US Opioid Crisis Research Articles

\u201cWe don't get much of a voice about anything\u201d: perspectives on photovoice among people who inject drugs

BackgroundIn the context of the current US opioid crisis, people who inject drugs (PWID) are increasingly researched, but their ability to tell their own stories may be limited. Photovoice is a participatory action research method that allows participants to use photography to directly depict their experiences.MethodsWe conducted interviews with PWID (n = 33) as part of a qualitative study on the health needs of PWID in the USA to explore interest and acceptability of photovoice as a potential research method and way to share their voices.ResultsParticipants identified facilitators and barriers to participating in a future photovoice project. Facilitators included a chance to depict one’s unique experience, help others in need by sharing one’s own story, and photography being a more “comfortable” way to tell their stories than traditional research methods. Barriers included safety concerns, embarrassment, and ability to retain cameras. Participants also identified areas of sensitivity related to documenting drug use.ConclusionsWhile we found broad acceptability of photovoice, barriers would need to be addressed and additional training and support for research staff and potential participants related to the ethics of public photography and engaging PWID in photovoice research would be required.

Stigma as a fundamental hindrance to the United States opioid overdose crisis response.

Alexander Tsai and co-authors discuss the role of stigma in responses to the US opioid crisis.

Tracing the US opioid crisis to its roots.

Understanding how the opioid epidemic arose in the United States could help to predict how it might spread to other countries. Understanding how the opioid epidemic arose in the United States could help to predict how it might spread to other countries.

Postsurgical Opioid Prescriptions and Risk of Long-term Use: An Observational Cohort Study Across the United States.

The aim of this study was to evaluate differences in risk of long-term opioid therapy after surgery among an opioid-naive population using varying cutoffs based on days supplied (DS), total morphine milligram equivalents (MME) dispensed, and quantity of pills (QTY) dispensed. In response to the US opioid crisis, opioid prescription (Rx) limits have been implemented on a state-by-state basis beginning in 2016. However, there is limited evidence informing appropriate prescribing limits, and the effect of these policies on long-term opioid therapy. Using the MarketScan claims databases, we identified all opioid-naive patients undergoing outpatient surgery between July 1, 2006 and June 30, 2015. We identified the initial postsurgical opioid prescribed, examining the DS, total MME, and QTY dispensed. We used Poisson to estimate adjusted risk differences and risk ratios of long-term opioid use comparing those receiving larger versus smaller volume of opioids. We identified 5,148,485 opioid-naive surgical patients. Overall, 55.5% received an opioid for postoperative pain, with median days supply = 5 and median total MME = 240. The proportion of patients receiving prescriptions above 7 DS increased from 11% in 2006 to 19% in 2015. Among those receiving postoperative opioids, 8% had long-term opioid use, and risk of long-term use was 1.16 times [95% confidence interval (CI), 1.10-1.25] higher among those receiving >7 days compared with those receiving ≤7 days. Those receiving >400 total MME (15% of patients) were at 1.17 times (95% CI, 1.10-1.25) the risk of long-term use compared with those receiving ≤400 MME. Between 2005 and 2015, the amounts of opioids prescribed for postoperative pain increased dramatically, and receipt of larger volume of opioids was associated with increased risk of long-term opioid therapy.

Optimizing Pain Control During the Opioid Epidemic.

The current opioid crisis has raised awareness of the risks of misuse, addiction, and overdose with opioid prescribing for pain management in the perioperative and nonoperative care of surgical patients. Despite these risks, it is essential for surgical providers to provide safe and adequate functional pain control to enhance recovery. The purpose of this review is to outline the relevance of the US opioid crisis to surgical prescribing, describe strategies for opioid reduction using a stepwise therapy approach, and provide recommendations for improving the safety of opioid prescribing. Additional recommendations for risk assessment and naloxone coprescribing for high-risk patients are addressed.

Targeting Youth to Prevent Later Substance Use Disorder: An Underutilized Response to the US Opioid Crisis.

The evolving US opioid crisis is complex and requires myriad different interventions. These include reducing opioid overprescribing and curtailing the supply of illicit opioids, overdose rescue interventions, and treatment and recovery support services for those with opioid use disorders. To date, more distal primary prevention strategies that have an evidence base are underutilized. Yet, the impact of early environments on later substance use disorder risk is increasingly well understood, including knowledge of the mechanistic linkages between brain development and subsequent risk behaviors. Applying this developmental framework to prevention shows promise, and some middle-school interventions have demonstrated significant reductions in prescription opioid misuse. Reducing these risks of initial misuse of opioids may be the "ounce of prevention" that makes a substantial difference in a society now reeling from the worst drug crisis our country has seen. The challenge is to continue to develop and test promising distal interventions and to support implementation fidelity through frameworks that ensure their cultural appropriateness and sustainability. In addition, research is needed to develop new prevention strategies for adults, including patients with pain at risk for transitioning from prescription to illicit opioids.

Tools for Community-Based Pharmacist Patient Care Services to Support Optimal Opioid Use

Tools for Community-Based Pharmacist Patient Care Services to Support Optimal Opioid Use

Opioid Use Disorder and Prescribed Opioid Regimens: Evidence from Commercial and Medicaid Claims, 2005-2015.

In response to the US opioid crisis, interventions are being implemented to lower opioid prescribing to reduce opioid misuse and overdose. As opioid prescribing falls, opioid misuse may shift from prescriptions to other, possibly illicit, sources. We examined how the percentage of patients with an opioid use disorder (OUD) diagnosis in a given year without a current opioid prescription changed over a decade among commercially insured enrollees and Medicaid beneficiaries. We also examined how the percentages differed by enrollee demographic factors. We used commercial and Medicaid claims from the IBM MarketScan® databases from 2005 to 2015 to identify enrollees with and without current opioid prescriptions who have been diagnosed with OUD. We measured the percentage of enrollees with OUD without a current opioid prescription by year and demographic factors. We identified 99,396 enrollee-years with OUD covered by commercial insurance and 60,492 enrollee-years with OUD covered by Medicaid. Among enrollees with OUD, the percentage without a current opioid prescription increased from 37% in 2005 to 49% in 2012 before falling back to 39% in 2015 in the commercial population, and increased from 32% in 2005 to 38% in 2015 in the Medicaid population. Differences in percentages were observed by age, sex, race, and region, particularly among young people where 70 to 89% had OUD without a current prescription. Most enrollees with OUD in the data had current opioid prescriptions, suggesting that continuing efforts to reduce misuse of prescribed opioids among patients with prescriptions may be effective. However, a substantial percentage of enrollees with OUD may be obtaining opioids via other, likely illegitimate, channels, particularly younger people, which suggests an opportunity for targeted efforts to reduce opioid diversion.

Mobile applications for pain management: an app analysis for clinical usage

BackgroundPain is the most common and distressing symptom for patients in all clinical settings. The dearth of health informatics tools to support acute and chronic pain management may be contributing to the chronic pain and opioid abuse crises. The purpose of this study is to qualitatively evaluate the content and functionality of mobile pain management apps.MethodsThe Apple App Store and the Google Play Store were searched to identify pain management apps. The inclusion criteria were as follows: (1) that apps include a pain diary function allowing users to record pain episodes, (2) are available in either Apple App Store or Google Play Store, and (3) are available in the English language. We excluded apps if they were limited to only specific forms of pain or specific diseases.ResultsA total of 36 apps met the inclusion criteria. Most of the apps served as pain diary tools to record the key characteristics of pain. The pain diary features of the apps were grouped into nine categories: the recordings of pain intensity, pain location, pain quality, pain’s impacts on daily life, other features of pain, other related symptoms, medication, patients’ habits and basic information, and other miscellaneous functions. The apps displayed various problems in use. The problem of not involving healthcare professionals in app development has not been resolved. Approximately 31% of apps including a pain diary function engaged clinicians in app development. Only 19% involved end-users in development and then only in an ad-hoc way. Only one third of the apps supported the cross-platforms, none of the apps supported clinician access to graphical pain data visualization, none secured HIPAA compliance, and none endorsed the PEG tool for primary care physicians’ chronic pain management.ConclusionsMost of the 36 pain management apps demonstrated various problems including user interface and security. Many apps lacked clinician and end-user involvement in app development impacting the clinical utility of these apps. We could not find any pain apps suitable for clinical usage despite high demand from clinicians due to the US opioid crisis.

The Work of ‘Crisis’ in the ‘Opioid Crisis’

This commentary is an edited version of discussant comments to the Executive Session panel ‘Anthropological Interventions in the US Opioid Crisis’ organized by Jennifer Carroll at the 117th Annual Meeting of the American Anthropological Association, San Diego, CA, November 14-18, 2018.

Public Health Surveillance of Prenatal Opioid Exposure in Mothers and Infants.

* Abbreviation: NAS — : neonatal abstinence syndrome The US opioid crisis is the public health emergency of our time and requires urgent public health action to monitor and protect the most vulnerable Americans. We have witnessed a startling death toll in 2017 with 70 237 drug overdose deaths in the United States, of which two-thirds involved opioids.1 The devastating consequences of this epidemic for mothers and infants have received less attention. Increases in opioid use and misuse in pregnancy have paralleled the increases in the general population; at delivery hospitalization, there were 4 times as many women with an opioid use disorder in 2014 compared with 1999.2 One of the most immediate and visible impacts of the opioid crisis on infants is the drug withdrawal in the newborn period, termed neonatal abstinence syndrome (NAS). On the basis of 2014 data, 1 newborn was diagnosed with NAS every 15 minutes in the United States, totaling about 32 000 infants annually with associated hospital costs estimated at $563 million.3 Because prevention and treatment of opioid use disorder in pregnancy is important to both maternal and infant health, there is an urgent need to expand prevention efforts and reduce barriers for medication-assisted treatment before, during, and after pregnancy. The stigma of substance exposure during pregnancy and fears of punitive consequences can be obstacles to women receiving the treatment and care they need, and studies with inadequate control of cofactors can exaggerate the specific effects of an individual substance as occurred with … Address correspondence to Margaret A. Honein, PhD, MPH, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mailstop S106-3, Atlanta, GA 30341. E-mail: mrh7{at}cdc.gov

Evidence-based and guideline-concurrent responses to narratives deferring HCV treatment among people who inject drugs

BackgroundHepatitis C virus (HCV) infection is increasingly prevalent among people who inject drugs (PWID) in the context of the current US opioid crisis. Although curative therapy is available and recommended as a public health strategy, few PWID have been treated. We explore PWID narratives that explain why they have not sought HCV treatment or decided against starting it. We then compare these narratives to evidence-based and guideline-concordant information to better enable health, social service, harm reduction providers, PWID, and other stakeholders to dispel misconceptions and improve HCV treatment uptake in this vulnerable population.MethodsWe recruited HIV-uninfected PWID (n = 33) through community-based organizations (CBOs) to participate in semi-structured, in-depth qualitative interviews on topics related to overall health, access to care, and knowledge and interest in specific HIV prevention methods.ResultsIn interviews, HCV transmission and delaying or forgoing HCV treatment emerged as important themes. We identified three predominant narratives relating to delaying or deferring HCV treatment among PWID: (1) lacking concern about HCV being serious or urgent enough to require treatment, (2) recognizing the importance of treatment but nevertheless deciding to delay treatment, and (3) perceiving that clinicians and insurance companies recommend that patients who currently use or inject drugs should delay treatment.ConclusionsOur findings highlight persistent beliefs among PWID that hinder HCV treatment utilization. Given the strong evidence that treatment improves individual health regardless of substance use status while also decreasing HCV transmission in the population, efforts are urgently needed to counter the predominant narratives identified in our study. We provide evidence-based, guideline-adherent information that counters the identified narratives in order to help individuals working with PWID to motivate and facilitate treatment access and uptake. An important strategy to improve HCV treatment initiation among PWID could involve disseminating guideline-concordant counternarratives to PWID and the providers who work with and are trusted by this population.

Too much or too little opioid use? A comment on Bosetti et al.

Opioids have incredible power to make lives better, as well as destroy them. After the latest US opioid overuse crisis reported by the United Nations (UN) in 2017, several other countries started observing their own opioid consumption tendencies in order to better understand current practices, predict future changes and protect their nations if necessary (International Narcotics Control Board, 2017). The report presented by the UN showed the use of opioid in the United States as being the highest of any country in the world, and more than fifty percent higher than Germany, the second country in the rank (International Narcotics Control Board, 2017). When considering a broader extent of the European continent, as Bosetti et al. (2018) did in their longitudinal analysis published in the latest issue of the European Journal of Pain, it is noted that, besides following the US trend on the rise of opioid consumption, there are still substantial differences in opioid consumption within countries. We would like to compliment the authors on the extent of their discussion, which considers not only the policy barriers imposed by governments, but also the social and cultural characteristics of the prescription and use of these drugs. It specifically caught our attention due to similarities regarding the same phenomenon in Brazil. As in Southern Europe, Brazilian regulation is restrictive, and not only in terms of the formulary availability of opioids. In order to prescribe an opioid, Brazilian physicians must go to the local health surveillance agency and sign up as opioid and amphetamine prescribers. Once registered, they are allowed to withdraw a certain amount of prescription pads monthly, which are numbered. Physicians must stamp all the pages while still in the agency, and each sheet can only be used for the prescription of one medicine for a limited 30-day treatment. Added to this bureaucratic barrier is the lack of adequate training on the responsible use of opioids to treat chronic pain. While in training, medical students are discouraged from using strong opioids except for terminal patients, probably due to the fear of possible addiction. The question that remains is as follows: Are Brazilians suffering from chronic pain? The answer is yes. While high opioid usage is undoubtedly a serious problem, low opioid prescribing can also be a threat. According to de Souza et al. (2017), who performed a cross-national survey, chronic pain prevalence was 39% in the Brazilian adult population and 50% of these people classified their chronic pain treatment as inefficient on pain management. So, how are Brazilians managing their pain? As observed by the National Survey on Access, Use and Promotion of Rational Use of Medicines (Pnaum, 2014), around 25% of Brazilian adults reported being under the use of at least one analgesic. The referred analgesics were mostly anilides, salicylic, pyrazolone derivates or nonsteroidal anti-inflammatories. Opioids counted for less than 2% of these medicines and were represented by codeine and tramadol, weak opioids which do not require a special prescription pad. Furthermore, the use of nonanalgesics for chronic pain treatment, such as tricyclic antidepressants, was almost nonexistent, with a few records for migraine treatment Mengue et al. (2016). Further research on the characteristics of opioid consumption and nonopioid pain management is yet to guide us toward a solution. At present, countries with diverse scenarios could join forces and exchange experiences with an emphasis on caring for patients suffering from pain while avoiding the development of new addiction patterns. In the end, we are all working toward the optimization of pain treatment. All authors have no conflicts of interest to declare. ATF conducted data analysis and drafted the manuscript; CMB contributed to drafting the manuscript; TSDP and SSM critically revised the manuscript.

The triple wave epidemic: Supply and demand drivers of the US opioid overdose crisis

The US mortality rate has gone up three years in a row from 2014 to 2017 (Murphy, Xu, Kochanek, & Arias, 2016, 2018; National Center for Health Statistics, 2017). Correspondingly, life expectancy at birth has declined; the first triple year decline since World War One and the devastating influenza pandemic one hundred years ago (Tejada Vera B, 2017). Most of the top ten causes of death are declining year over year; however, the third leading cause of death, unintentional injuries, has climbed in rate and rank since 2014 (Murphy et al., 2016). Driving this are deaths due to drug poisoning which exceeded 70,000 in 2017 (Hedegaard H, 2018). Annual deaths due to drug overdoses now exceed those from motor vehicle deaths, gun violence and even HIV at the height of the 1990s HIV epidemic (J Katz, 2017).

Pharmaceutical payments to physicians may increase prescribing for opioids.

Given the recent complete suspension of opioid-related promotional activities aimed at physicians, interest has renewed in understanding the role of promotion in the US opioid crisis. The present analysis aimed to measure associations between such interactions and opioid prescribing. Data on all promotions by pharmaceutical companies directly to physicians were linked to physician-level data on opioid prescriptions filled in a federal insurance program and analyzed using multivariate regression. United States. A total of 865 347 US physicians, with prescriptions filled in Medicare Part D, that might receive payments from pharmaceutical promotional activities from 2014 to 2016. The outcome variable was days' supply dispensed by each prescriber, by year, for all opioids (collectively) and separately for the following opioid classes: hydrocodone, oxycodone, fentanyl, tapentadol, morphine and a catch-all 'other opioids'. The independent variables were receipt of any payments and dollar amounts of payments received by each prescriber by year for all opioids and separately for opioid categories. Prescribers who received opioid-specific payments prescribed 8784 opioid daily doses per year more than their peers who did not receive any such payments (P<0.001). Recipient of hydrocodone-related payments was associated with 5161 additional daily doses of hydrocodone (P<0.001). Recipient of oxycodone-related payments was associated with 3624 additional daily doses of oxycodone (P<0.001). Prescribers receiving any fentanyl-specific payments prescribed 1124 daily doses per year more than their peers (P<0.001). Among recipients of opioid-specific payments (63 062 physicians), a 1% increase in amount of payments was associated with 50 daily doses of opioid prescription (P<0.001). In the United States, physicians who receive direct payments from providers for opioid prescribing tend to prescribe substantially larger quantities, particularly for hydrocodone and oxycodone.

PHP106 - IMPACT OF ACCESS RESTRICTION ON USE OF SHORT-ACTING PRESCRIPTION OPIOIDS IN A US HEALTH PLAN

In light of the US opioid crisis, a variety of policies to curb prescription opioid use are being implemented. This study evaluated the impact of access restriction to short-acting prescription opioids (SAPOs) on proportion of members with any prescription medication use filling SAPOs and average annual per-member utilization among SAPO users in one health plan in the state of Massachusetts, USA. The policy restricting access to SAPOs (included 7-day supply quantity limit and prior authorization requirement for higher quantities) was implemented in a ∼200,000 members Massachusetts health plan on January 1, 2017. Pre-post analyses were used to compare proportion of members filling SAPOs before vs after policy implementation. In addition, average per-member annual quantity among SAPO users was compared between the two periods. The policy under analyses applied to Medicaid and commercially covered members. Medicare Advantage members served as a control group. In 2016, 17.1% (20,079/117,176) of commercial, 18.1% of Medicaid (11,723/64,603) and 22.5% of Medicare Advantage members (2,041/9,078) with ≥ 1 prescription medication, filled ≥ 1 SAPO, respectively. In 2017, these values were 14.8 % (17,737/120,194), 16.0% (8,549/53,521) and 20.8% (1,881/9,066), respectively. The proportion of members with any prescription medication use filling SAPOs dropped 2.3%, 2.1% , and 1.7% among commercial, Medicaid, and Medicare Advantage populations. In 2016, among members with ≥ SAPO use, a per-member annual average of 150 and 163 tablets of SAPOs were filled by commercial and Medicaid populations, respectively. In 2017, these values were 136 and 155 tablets, respectively. The policy restricting access to short-acting prescription opioids had an impact both on reducing proportion of members filling short-acting agents and the annual per-member average tablet count among SAPO users. These findings indicate that managed care access policies can play a role in curbing the national opioid epidemic.

Reconnecting Fathers with Their Children: The Need to Directly Confront the Political and Structural Barriers for Successful Re‐integration

Key principles and theories in community psychology are used as a lens to analyse some of the ways social ecological factors impact low‐income fathers and their families. The US opioid crisis is often discussed as a public health crisis mostly affecting white populations, yet people of colour are nonetheless strongly impacted, especially in terms of contact with the criminal justice system. Punitive approaches to managing substance use have created myriad challenges for low‐income families of colour. The authors discuss the Fatherhood in Action (FIA) program in Chicago that provides individual training to support men in improving their relationships with their children. The program aims to re‐integrate formerly justice system‐involved men into communities to enhance the contributions they make to their families and broader communities. Preliminary results point to promising program effects related to individual and community empowerment. At the same time, the paper discusses the need to work on broader liberatory approaches with participants, in addition to structural change efforts, to ultimately confront the injustices in the broader political system. The racialised effects of the criminal justice system create challenges for fathers, as well as mothers and children, that cannot be easily overcome through programmatic solutions. The examination of these different approaches and levels utilises Rappaport's empowerment theory (1987), Bronfenbrenner's ecological systems theory (1979), and others.

Exploring the Multiple Roles of Acupuncture in Alleviating the Opioid Crisis.

Exploring the Multiple Roles of Acupuncture in Alleviating the Opioid Crisis.

Opioid-Related Critical Care Resource Use in US Children's Hospitals.

There has been a rapid increase in the rate of pediatric opioid-related hospitalizations. It is unknown how this increase has impacted the use of pediatric critical care. Our objective in this study was to assess the trends in pediatric hospitalization for opioid ingestions in a cohort of US children's hospitals and, specifically, to evaluate the impact on pediatric critical care resource use. A retrospective cohort study of the Pediatric Health Information System was performed to identify hospitalizations for opioid ingestions from 2004 to 2015. Admission to the PICU and the use of naloxone, vasopressors, and ventilation were assessed by using billing data. The primary outcome measure was the trend in the rate of PICU admission for opioid-related ingestion over time, assessed by using Poisson regression. There were 3647 opioid-related hospitalizations in 31 hospitals; 42.9% required PICU care. The overall mortality was 1.6%, with annual deaths decreasing from 2.8% to 1.3% (P < .001). The number of opioid-related hospitalizations requiring PICU care doubled between 2004 and 2015. The rate of PICU admission for opioid-related hospitalization increased significantly, from 24.9 to 35.9 per 10 000 PICU admissions (P < .001). Among PICU admissions, 37.0% required mechanical ventilator support, and 20.3% required vasopressors. The US opioid crisis is negatively impacting children, and the rate of hospitalization and PICU admission for pediatric opioid ingestions is increasing. Current efforts to reduce adult opioid use have not curtailed the incidence of pediatric opioid ingestions, and additional efforts are needed to reduce preventable opioid exposure in children.

Neonatal Abstinence Syndrome and the Pediatric Hospitalist: 5 Years Later.

As the US opioid crisis grows, neonatal abstinence syndrome (NAS) is increasingly common in inpatient settings, from community-hospital nurseries to inpatient units and NICUs at large children’s hospitals. NAS is stressing perinatal care systems because of lengthy and costly hospital stays and is garnering attention not only in health care but also in public policy circles and the media.1 Commensurate with the dramatic increase in NAS cases, in some settings, the management of NAS is shifting from neonatology to pediatric hospital medicine. This represents a unique opportunity. In this issue of Hospital Pediatrics , Milliren et al2 report significant variability in NAS care practices across US hospitals, including rates of pharmacotherapy use, choice of treatment medication, length of treatment, and length of stay. These inconsistencies exist despite the majority of US hospitals using some form of the Finnegan Neonatal Abstinence Scoring System (FNASS) to assess infants with NAS. This is less surprising when one considers that neither the tool (which was created in 1975) nor the protocols developed for its clinical application have ever been rigorously validated.3 As Milliren et al2 find, treatment with pharmacologic agents is associated with higher costs and longer lengths of stay. Because rates of medication use for symptom management vary by hospital from 13% to …