Prescription Opioid Addiction Research Articles

Shifting blame: Buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America.

Growing nonmedical prescription opioid analgesic use among suburban and rural Whites has changed the public's perception of the nature of opioid addiction, and of appropriate interventions. Opioid addiction has been recast as a biological disorder in which patients are victims of their neurotransmitters and opioid prescribers are irresponsible purveyors of dangerous substances requiring controls. This framing has led to a different set of policy responses than the "War on Drugs" that has focused on heroin trade in poor urban communities; in response to prescription opioid addiction, prescription drug monitoring programs and tamper-resistant opioid formulations have arisen as primary interventions in place of law enforcement. Through the analysis of preliminary findings from interviews with physicians who are certified to manage opioid addiction with the opioid pharmaceutical buprenorphine, we argue that an increase in prescriber monitoring has shifted the focus from addicted people to prescribers as a threat, paradoxically driving users to illicit markets and constricting their access to pharmaceutical treatment for opioid addiction. Prescriber monitoring is also altering clinical cultures of care, as general physicians respond to heightened surveillance and the psychosocial complexities of treating addiction with either rejection of opioid dependent patients, or with resourceful attempts to create support systems for their treatment where none exists.

The War on Drugs That Wasn’t: Wasted Whiteness, “Dirty Doctors,” and Race in Media Coverage of Prescription Opioid Misuse

The past decade in the U.S. has been marked by a media fascination with the white prescription opioid cum heroin user. In this paper, we contrast media coverage of white non-medical opioid users with that of black and brown heroin users to show how divergent representations lead to different public and policy responses. A content analysis of 100 popular press articles from 2001 and 2011 in which half describe heroin users and half describe prescription opioid users revealed a consistent contrast between criminalized urban black and Latino heroin injectors with sympathetic portrayals of suburban white prescription opioid users. Media coverage of the suburban and rural opioid "epidemic" of the 2000s helped draw a symbolic, and then legal, distinction between (urban) heroin addiction and (suburban and rural) prescription opioid addiction that is reminiscent of the legal distinction between crack cocaine and powder cocaine of the 1980s and 1990s. This distinction reinforces the racialized deployment of the War on Drugs and is sustained by the lack of explicit discussion of race in the service of "color blind ideology." We suggest potential correctives to these racially divergent patterns, in the form of socially responsible media practices and of clinical engagement with public policy.

Day-to-day pain symptoms are only weakly associated with opioid craving among patients with chronic pain prescribed opioid therapy

BackgroundOver the past decade, there has been a substantial rise in the use of opioids for the treatment of chronic noncancer pain. Despite the potential benefits of opioid therapy, the rise in the use of opioids has been accompanied by escalating rates of prescription opioid misuse and addiction. There is now a growing body of evidence indicating that opioid craving (i.e., the subjective desire to consume opioids) is one of the strongest determinants of opioid misuse among patients with chronic pain prescribed opioids. Although research has elucidated some of the factors associated with opioid craving, the contribution of patients' levels of pain to opioid craving remains unclear. ObjectiveThe main objective of this study was to examine the day-to-day association between pain and opioid craving. MethodsIn this longitudinal cohort study, patients with chronic pain prescribed opioid therapy completed baseline measures and were then asked to provide daily reports of pain intensity and opioid craving for a period of 14 days. ResultsMultilevel analyses indicated that day-to-day elevations in patients' levels of pain were associated with heightened opioid craving. That is, on more painful days, patients reported higher levels of craving. Within-person changes in pain intensity, however, explained less than 5% of the variance in patients' reports of craving. ConclusionFindings from this study suggest that patients with chronic pain do not crave their opioid medications simply because they experience high levels of pain. The theoretical and clinical implications of our findings are discussed.

Prescription Opioid Abuse, Prescription Opioid Addiction, and Heroin Abuse Among Adolescents in a Recovery High School: A Pilot Study

ABSTRACTThe progression from prescription opioid (RXO) abuse to RXO addiction is not well understood in adolescents, nor is the progression from RXO addiction to heroin abuse. The purpose of this pilot study was to characterize the development of RXO drug abuse, RXO drug addiction, and heroin abuse in a small cohort of adolescents recovering from opioid addiction at Massachusetts Recovery High Schools (RHS). A self-report questionnaire was administered to 31 adolescent, former RXO abusers across two Massachusetts RHS. RXO abuse was primarily initiated due to curiosity; RXOs were initially obtained through illicit and licit methods. Fifty-eight percent (N = 18) of the RXO abusers became addicted to RXOs. Many addicted adolescents initiated RXO abuse under the influence of marijuana, yet believed that they became addicted due to the stress from difficult life situations. A subgroup indicated they abused and became addicted to RXOs that had been obtained from legitimate prescriptions due to their pain. Sixteen percent (N = 5) of the sample abused heroin. Most heroin abusers (4/5) were addicted to RXOs prior to onset of heroin use. Heroin abusers indicated that they considered using heroin after they began tampering with RXOs. A portion of the sample felt that abuse deterrent formulations (ADFs) would have reduced their RXO use. This pilot study discovered areas where further research could be targeted, such as drug combinations, adolescent coping mechanisms, adolescent pain management, and the use of ADFs to disrupt the transition from RXO addiction to heroin use.

President Announces New Measures to Fight Prescription Opioid Addiction After Thousands Rally Locally and in Washington to Criticize “Silence”

Topics in Pain Management: December 2015 - Volume 31 - Issue 5 - p 8-10 doi: 10.1097/01.TPM.0000475398.72348.c3

Migration and time to first tobacco cigarette after waking

Migration and time to first tobacco cigarette after waking

Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network prescription opioid addiction treatment study

Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network prescription opioid addiction treatment study

Short term health-related quality of life improvement during opioid agonist treatment

BackgroundOpioid dependence is associated with high levels of morbidity, yet sparse data exists regarding the health-related quality of life (HRQoL) of individuals with opioid dependence, particularly following treatment initiation. To inform cost-effectiveness analyses of treatment modalities, this study investigates short-term changes in HRQoL following enrollment into opioid agonist treatment (OAT), across treatment modalities and patient subgroups. MethodsData was analyzed from the Starting Treatment with Agonist Replacement Therapies (START) and Prescription Opioid Addiction Treatment Studies (POATS) randomized controlled trials. Participants included individuals dependent on prescription opioids (POs) or heroin, receiving limited-term or time-unlimited treatment. PO- or heroin-users in START received buprenorphine/naloxone (BUP/NX) or methadone (MET) over 24 weeks. PO-users in POATS received psychosocial care and short-term (4-week) taper with BUP/NX, with non-responders offered subsequent extended (12-week) stabilization and taper. HRQoL was assessed using the short-form SF-6D while in and out of OAT, with distinction between MMT and BUP/NX in START. Linear mixed effects regression models were fitted to determine the independent effects of OAT on HRQoL and characterize HRQoL trajectories. ResultsTreatment had a similar immediate and modest positive association with HRQoL in each patient subgroup. The association of OAT on HRQoL was statistically significant in each model, with effect sizes between 0.039 (heroin-users receiving BUP/NX) and 0.071 (PO-users receiving MET). After initial improvement, HRQoL decreased slightly, or increased at a diminished rate. ConclusionsOAT, whether delivered in time-limited or unlimited form, using BUP/NX or MET, is associated with modest immediate HRQoL improvements, with diminishing benefits thereafter.

Prescription Opioid Misuse, Abuse, Morbidity, and Mortality: Balancing Effective Pain Management and Safety

The burgeoning rate of prescription opioid misuse, abuse, addiction, and opioid related overdose deaths has gained substantial professional and national media attention. This manuscript provides a narrative review and critique of the literature on prescription opioid misuse, abuse, addiction and opioid-related mortality and discusses future research needs in this area. Current literature on misuse, abuse, addiction and opioid related fatalities was reviewed in patients with chronic noncancer pain receiving long-term prescription opioid therapy. There have been inconclusive results on the efficacy of long-term opioid therapy in patients with chronic pain but moderate level evidence of dose-dependent risk of harm. The estimated prevalence of prescription opioid abuse and opioid use disorders ranges from <1% to 40% due to the paucity of uniform definitions of what constitutes misuse, abuse, and addiction but several recent studies have developed unique methodology to more accurately assess these states in the pain population. The rate of opioid-related overdose deaths is not inconsequential and a number of patient related and medication specific risk factors have been identified that may provide a basis for risk mitigation strategies. Accurately assessing the prevalence of misuse, abuse, and addiction in the pain population has been challenging due to inconsistent definitions between studies. Additional high-quality research is needed in this area utilizing consistent definitions and in reducing the risk of opioid-related overdose fatalities.

Prescription opioid abuse: Problems and responses

Prescription opioid abuse and addiction, along with consequences such as overdose death and increasing transition to heroin use, constitute a devastating public health problem in the United States. Increasingly it is clear that overprescription of these medications over the past two decades has been a major upstream driver of the opioid abuse epidemic. This commentary considers the factors that have led to overprescription of opioids by clinicians, discusses recent evidence casting doubt on the efficacy of opioids for treating chronic pain, and describes the ongoing efforts by federal and community stakeholders to address this epidemic—for example, supporting prescription drug monitoring programs and improved clinician training in pain management to help reduce the supply of opioids, increasing dissemination of evidence-based primary prevention programs to reduce demand for opioids, and expanding access to effective opioid agonist therapies and antagonist medications for both treatment and overdose prevention.

Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study

BackgroundDespite the growing prevalence of prescription opioid dependence, longitudinal studies have not examined long-term treatment response. The current study examined outcomes over 42 months in the Prescription Opioid Addiction Treatment Study (POATS). MethodsPOATS was a multi-site clinical trial lasting up to 9 months, examining different durations of buprenorphine-naloxone plus standard medical management for prescription opioid dependence, with participants randomized to receive or not receive additional opioid drug counseling. A subset of participants (N=375 of 653) enrolled in a follow-up study. Telephone interviews were administered approximately 18, 30, and 42 months after main-trial enrollment. Comparison of baseline characteristics by follow-up participation suggested few differences. ResultsAt Month 42, much improvement was seen: 31.7% were abstinent from opioids and not on agonist therapy; 29.4% were receiving opioid agonist therapy, but met no symptom criteria for current opioid dependence; 7.5% were using illicit opioids while on agonist therapy; and the remaining 31.4% were using opioids without agonist therapy. Participants reporting a lifetime history of heroin use at baseline were more likely to meet DSM-IV criteria for opioid dependence at Month 42 (OR=4.56, 95% CI=1.29–16.04, p<.05). Engagement in agonist therapy was associated with a greater likelihood of illicit-opioid abstinence. Eight percent (n=27/338) used heroin for the first time during follow-up; 10.1% reported first-time injection heroin use. ConclusionsLong-term outcomes for those dependent on prescription opioids demonstrated clear improvement from baseline. However, a subset exhibited a worsening course, by initiating heroin use and/or injection opioid use.

The prescription opioid addiction and abuse epidemic: how it happened and what we can do about it

The prescription opioid addiction and abuse epidemic: how it happened and what we can do about it

Pain Management: Is it the Time to Reconsider Using Opioids?

Pain is an unwanted sensation for anyone. The management of pain becomes an important issue in medicine. The pain management is usually important consideration in medical procedure practice and surgery. Several drugs and techniques have been introduced for using in anesthesiology and pain medicine. Opium is a classical plant that human beings knew for years. Modification of opium to produce the pain management product has been done for many decades [1]. However, the big issue is the fact that opium and its derivation, opioids, is considered narcotic and become illegal things if used in nonmedical purpose. It is no doubt that opioids can be effective pain killer for the patient but the important issue is on its side effects. It is the present question whether it is appropriate that opioids are widely used in medical society. Setting a guideline to control the use of opioids becomes important issue in present pain medicine [2,3]. Del Portal et al. noted that “an opioid prescribing guideline significantly decreased the rates at which opioids were prescribed for minor and chronic complaints in an acute care setting [2].” According to the recent guideline by American Society of Interventional Pain Physicians, “opioid therapy may be initiated with low doses and short-acting drugs with appropriate monitoring to provide effective relief and avoid side effects [4].” Nevertheless, as noted by Katz et al. “prescription opioid abuse and addiction are serious problems with growing societal and medical costs [5].” A more strict control by law has also been used in some countries [6,7]. This can be useful for control of some non-ethic practitioner who illegal prescribe or sell opioids [7]. For example, the Washington State Legislature has just established “new legal standards of practice regarding chronic non-cancer pain management” for control using of opioids [6]. A challenge is whether we can stop using opioids and use other new non-opioids pain killer that are effective to manage the case.

Using behavioral economics to predict opioid use during prescription opioid dependence treatment

BackgroundResearch grounded in behavioral economics has previously linked addictive behavior to disrupted decision-making and reward-processing, but these principles have not been examined in prescription opioid addiction, which is currently a major public health problem. This study examined whether pre-treatment drug reinforcement value predicted opioid use during outpatient treatment of prescription opioid addiction. MethodsSecondary analyses examined participants with prescription opioid dependence who received 12 weeks of buprenorphine–naloxone and counseling in a multi-site clinical trial (N=353). Baseline measures assessed opioid source and indices of drug reinforcement value, including the total amount and proportion of income spent on drugs. Weekly urine drug screens measured opioid use. ResultsObtaining opioids from doctors was associated with lower pre-treatment drug spending, while obtaining opioids from dealers/patients was associated with greater spending. Controlling for demographics, opioid use history, and opioid source frequency, patients who spent a greater total amount (OR=1.30, p<.001) and a greater proportion of their income on drugs (OR=1.31, p<.001) were more likely to use opioids during treatment. ConclusionsIndividual differences in drug reinforcement value, as indicated by pre-treatment allocation of economic resources to drugs, reflects propensity for continued opioid use during treatment among individuals with prescription opioid addiction. Future studies should examine disrupted decision-making and reward-processing in prescription opioid users more directly and test whether reinforcer pathology can be remediated in this population.

Neurophysiological evidence for remediation of reward processing deficits in chronic pain and opioid misuse following treatment with Mindfulness-Oriented Recovery Enhancement: exploratory ERP findings from a pilot RCT.

Dysregulated processing of natural rewards may be a central pathogenic process in the etiology and maintenance of prescription opioid misuse and addiction among chronic pain patients. This study examined whether a Mindfulness-Oriented Recovery Enhancement (MORE) intervention could augment natural reward processing through training in savoring as indicated by event-related brain potentials (ERPs). Participants were chronic pain patients at risk for opioid misuse who were randomized to 8 weeks of MORE (n = 11) or a support group control condition (n = 18). ERPs to images representing naturally rewarding stimuli (e.g., beautiful landscapes, intimate couples) and neutral images were measured before and after 8 weeks of treatment. Analyses focused on the late positive potential (LPP)--an ERP response in the 400-1,000 ms time window thought to index allocation of attention to emotional information. Treatment with MORE was associated with significant increases in LPP response to natural reward stimuli relative to neutral stimuli which were correlated with enhanced positive affective cue-responses and reductions in opioid craving from pre- to post-treatment. Findings suggest that cognitive training regimens centered on strengthening attention to natural rewards may remediate reward processing deficits underpinning addictive behavior.

Pick your poison: not all opioids are created equal in the eyes of dopamine (commentary on Vander Weele et al.).

In the current issue, Vander Weele et al. (2014) provide a previously unseen characterization of opioid-induced potentiation of dopamine release in the nucleus accumbens (NAc), an effect shared by all commonly abused drugs and thought to critically contribute to drug reinforcement. This work is extremely timely as prescription opioid abuse and addiction are currently at epidemic levels. Indeed, the rise in prescription opioid abuse may be driven by an elevated prevalence of more addictive opioids. The most common opioid analgesic has traditionally been morphine, a naturally occurring alkaloid from the opium poppy plant. However, newer synthetic opioids, such as oxycodone, are gaining popularity despite (or perhaps because of) their reportedly greater abuse potential. The work by Vander Weele et al. (2014) suggests that the greater abuse potential of oxycodone may arise from its increased ability to produce changes in NAc dopamine release. Fast-scan cyclic voltammetry was used to measure real-time dopamine fluctuations in the NAc of behaving rats. These measures add opioids to the growing list of abused drugs (including ethanol, nicotine, cocaine and cannabinoids) that elicit rapid surges in NAc dopamine concentrations. Because these dopamine ‘transients’ are causally linked to reward seeking, the ability of abused drugs to give rise to these signals is an important mechanism supporting drug reinforcement. Interestingly, Vander Weele et al. (2014) found that morphine exhibits a surprisingly brief effect on dopamine transients, augmenting these signals for <1 min. In stark contrast, oxycodone elicited a stable and significant increase in the frequency of transients for the entire 15 min recording period. Additionally, state-of-the-art microdialysis simultaneously sampled the extracellular levels of 15 different neurotransmitters at 60 s intervals. These elegant measures corroborated the fast-scan cyclic voltammetry dopamine recordings and also showed that morphine, but not oxycodone, elevated extracellular GABA levels in the NAc. If this increase in GABA acts to inhibit terminal dopamine release, it could explain morphine's weak effects on dopamine transmission. The source of this GABA signal, however, remains to be identified. Moreover, this increase in GABA is paradoxical, as it has been theorized that morphine exerts its dopamine-releasing effects through μ-opioid receptor-mediated disinhibition of dopamine neurons. Based on reported differences in the abuse potential of oxycodone and morphine, and their distinct effects on dopamine release, the current findings suggest that monitoring a drug's ability to pharmacologically elicit dopamine transients could serve as an objective assay for rational drug policy, as we have postulated for cannabinoids. Alternatively, the observed differences between morphine and oxycodone may have simply arisen from their different pharmacokinetic actions. Indeed, although both drugs were administered at the same dose, oxycodone can reach brain concentrations six times that of morphine. Nonetheless, the authors state that both drugs evoked a similar maximal increase in extracellular dopamine and inhibited movement for a similar duration. Clearly, future work will need to employ more rigorous behavioral assays (such as drug self-administration) to determine whether the differential effects of morphine and oxycodone on the dynamics of dopamine release cause their different reinforcing properties.

Opioid withdrawal, craving, and use during and after outpatient buprenorphine stabilization and taper: A discrete survival and growth mixture model

IntroductionMost patients relapse to opioids within one month of opioid agonist detoxification, making the antecedents and parallel processes of first use critical for investigation. Craving and withdrawal are often studied in relationship to opioid outcomes, and a novel analytic strategy applied to these two phenomena may indicate targeted intervention strategies. MethodsSpecifically, this secondary data analysis of the Prescription Opioid Addiction Treatment Study used a discrete-time mixture analysis with time-to-first opioid use (survival) simultaneously predicted by craving and withdrawal growth trajectories. This analysis characterized heterogeneity among prescription opioid-dependent individuals (N=653) into latent classes (i.e., latent class analysis [LCA]) during and after buprenorphine/naloxone stabilization and taper. ResultsA 4-latent class solution was selected for overall model fit and clinical parsimony. In order of shortest to longest time-to-first use, the 4 classes were characterized as 1) high craving and withdrawal, 2) intermediate craving and withdrawal, 3) high initial craving with low craving and withdrawal trajectories and 4) a low initial craving with low craving and withdrawal trajectories. Odds ratio calculations showed statistically significant differences in time-to-first use across classes. ConclusionsGenerally, participants with lower baseline levels and greater decreases in craving and withdrawal during stabilization combined with slower craving and withdrawal rebound during buprenorphine taper remained opioid-free longer. This exploratory work expanded on the importance of monitoring craving and withdrawal during buprenorphine induction, stabilization, and taper. Future research may allow individually tailored and timely interventions to be developed to extend time-to-first opioid use.

The multi-site prescription opioid addiction treatment study: 18-month outcomes

Despite the high prevalence of prescription opioid dependence in the U.S., little is known about the course of this disorder and long-term response to treatment. We therefore examined 18-month post-randomization outcomes of participants in the Prescription Opioid Addiction Treatment Study, a multi-site, randomized controlled trial examining varying durations of buprenorphine-naloxone treatment and different intensities of counseling for prescription opioid dependence. Thus the current follow-up study provides a unique contribution to the field by reporting longer-term outcomes of a well-characterized population of treatment-seeking prescription opioid dependent patients. Participants from the treatment trial (N=252/653) completed an 18-month follow-up telephone assessment. Multivariable analyses examined associations between participant characteristics and key indicators of month-18 status: opioid abstinence, DSM-IV opioid dependence, and opioid agonist treatment. Overall, participants showed improvement from baseline to month 18: 49.6% were abstinent in the previous 30days, with only 16.3% opioid-dependent. Some participants, however, had initiated past-year heroin use (n=9) or opioid injection (n=17). Most participants (65.9%) engaged in substance use disorder treatment during the past year, most commonly opioid agonist therapy (48.8%). Of particular interest in this population, multivariable analysis showed that greater pain severity at baseline was associated with opioid dependence at 18months. In conclusion, although opioid use outcomes during the treatment trial were poor immediately following a buprenorphine-naloxone taper compared to those during 12weeks of buprenorphine-naloxone stabilization, opioid use outcomes at 18-month follow-up showed substantial improvement over baseline and were comparable to the rate of successful outcomes during buprenorphine-naloxone stabilization in the treatment trial.

Who benefits from additional drug counseling among prescription opioid-dependent patients receiving buprenorphine–naloxone and standard medical management?

BackgroundIn the multi-site Prescription Opioid Addiction Treatment Study (POATS), conducted within the National Drug Abuse Clinical Trials Network, participants randomly assigned to receive individual drug counseling in addition to buprenorphine–naloxone and medical management did not have superior opioid use outcomes. However, research with other substance-dependent populations shows that subgroups of participants may benefit from a treatment although the entire population does not. MethodWe conducted a secondary analysis of POATS data to determine whether a subgroup of participants benefited from drug counseling in addition to buprenorphine–naloxone and medical management, either due to greater problem severity or more exposure to counseling as a result of greater treatment adherence. Problem severity was measured by a history of heroin use, higher Addiction Severity Index drug composite score, and chronic pain. Adequate treatment adherence was defined a priori as attending at least 60% of all offered sessions. ResultsPatients who had ever used heroin and received drug counseling were more likely to be successful (i.e., abstinent or nearly abstinent from opioids) than heroin users who received medical management alone, but only if they were adherent to treatment and thus received adequate exposure to counseling (OR=3.7, 95% CI=1.1–11.8, p=0.03). The association between severity and outcome did not vary by treatment condition for chronic pain or ASI drug severity score. ConclusionsThese findings emphasize the importance of treatment adherence, and suggest that patients with prescription opioid dependence are a heterogeneous group, with different optimal treatment strategies for different subgroups.

Reasons for opioid use among patients with dependence on prescription opioids: The role of chronic pain

The number of individuals seeking treatment for prescription opioid dependence has increased dramatically, fostering a need for research on this population. The aim of this study was to examine reasons for prescription opioid use among 653 participants with and without chronic pain, enrolled in the Prescription Opioid Addiction Treatment Study, a randomized controlled trial of treatment for prescription opioid dependence. Participants identified initial and current reasons for opioid use. Participants with chronic pain were more likely to report pain as their primary initial reason for use; avoiding withdrawal was rated as the most important reason for current use in both groups. Participants with chronic pain rated using opioids to cope with physical pain as more important, and using opioids in response to social interactions and craving as less important, than those without chronic pain. Results highlight the importance of physical pain as a reason for opioid use among patients with chronic pain.