first year following up-scheduling on 1 February 2018, and decreased each subsequent year to 2014 (15.7%) in 2020—the lowest proportion since 2015. The treatment and non-medical use data presented here support recent studies that indicate no evidence of unintended harms with codeine re-scheduling. This differs from that seen with re-scheduling of hydrocodone in the United States with a shift to other opioids [12]. This also contrasts with perceptions of pharmacists and consumers, and with concerns raised in submissions to the Therapeutic Goods Administration [13]. These findings may give the small number of countries who continue to supply codeine without a prescription confidence that, with appropriate implementation efforts, such a change can be made without adverse consequences for individuals and the community. Suzanne Nielsen was a co-author in the Addiction paper McCoy et al. to which we refer for this commentary.

Re-creating the homeplace: more-than-human constellations and the political consequences of storytelling in central Appalachian community-based theatre

ABSTRACT This paper details ethnographic observation of the development and performance of a community-based theatre production in eastern Kentucky, titled The Homecoming. Participating in community-based theatre provides community members an opportunity to collaboratively, creatively tell the story of their place. In Central Appalachia, where the artform has over four decades of history, community-based plays regularly push back on damaging stereotypes and actively encourage open dialogue. Productions both highlight and demonstrate community members’ agency to imagine – and bring about – possible futures for what eastern Kentuckians call their ‘homeplace’. I mobilize literature from feminist geography, more-than-human geography, and Appalachian studies to frame an analysis of my ethnographic findings. I contend that the ‘homeplace’ emerges in the interplay between humans and the material world. Coal, pharmaceutical opioids, and organic vegetables populate and shape political identities, opinions, and dialogues, as political contention is navigated through narratives. I offer ‘constellations’ as a theoretical framing to help us think through these more-than-human politics, emphasizing human storytelling as one of many forces that shape those politics. I argue that the collaborative, reflexive process of storytelling utilized by community-based theatre has political and material consequence, changing how participants perceive and interact with themselves, each other, and their shared homeplace.

The use of diverted pharmaceutical opioids is associated with reduced risk of fentanyl exposure among people using unregulated drugs in Vancouver, Canada

BackgroundAlthough non-medical use of pharmaceutical opioids (POs) is associated with a number of risks, in the context of the opioid-overdose crisis, it may have the secondary benefit of decreasing the risk of exposure to more potent opioids from unregulated sources. The aim of this study was to assess the effects of using diverted POs on fentanyl exposure. MethodsUsing data from two prospective community-recruited cohorts of people who use drugs (PWUD) in Vancouver, Canada, we estimated the independent relationship between using diverted POs and fentanyl exposure (assessed through urine drug test [UDT]) between 2016 and 2018. We also explored if participant characteristics modified this relationship. ResultsOver the study period, among 1150 participants, 241 (21.0%) reported using diverted POs in 292 (12.8%) occasions. In adjusted analyses, PWUD using diverted POs had decreased odds of fentanyl exposure (Adjusted odds ratio [AOR] = 0.70, 95% CI: 0.52–0.94). The reduced odds of fentanyl exposure persisted among participants with morphine positive UDT (AOR = 0.57, 95% CI: 0.40–0.82), but not among those with negative morphine UDT (AOR = 0.91, 95% CI: 0.54–1.55). ConclusionPWUD using diverted POs in our sample were 30% less likely to be exposed to fentanyl. This reduced likelihood was primarily observed among PWUD with morphine positive UDT, which could partially be explained by longer duration of action and lower street cost of slow-release oral morphine relative to other POs and fentanyl. Findings suggest that access to a regulated supply of pharmaceutical-grade opioids may serve to reduce fentanyl-related harms.

Pharmaceutical opioid poisonings in Victoria, Australia: Rates and characteristics of a decade of emergency department presentations among nine pharmaceutical opioids.

Background and aimsPharmaceutical opioids are a significant contributor to the global ‘opioid crisis’, yet few studies have comprehensively distinguished between opioid types. We measured whether a range of common pharmaceutical opioids varied in their contribution to the rates and characteristics of harm in a population‐wide indicator of non‐fatal overdose.DesignRetrospective observational study of emergency department (ED) patient care records in the Victorian Emergency Minimum Data set (VEMD), July 2009 to June 2019.SettingVictoria, Australia.CasesED presentations for non‐fatal overdose related to pharmaceutical opioid use (n = 5403), where the specific pharmaceutical opioid was documented.MeasurementsWe compared harms across the nine individual pharmaceutical opioids most commonly sold, and considered where multiple opioids contributed to the overdose. We calculated supply‐adjusted rates of ED presentations using Poisson regression and used multinomial logistic regression to compare demographic and clinical characteristics of presentations among nine distinct pharmaceutical opioids and a 10th category where multiple opioids were documented for the presentation.FindingsThere were wide differences, up to 27‐fold, between supply‐adjusted rates of overdose. When considering presentations with sole opioids, the highest supply‐adjusted overdose rates [per 100 000 oral morphine equivalents (OME); 95% confidence interval (CI)] were for codeine (OME = 0.078, 95% CI = 0.073–0.08) and oxycodone (OME =0.029, 95% CI = 0.027–0.030) and the lowest were for tapentadol (OME = 0.004, 95% CI = 0.003–0.006) and fentanyl (OME = 0.003, 95% CI = 0.002–0.004). These rates appeared related to availability rather than opioid potency. Most (62%) poisonings involved females. Codeine, oxycodone and tramadol were associated with younger presentations (respectively, 59.5%, 41.7% and 49.8% of presentations were 12‐34 years old), and intentional self‐harm (respectively 65.2%, 50.6%, and 52.8% of presentations). Relative to morphine, fentanyl [ 0.32 relative risk ratio (RRR)] and methadone ( 0.58 RRR) presentations were less likely to be coded as self‐harm. Relative to morphine–buprenorphine, codeine, oxycodone and tramadol presentations were significantly more likely to be associated with the less urgent triage categories (respectively 2.18, 1.80, 1.52, 1.65 RRR).ConclusionsIn Victoria, Australia, rates and characteristics of emergency department presentations for pharmaceutical opioids show distinct variations by opioid type.

What Your Death Certificate Says About You May Be Wrong: A Narrative Review on CDC's Efforts to Quantify Prescription Opioid Overdose Deaths.

Mortality data in most countries are reported using the International Classification of Diseases (ICD), managed by the WHO. In this paper, we show how the ICD is ill-suited for classifying drug-involved deaths, many of which involve polysubstance abuse and/or illicitly manufactured fentanyl (IMF).Opioids identified in death certificates are categorized according to six ICD T-codes: opium (T40.0), heroin (T40.1), methadone (T40.3), other synthetic narcotics (T40.4), and other and unspecified narcotics (T40.6). Except for opium, heroin, and methadone, all other opioids except those that are unspecified are aggregated in two T-codes (T40.2 and T40.4), depending upon whether they are natural/semisynthetic or synthetic opioids other than methadone. The result is a system that obscures the actual cause of most drug overdose deaths and, instead, just tallies the number of times each drug is mentioned in an overdose situation.We examined the CDC’s methodology for coding other controlled substances according to the ICD and found that, besides fentanyl, the ICD does not distinguish between other licit and illicitly manufactured controlled substances. Moreover, we discovered that the CDC codes all methadone-related deaths as resulting from the prescribed form of the drug. These and other anomalies in the CDC’s mortality reporting are discussed in this report.We conclude that the CDC was at fault for failing to correct the miscoding of IMF. Finally, we briefly discuss some of the public policy consequences of this error, the misguided focus by public health and safety officials on pharmaceutical opioids, their prescribers and users, and the pressing necessity for the CDC to reassess how it measures and reports drug-involved mortality.

Efficacy of Short Message Service Text Messaging Interventions for Postoperative Pain Management: Systematic Review.

BackgroundAddiction to opiates and synthetic opioids poses a major threat to public health worldwide, with pharmaceutical opioids prescribed to manage pain constituting the main problem. To counteract this threat, suitable pain management strategies should be implemented in health care. Monitoring pain management seems to be feasible using telemedicine with a certain degree of resource intensity and digitization. As a communication channel for this type of monitoring, SMS appears to be a valid alternative.ObjectiveThe aim of this systematic literature review was to (1) provide information on the state of research regarding postoperative pain management via SMS, (2) establish a basic understanding of SMS-based pain management, and (3) provide insight into the feasibility of these management strategies. The research question was as follows: Is postoperative pain management feasible and effective utilizing SMS?MethodsA systematic literature review was performed mainly following the PRISMA guidelines and another guide on performing a systematic literature review for information systems–related research. A search string was developed based on the objectives and research question, and eight databases were searched.ResultsThe initial search resulted in 2083 records, which could be narrowed down by applying various exclusion criteria. Thereby, 11 articles were identified as relevant, which were accordingly analyzed and evaluated by full-text screening. In all articles, pain management interventions were performed using SMS communication between health care professionals and patients or their legal guardians. A prospective approach was predominantly chosen as the study design (91%) with the leading research objective of determining the intervention’s feasibility (73%). The primary reason for sending SMS messages was to monitor patients (64%). Overall, the use of SMS improved adherence, acceptance, and satisfaction regarding postoperative pain management. With an average response rate of approximately 89.5% (SD 3.8%), the reliability of SMS as a communication and monitoring tool was further emphasized. This response rate is significantly higher than that for email interventions (66.63%, P<.001).ConclusionsThis study provides a comprehensive picture of the current status on postoperative pain management by SMS. Communication via SMS was beneficial in all interventions, even preoperative. Six SMS interventions could be certified by the respective institutional review board and three were Health Insurance Portability and Accountability Act–compliant. Therefore, the results of this study could be leveraged to address the opioid epidemic. Overall, the research question could be confirmed. Future research should extend this systematic literature review regarding preoperative pain management. Based on these findings, a pre- and postoperative communication model should be developed to address the opioid epidemic effectively.

Assessing the Relationships Between COVID-19 Stay-at-Home Orders and Opioid Overdoses in the State of Pennsylvania

COVID-19 is compounding opioid use disorder throughout the United States. While recent commentaries provide useful policy recommendations, few studies examine the intersection of COVID-19 policy responses and patterns of opioid overdose. We examine opioid overdoses prior to and following the Pennsylvania stay-at-home order implemented on April 1, 2020. Using data from the Pennsylvania Overdose Information Network, we measure change in monthly incidents of opioid-related overdose pre- versus post-April 1, and the significance of change by gender, age, race, drug class, and naloxone doses administered. Findings demonstrate statistically significant increases in overdose incidents among both men and women, White and Black groups, and several age groups, most notably the 30–39 and 40–49 ranges, following April 1. Significant increases were observed for overdoses involving heroin, fentanyl, fentanyl analogs or other synthetic opioids, pharmaceutical opioids, and carfentanil. The study emphasizes the need for opioid use to be addressed alongside efforts to mitigate and manage COVID-19 infection.

Public health strategies to combat opioid crisis in the United States?

Background: The opioid epidemic in the United States is a national public health crisis. Driven by an increase in availability of pharmaceutical opioids and by an increase in their consumption, specifically, for pain treatment, more so in the past twenty years, it has led to an economic cost of prescription opioid abuse, overdose, and dependence in the United States estimated to be 78.5 billion USD. Methods: A thorough evaluation of the relevant extracted literature has been used to answer the question of the most effective ways to regulate health markets to decrease the opioid crisis in the United States, using keywords and phrases such as opioid epidemic in the US, prescription drug abuse, prescription medication abuse in US, medication misuse, cost-effective ways to health market regulation, drug monitoring programs, prescriber continuing education, provider continuing education, and pain management optimization. Results: Overcoming this epidemic nationwide requires improvement in patient utilization of and access to safe and effective treatment options for opioid abuse and overdose, addressing the stigma correlated with opioid use, considering appropriate use of abuse deterrent formulations (ADF) along with patient education, and improving prescribing practices via utilization of drug monitoring programs, CDC opioid prescribing guidelines and provider continuing education. Conclusion: Utilizing and implementing the aforementioned steps has shown to be a challenge. Further and repeated attempts are needed, while at the same time considering possible new steps that could help reinforce their utilization further.

Should we be routinely co-prescribing naloxone for patients on long term opioids?

Community naloxone supply to prevent fatal overdose needs to consider patients using pharmaceutical opioids.

Drug overdose death rates and criminal sentencing of federal drug offenders in the United States

The rate of drug overdose deaths has increased substantially in the United States in the past two decades. However, limited research has examined how the criminal justice system is responding to this growing epidemic. Using data on criminal sentences in federal district courts, the current study assesses the relationship between drug overdose death rates and criminal sentences in the United States. Results from multilevel regression models demonstrate that sentences for federal drug offenders were shorter in areas that experienced higher overdose rates and increased growth in overdose rates over time. Findings also demonstrated substantial heterogeneity by drug type, such that substances most closely associated with the overdose crisis (i.e., pharmaceutical opioids and methamphetamines) were sentenced less harshly in areas with higher drug overdose rates. Analyses assessing the change in overdose rates over time, demonstrated that several substances (crack-cocaine, heroin, marijuana, and methamphetamine) were sentenced more harshly in areas with greater growth in the overdose rate, whereas cocaine and pharmaceutical opioids were not impacted by changes in drug overdose rate. These findings are interpreted through the lens of theoretical perspectives and contemporary research pertaining to ways levels of crime and social problems influence punishment decisions.