Use Of Other Opioids Research Articles

Examining buprenorphine diversion through a harm reduction lens: an agent-based modeling study

BackgroundRecent policies have lessened restrictions around prescribing buprenorphine-naloxone (buprenorphine) for the treatment of opioid use disorder (OUD). The primary concern expressed by critics of these policies is the potential for buprenorphine diversion. However, the population-level effects of increased buprenorphine diversion are unclear. If replacing the use of heroin or fentanyl, use of diverted buprenorphine could be protective.MethodsOur study aim was to estimate the impact of buprenorphine diversion on opioid overdose using an agent-based model calibrated to North Carolina. We simulated the progression of opioid misuse and opioid-related outcomes over a 5-year period. Our status quo scenario assumed that 50% of those prescribed buprenorphine diverted at least one dose per week to other individuals with OUD and 10% of individuals with OUD used diverted buprenorphine at least once per week. A controlled prescription only scenario assumed that no buprenorphine would be diverted, while an increased diversion scenario assumed that 95% of those prescribed buprenorphine diverted and 50% of individuals with OUD used diverted buprenorphine. We assumed that use of diverted buprenorphine replaced the use of other opioids for that day. Sensitivity analyses increased the risk of overdose when using diverted buprenorphine, increased the frequency of diverted buprenorphine use, and simulated use of diverted buprenorphine by opioid-naïve individuals. Scenarios were compared on opioid overdose-related outcomes over the 5-year period.ResultsOur status quo scenario predicted 10,658 (credible interval [CI]: 9699–11,679) fatal opioid overdoses. A scenario simulating controlled prescription only of buprenorphine (i.e., no diversion) resulted in 10,741 (9895–11,650) fatal opioid overdoses versus 10,301 (9439–11,244) within a scenario simulating increased diversion. Compared to the status quo, the controlled prescription only scenario resulted in a similar number of fatal overdoses, while the scenario with increased diversion of buprenorphine resulted in 357 (3.35%) fewer fatal overdoses. Even when increasing overdose risk while using diverted buprenorphine and incorporating use by opioid naïve individuals, increased diversion did not increase overdoses compared to a scenario with no buprenorphine diversion.ConclusionsA similar number of opioid overdoses occurred under modeling conditions with increased rates of buprenorphine diversion among persons with OUD, with non-statistical trends toward lower opioid overdoses. These results support existing calls for low- to no-barrier access to buprenorphine for persons with OUD.

Use of opioids among pregnant women 1997–2016: A Danish drug utilization study

ObjectiveUse of opioids in pregnancy is of concern yet little is known on opioid prescription patterns in Denmark. The aim of this drug utilization study was to describe prescription patterns for opioids during pregnancy in Denmark from 1997 to 2016. Study designUsing the nationwide health care registers, we obtained information on all women with a registered pregnancy in the period 1 January 1997 to 31 December 2016. Opioids were grouped in four: opioids (N02A except codeines), opioid dependency medications (N07BC), cough medications (R05DA except codeines), and codeines (N02AJ06, N02AJ07, N02BA75, and R05DA04). We used logistic regression analyses to identify factors associated with opioid use in pregnancy and cumulative oral morphine equivalent (OMEQ) to estimate volume of use in pregnancy. ResultsPrescription patterns were similar for women with live births, non-live births, and terminations. Total use of opioids among women with live born deliveries remained stable at 19.8 per 1000 pregnancies from 1997 to 2016. Codeine use declined from 2008 onwards, while use of other opioids increased from 2007 onwards. This was dominated by a threefold increase in tramadol use (2.0–7.6 per 1000 pregnancies with live births). Codeine was the most used opioid, followed by tramadol and codeine combined with paracetamol. The number of women, who used opioids before pregnancy and continued into their pregnancy, was reduced as the pregnancy progressed. The cumulative oral morphine equivalent during pregnancy was stable until 2007, after which, use prior to pregnancy and during the first two trimesters increased. The odds ratios for opioid use were higher in pregnancies of women of lower socioeconomic status or older age. For live births, odds ratios for opioid use in pregnancy were higher among women with obesity or smoking. ConclusionsOverall use of opioids was stable from 2007 to 2016. This covers a decline in the use of codeine, but a 3-fold increase in tramadol. The number of pregnant women who continued use throughout pregnancy decreased, while OMEQ among persistent users increased. The real-world data suggest an unmet need of specific focus in local Danish Outpatient Clinics and Multidisciplinary Pain Centers both pre-conceptionally and during pregnancy.

Study: Fentanyl did not hurt outcomes for buprenorphine initiators in ED

Results of a newly published study suggest that offering immediate access to buprenorphine in hospital emergency departments (EDs) improves engagement in follow‐up services, even among those with opioid use disorder (OUD) who have reported fentanyl use. Clinicians have expressed concern that fentanyl use, compared with use of other opioids, can lead to suboptimal response to buprenorphine treatment for OUD.

New Patients in Treatment for Opioid Addiction in Spain.

Patients seeking first time treatment for opioid consumption reflect the characteristics of the consumer population. This group has not been studied in Spain in decades. The objective of this study was to characterize the opioid user population seeking first time treatment (incidents) and compare them group with those with prior treatment (prevalents). Cross-sectional study (N = 3325) with patients with opioid addiction seeking care at public addiction centers in the Community of Madrid from 2017 through 2019. Differentiation and comparisons were carried out using bivariate analysis, adjusted by sociodemographic characteristics related and those related to substance use consumption in incident and prevalent patients. About 12.2% were incidents. Compared to prevalents, there were more foreigners (34.1% vs 19.1% P < .001), but with a better social network. Regarding opioid use, incidents were less likely to use injection (10.7% compared to 16.8% P = .008), but had greater daily frequency (75.8% vs 52.2%, P < .001). The age of initial consumption was greater (27 years vs 21.3 years, (P < .001)). About 15.5% of incidents sought care for non-heroin opioids, compared to 4.8% of prevalents (P < .001). Women sought care at twice the rate of men (29.3% vs 12.3%; P > .001). New patients presented a profile with many stable characteristics, but which highlighted an increase in the use of other opioids, as occurs in the international context. Surveillance of the new patient characteristics can serve as an early indicator of consumption changes in. Thus, periodic monitoring is important.

Effects of fentanyl administration in mechanically ventilated patients in the intensive care unit: a systematic review and meta-analysis

BackgroundFentanyl is selected to manage pain in critical care patients on mechanical ventilation in the intensive care unit (ICU). However, the usefulness of fentanyl compared with other opioids is unknown. This study examined the evidence for using fentanyl to improve the clinical outcomes of ICU patients, using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.MethodsWe searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi databases in June 2021. Two independent assessors reviewed studies to identify randomized, controlled trials (RCTs) that compared the intravenous administration of fentanyl and other opioids in mechanically ventilated patients in the ICU. The study quality was assessed using the GRADE system and Cochrane methodology. The primary outcome was mortality. The secondary outcomes were the duration of mechanical ventilation, duration of the ICU stay, incidence of severe adverse events, and incidence of delirium. We integrated outcome data using a random-effects model and showed absolute values and certainty of evidence in the GRADE evidence profile.ResultsSeven RCTs met the study inclusion criteria with 534 patients (251 were treated with fentanyl and 283 with other opioids, including 242 with remifentanil and 41 with morphine). Among 191 participants from 2 RCTs, fentanyl was not associated with mortality (risk ratio [RR], 0.79; 95% confidence interval [CI], 0.24 to 2.60; low-quality evidence). Regarding the secondary outcomes, fentanyl did not shorten the duration of mechanical ventilation (mean difference, 0.49 h; 95% CI, − 0.90 to 1.88; moderate-quality evidence) or the duration of the ICU stay (mean difference, 7.04 h; 95% CI, − 3.27 to 17.35; moderate-quality evidence) compared with other opioids. Fentanyl did not increase the incidence of severe adverse events (RR, 0.98; 95% CI, 0.50 to 1.90; low-quality evidence) or delirium (RR, 1.27; 95% CI, 0.79 to 2.04; low-quality evidence).ConclusionsAlthough fentanyl is a frequently administered opioid in the ICU, patients’ outcomes are not different between fentanyl use and use of other opioids. However, the GRADE evaluation provides little certainty to support the results of this systematic review. Therefore, further large RCTs are required to confirm our conclusions.Trial registrationPROSPERO, CRD42019130648 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130648).

Novel Opioid Analgesics for the Development of Transdermal Opioid Patches That Possess Morphine-Like Pharmacological Profiles Rather Than Fentanyl: Possible Opioid Switching Alternatives Among Patch Formula.

BACKGROUND:Transdermal fentanyl is widely used in the treatment of severe pain because of convenience, safety, and stable blood concentrations. Nevertheless, patients often develop tolerance to fentanyl, necessitating the use of other opioids; transdermal buprenorphine patch is widely used as an analgesic agent, though available formulation does not provide comparable analgesic effect as transdermal fentanyl patch. Opioids bind to the opioid receptor (OR) to activate both G protein–mediated and β-arrestin–mediated pathways. We synthesized morphine-related compounds with high transdermal absorbability (N1 and N2) and evaluated their OR activities pharmacologically in comparison with fentanyl and morphine.METHODS:In cells stably expressing μ-opioid receptor (MOR), δ-opioid receptor (DOR), and κ-opioid receptor (KOR), G protein–mediated pathways were assessed using the CellKey and an intracellular cyclic adenosine monophosphate (cAMP) assay, while β-arrestin–mediated pathways were analyzed with β-arrestin recruitment and receptor internalization assays. Furthermore, analgesic effects were evaluated using a tail-flick test in mice, and the analgesic effect on fentanyl-tolerant mice was evaluated.RESULTS:In the CellKey and cAMP assays, both N1 and N2 showed the highest affinity for MOR and acted as full agonists as well as partial agonists for DOR and KOR. In the β-arrestin and internalization assays, only fentanyl acted as a full agonist; N1 and N2 acted as partial agonists of MOR. In the mouse tail-flick test, N1 and N2 showed analgesic effects equivalent to those of fentanyl and morphine. In fentanyl-tolerant mice, fentanyl showed a diminished analgesic effect, whereas N1 and N2 as well as morphine retained their analgesic effects.CONCLUSIONS:While N1 and N2 have higher transdermal absorbability than fentanyl, they also have analgesic effects comparable to those of morphine, suggesting that they may be attractive compounds for the development of novel opioid patches for transitioning from fentanyl patches.

Transition From Full Mu Opioid Agonists to Buprenorphine in Opioid Dependent Patients-A Critical Review.

Methadone, a full opioid agonist at the mu-, kappa-, and delta-receptor, and buprenorphine, a partial agonist at the mu receptor, are first-line medications in opioid maintenance treatment. Transition from methadone to buprenorphine may precipitate withdrawal, and no accepted algorithm for this procedure has been developed. Current treatment strategies recommend transfer from methadone to buprenorphine predominantly in patients at low doses of methadone (30–40 mg/day). There are some reports indicating that transition from higher doses of methadone may be possible. A number of dosing strategies have been proposed to soften withdrawal symptoms and facilitate transfer including use of other opioids or medications and especially microdosing techniques for buprenorphine. The case series and studies available thus far are reviewed.

Beyond harm-producing versus harm-reducing: A qualitative meta-synthesis of people who use drugs' perspectives of and experiences with the extramedical use and diversion of buprenorphine

IntroductionThis review synthesizes the literature on the perspectives and experiences of people who use drugs to better understand motivations and behaviors related to the extramedical use and diversion of buprenorphine. Given the particular social construction of buprenorphine against methadone, and the centrality of concerns around extramedical use in delivering opioid agonist therapies, a focus on extramedical buprenorphine use can provide an important lens through which to analyze treatment for opioid use disorder. This review is framed within persistent tensions between potential harm-producing versus harm-reducing effects of extramedical use that have long been described for opioid agonist therapies. MethodsThe research team conducted a qualitative meta-synthesis based on a systematic search of eight databases as well as hand searching. The review includes all primary qualitative and mixed-methods studies related to the perspectives and experiences of people who use drugs on extramedical buprenorphine use. The study team carried out three rounds of qualitative coding using NVivo 12, and constructivist grounded theory and the constant comparative method informed the synthesis. ResultsThe review includes twenty-one studies. Findings are organized into the following three themes: 1) the experiences of people who use drugs (PWUD) with extramedical use of buprenorphine and their motivations to engage in it (including the desire to self-medicate and achieve “stability”, to manage ongoing use of other opioids, and to “get high”); 2) the relationship between extramedical use and formal medical opioid agonist therapy programs; and 3) the established drug economy of extramedical buprenorphine. ConclusionsThe review identified varied and often divergent perspectives and experiences with extramedical buprenorphine use. An examination of the reported “normalizing” effects of extramedical buprenorphine suggests this practice as extending medicalized discipline beyond the clinical environment. Taken together, these findings identify a need to move beyond the tension of harm-reducing versus harm-producing effects toward forms of health care and promotion that focus on the needs, perspectives, and priorities of people who use drugs.

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.

Evaluation of Infectious Disease Test Ordering and Positivity Rates in Illicit Fentanyl Users.

The emergence of illicit fentanyl use has resulted in considerable morbidity and mortality. Although illicit use of other opioids has been associated with transmission of viral and bacterial infections, limited data exist for the prevalence of infectious diseases among illicit fentanyl users. The purpose of this study was to assess the likelihood of infectious disease testing and infection prevalence among illicit fentanyl users. Results from urine drug screens (UDSs) performed from August 13, 2019, to October 16, 2019, were obtained from the laboratory information system with concurrent microbial testing. Patients were categorized based on UDS results, and illicit drug use was inferred from physician encounter notes in the electronic medical record. Suspected illicit drugs users with fentanyl detected by UDS were more likely to be screened [odds ratio (OR): 1.7; 95% CI, 1.26-2.4] and test positive for hepatitis C virus (HCV) by immunoassay (OR: 5.89; 95% CI, 2.93-11.31) than patients without drugs detected. Patients with suspected illicit fentanyl use who were discharged from the emergency department (ED) were less likely to be tested for HCV than patients in outpatient settings (OR: 3.47; 95% CI, 1.05-10.4) and inpatient settings (OR: 17.43; 95% CI, 6.53-45.88). Patients with suspected illicit fentanyl use were more likely to have infected abscesses or wounds (OR: 5.12; 95% CI, 2.07-13.7) and Staphylococcus aureus infections (OR: 4.5; 95% CI, 1.59-12.28) than patients without drugs detected. Patients with a positive UDS for fentanyl and suspected illicit use were more likely to test positive for HCV, were rarely screened for HCV in the ED, and had an increased risk of invasive S. aureus wound or abscess infection. These findings may represent considerable barriers to care for patients who use fentanyl illicitly.

Tapentadol, the new kid on the block in India: Is it time to worry?

Background and Objectives:Large-scale prospective case series of tapentadol abuse or dependence in India is not available. Hence, we aimed to study the prevalence and profile of tapentadol users in a treatment-seeking population.Materials and Methods:The study had prospective and retrospective arms. We collected 8-month prospective data by face-to-face interviews (n = 70) and 8-year retrospective data from case notes (n = 26) with either tapentadol misuse/abuse or dependence in patients attending a de-addiction center.Results:The prevalence of tapentadol abuse or dependence was 25% among the pharmaceutical opioid users. Concurrent use of other opioids was seen in >80% of participants of both the arms. Major sources of tapentadol were chemists (without a prescription) (53%) and doctors (prescriptions) (40%). Patients in the tapentadol dependence group had a significantly higher dose, duration, and pharmaceutical opioid use.Conclusion:India needs awareness promotion, training, availability restriction, and provision of treatment for tapentadol abuse or dependence.

Evaluation of the fentanyl patch-for-patch program in Ontario, Canada

BackgroundRising use of prescription opioids is a major public health concern associated with increased risk of mortality worldwide. Fentanyl, a synthetic opioid available in patch form, is particularly concerning given its high potency. To curb the misuse and diversion of fentanyl patches, a Patch-for-Patch (P4P) program was implemented in some counties in Ontario between 2012 and 2015. The program requires that patients prescribed fentanyl must return used patches to the pharmacy before receiving more patches. ObjectiveTo evaluate the impact of the P4P program on fentanyl and non-fentanyl dispensing and opioid-related hospitalizations and deaths. MethodsWe conducted a repeated cross-sectional time-series analysis among counties that implemented the P4P program using Ontario administrative claims data. Because intervention dates varied by county due to staggered program initiation, we aligned all intervention months and examined outcome rates in the 5 years preceding and 12 and 24 months following implementation. We explored the monthly rate of prescriptions dispensed for fentanyl and non-fentanyl opioids, opioid toxicity-related hospital and emergency department visits, and opioid-related deaths. We modeled each outcome using an interventional autoregressive integrated moving average (ARIMA) model and tested the impact of the P4P program using a ramp function. ResultsWe analyzed 16 counties that implemented the P4P program and had at least 12 months of follow-up. The introduction of the P4P program was associated with a 30.5% decline in the volume of fentanyl patches dispensed at 24 months (from 1,277–888 patches per 10,000 population; p = 0.04). In contrast, there was no significant change in the rate of non-fentanyl opioid dispensing (p = 0.32), opioid toxicity related hospitalizations and emergency department visits (p = 0.4) or opioid-related deaths (p = 0.96) in the 12 months following implementation of the program. ConclusionsWe found that the implementation of a P4P program in select counties in Ontario was associated with a lower volume of fentanyl patches dispensed by pharmacies, without an increase in use of other opioids. The program had no measurable impact on rates of opioid toxicity-related hospital visits or deaths. Policymakers should consider the use of P4P programs as part of larger opioid strategy.

Single high-dose buprenorphine for opioid craving during withdrawal

BackgroundOpioid use disorder is one of the most prevalent addiction problems worldwide. Buprenorphine is used as a medication to treat this disorder, but in countries where buprenorphine is unavailable in combination with naloxone, diversion can be a problem if the medication is given outside a hospital setting.ObjectiveThe objective of this research is to evaluate the effect of a single, high dose of buprenorphine on craving in opioid-dependent patients over 5 days of abstinence from use of other opioids. The primary goal was to determine the safety and efficacy of buprenorphine during withdrawal in a hospital setting.MethodsNinety men who used opium, heroin, or prescribed opioids and met DSM-5 criteria for opioid use disorder (severe form) were randomized to three groups (n = 30 per group) to receive a single, sublingual dose of buprenorphine (32, 64, or 96 mg). The study was conducted in an inpatient psychiatric ward, with appropriate precautions and monitoring of respiratory and cardiovascular measures. Buprenorphine was administered when the patients were in moderate opiate withdrawal, as indicated by the presence of four to five symptoms. A structured clinical interview was conducted, and urine toxicology testing was performed at baseline. Self-reports of craving were obtained at baseline and on each of the 5 days after buprenorphine administration.FindingsCraving decreased from baseline in each of the three groups (p < 0.0001), with a significant interaction between group and time (p < 0.038), indicating that groups with higher doses of buprenorphine had greater reduction.ConclusionsA single, high dose of buprenorphine can reduce craving during opioid withdrawal; additional studies with follow-up are warranted to evaluate safety.

Current Opioid Access, Use, and Problems in Central and Western European Jurisdictions

To provide recent data on opioid use in Central and Western Europe and available treatments, with focus on Spain and Switzerland. The prevalence of opioid use in Europe is around 0.4%, which represents 1.3 million individuals. Heroin use remains the main reason for treatment among patients with an opioid use disorder (> 80%). Opioid agonist treatment (OAT) is generally available, with methadone and buprenorphine being the most often used treatments. In some European countries, pharmaceutical heroin (diacetylmorphine, DAM) is also available as an OAT option. The prevalence of opioid use disorder is decreasing in Western Europe and OAT is widely available. Heroin remains the opioid of most concern but changes in the prevalence of use of other opioids should be closely monitored.

Changing Trends in Opioid Use Among Patients With Rheumatoid Arthritis in the United States.

Opioid prescribing recently has come under intense scrutiny. However, longitudinal patterns of prescription opioid receipt in a population-based cohort of patients with chronic pain, such as those with rheumatoid arthritis (RA), have not been well characterized. The aim of this study was to examine both trends over time and variability in individual physician prescribing of short-term and long-term use of opioids. We identified a cohort of RA patients based on 2006-2014 Medicare data and evaluated longitudinal time trends in "regular" use of opioids. A separate analysis conducted in 2014 assessed rheumatologist-specific variability in regular use of opioid prescriptions in patients with RA. We identified 97,859 RA patients meeting the eligibility criteria. The mean age of the patients was 67 years, 80% were female, 82% were white, and 12% were African American. The most commonly used opioids were those that combined acetaminophen with hydrocodone or propoxyphene. Regular opioid prescribing increased slowly but peaked in 2010 before propoxyphene was withdrawn from the market. Following the withdrawal of propoxyphene, receipt of hydrocodone and tramadol increased commensurately, and overall opioid use declined only slightly. Factors associated with regular use of opioids included younger age, female sex, African American race, back pain, fibromyalgia, anxiety, and depression. Variability between US rheumatologists (n = 4,024) in prescribing the regular use of opioids for their RA patients was high; in the average rheumatologist's practice, 40% of RA patients used prescription opioids regularly. In almost half of the patients, at least some opioid prescriptions were written by a rheumatologist, and 14% received opioids that were co-prescribed concurrently by more than 1 physician. In the US, opioid use in older patients with RA peaked in 2010 and is now declining slightly. Withdrawal of propoxyphene from the US market in 2010 had minimal effect on overall opioid use, because use of propoxyphene was replaced by increased use of other opioids.

Temporal trends in drug use in Adelaide, South Australia by wastewater analysis

Analysis of municipal wastewater for drug metabolites can reveal the scale of drug use within communities. An Australian city with a population of 1.2million inhabitants was assessed for 4 stimulants: cocaine, methamphetamine, 3.4-methylenedioxymethamphetamine (MDMA) and amphetamine; 6 opioids: codeine, morphine, heroin, fentanyl, oxycodone and methadone; 11 new psychoactive substances (NPS); benzylpiperazine (BZP), trifluoromethylphenylpiperazine (TFMPP), methcathinone, methylone, mephedrone, methylenedioxypyrovalerone (MDPV), alpha pyrrolidinopentiophenone (alpha-PVP), paramethoxyamphetamine (PMA), 25C-NBOMe, 25B-NBOMe, 25I-NBOMe; and cannabis, for up to four years between December 2011 and December 2015. Temporal trends revealed increasing usage rates of methamphetamine, cocaine, oxycodone, and fentanyl, while decreasing rates of use were observed for MDMA, BZP and methylone. Use of other opioids and cannabis was generally stable across years, while use of new psychoactive substances fluctuated without an apparent direction. Opioids and cannabis were used at a consistent level through the course of the week, while use of stimulants and some NPS increased on the weekend. Seasonal differences in use were observed for MDMA and cannabis (p$_amp_$lt;0.05) where, on average, MDMA use was approximately 90% higher in December than in other months and cannabis use was approximately 45% lower in each February. Residual month-to-month variability measures on trend-free data showed NPS use had higher variability than the stimulants and opioids. Frequent wastewater sampling and analysis over prolonged periods has yielded valuable insights into long-term drug use trends, in some instances revealed important within-year trends, and demonstrated the differing patterns of use of drugs on weekends compared to weekdays.

Successful interventions in decreasing oxycodone CR prescriptions within an underserved population

To use fundamental population health and Patient Centered Medical Home guidelines to create an effective intervention that would decrease the quantity of inappropriate oxycodone controlled release (CR) prescriptions within an uninsured population. This was a prospective interventional study. Patients seen in the newly formed University of Florida Community Health and Family Medicine Department Total Care Clinic, for chronic nonmalignant pain. This clinic was designed to serve the uninsured patients of Jacksonville, FL. A structured, step-wise pain management protocol was introduced and implemented, and an improved Controlled Substance User Agreement was created and implemented. Pharmacists and primary care providers collaborated on care. The primary study outcome measures were the number of oxycodone CR prescriptions over an 8-month period. At the initiation of the program, the authors averaged over 40 oxycodone CR prescriptions per month. After 3 months, the number of prescriptions dropped to an average of 10 per month, a 75 percent decrease. More importantly, the number of oxycodone CR tablets saw a corresponding 75 percent drop from over 2,500 tablets per month to approximately 600 per month. Of course, the authors were concerned that the reduction of oxycodone CR may lead to increases in the use of other opioids. However, trends for hydrocodone/acetaminophen also showed a reduction in total usage as well as all other long-acting opioids. In addition, patient satisfaction did not change significantly, and no significant complaints from patients regarding this specific change were received. By implementing criteria for oxycodone CR prescribing in an innovative, comprehensive, and unified patient-centered practice model, the authors saw a significant decrease in the number of oxycodone CR tablets prescribed per month and also a decrease in total prescriptions per month.

A typology of people who tamper with pharmaceutical opioids: responses to introduction of a tamper-resistant formulation of controlled-release oxycodone.

In April 2014, a tamper-resistant controlled-release oxycodone formulation was released in Australia. We aimed to determine whether there are latent classes of people who tamper with pharmaceutical opioids based on frequency of opioid and illicit drug use, the demographic and clinical profiles of these groups, and if there were changes in use and harms following the introduction. A prospective cohort of 606 people who regularly tamper with pharmaceutical opioids was interviewed January to March 2014 (Wave 1) and May to August 2014 (Wave 2). Latent class analysis identified groups based on non-prescribed opioid, illicit drug and prescribed opioid substitution therapy (OST) use at Wave 1. Regression models examined whether group membership predicted use and harms at Wave 2. Four groups were identified: frequent OST group (39%), mixed OST/heroin group (7%), infrequent pharmaceutical opioid and heroin group (44%) and frequent oxycodone group (25%). Compared with the frequent OST group, the infrequent pharmaceutical opioid/heroin group was more likely to report non-everyday pain and risky alcohol use, and the frequent oxycodone group had higher odds of homelessness. At Wave 2, oxycodone use decreased across groups (odds ratios (OR) ≤ 0.18, p < 0.001, particularly for the frequent oxycodone group: OR ≤ 0.05, p < 0.001), with reductions in days of use (g ≥ 0.35, p < 0.050). Non-prescribed pharmaceutical opioid use, illicit drug use and harms remained stable or decreased. Despite heterogeneity among people who tamper with pharmaceutical opioids, the tamper-resistant formulation was followed by reductions in oxycodone tampering among high-frequency and low-frequency users. There was no evidence of increased use of other opioids or illicit drugs.

Use of opioids for pediatric pain treatment: a population study

Little is known about the demographic, clinical and drug utilization characteristics of pediatric patients prescribed opioids for treatment of pain. Of commonly used opioids, only fentanyl is currently approved for pain treatment in pediatric patients. However data from administrative claims databases suggest off-label use of other opioids occurs. Our study objective was to describe pediatric opioid use under real-world clinical conditions. We identified patients ≤16 years of age with ≥1 incident prescriptions for oxycodone, fentanyl, hydrocodone, methadone, or extended release (ER) morphine in the HealthCore Integrated Research Database from 1/1/2001 to 9/30/2011.

Use of other opioids during methadone therapy: a population‐based study

To determine the extent to which other opioids are prescribed to patients receiving methadone in Ontario, Canada. Retrospective cohort study. Ontario, Canada from 1 April 2003 to 31 March 2010. We studied patients aged 15-64 years with publically funded drug coverage who received at least 30 days of continuous methadone maintenance therapy (MMT). The proportion of patients who received more than 7 days of a non-methadone opioid during MMT. A secondary analysis examined the extent to which non-methadone opioids were prescribed by physicians or dispensed by pharmacies not involved in a patient's MMT. Among 18,759 patients treated with methadone, 3456 (18.4%) received at least one prescription for non-methadone opioids of more than 7 days' duration. In this group, the median number of non-methadone opioid prescriptions dispensed per year was 11.9 (interquartile range 4.1-25.0). The most frequently prescribed opioids were codeine and oxycodone. Of the 73,520 non-methadone opioid prescriptions of more than 7 days' duration, nearly half (45.8%) originated from non-MMT prescribers and pharmacies. Many patients receiving methadone maintenance therapy in Ontario receive overlapping prescriptions for other opioids, often for extended periods. The associated prescribing patterns suggest that many such prescriptions may be duplicitous. The prescribing and dispensing of non-methadone opioids to patients receiving methadone maintenance therapy is likely to be observed in jurisdictions outside Ontario, Canada.