The following have been checked against all previous articles. 

1) Overdose Education and Naloxone Distribution in the San Francisco County Jail.

Wenger LD, Showalter D, Lambdin B, Leiva D, Wheeler E, Davidson PJ, Coffin PO, Binswanger IA, Kral AH. J Correct Health Care. 2019 Oct;25(4):394-404. doi: 10.1177/1078345819882771. Epub 2019 Oct 31.

Comments: San Francisco’s Opioid Education and Naloxone Distribution program was one of the first in the country. Out of the 637 participants who were given naloxone upon release from jail, 32% reported reversing an overdose and 44% received refills from community-based programs. People leaving correctional facilities can and should be recruited to support overdose prevention efforts nationwide.

2) Relay: A Peer-Delivered Emergency Department-Based Response to Nonfatal Opioid Overdose.

Welch AE, Jeffers A, Allen B, Paone D, Kunins HV. Am J Public Health. 2019 Oct;109(10):1392-1395. doi: 10.2105/AJPH.2019.305202. Epub 2019 Aug 15.

Comments: Description of the Relay program, which follows survivors of overdose for 90 days after an overdose event. Preliminary data only, showing high engagement from individuals who may not have other touch points at harm reduction centers or in naloxone distribution programs.

3) Stigma Associated with Opioid Use Disorders in Adolescents Limits Naloxone Prescribing.

Carson L. J Pediatr Nurs. 2019 Nov – Dec;49:92-96. doi: 10.1016/j.pedn.2019.10.005. Epub 2019 Oct 25. Review.

Comments: This review addresses healthcare provider communication and trends in caring for adolescents who use substances and families. It proposes further research on the impact of healthcare providers’ unconscious bias on naloxone prescription.

4) Impact of student pharmacist-led naloxone academic detailing at community pharmacies in Texas.

Evoy KE, Groff L, Hill LG, Godinez W, Gandhi R, Reveles KR. J Am Pharm Assoc (2003). 2020 Jan – Feb;60(1):81-86. doi: 10.1016/j.japh.2019.09.007. Epub 2019 Oct 25.

Comments: Pharmacy students conducted brief, one-on-one academic detailing visits to pharmacists at chain pharmacies that would not dispense naloxone without a prescription, despite state-wide standing orders. Pharmacists’ willingness to dispense naloxone increased significantly after the detailing intervention.

5) Capsule Commentary on Lin et al., “Association of Opioid Overdose Risk Factors and Naloxone Prescribing in US Adults.

Keller MS. J Gen Intern Med. 2020 Feb;35(2):620. doi: 10.1007/s11606-019-05500-x. No abstract available.

Comments: A large claims-based analysis of 23,778 patients found that less than 2% of patients at high risk for overdose filled a prescription for naloxone, neither was there an association between patients with a history of overdose or substance use disorder with a filled naloxone prescription. This commentary highlights their concerning findings, although it’s possible that some patients at risk for opioid overdose were dispensed naloxone in community-based settings.

6) Higher naloxone dosing may be required for opioid overdose.

Bardsley R. Am J Health Syst Pharm. 2019 Oct 30;76(22):1835-1837. doi: 10.1093/ajhp/zxz208.

Comments: 2 case studies of patients who needed 10-12mg naloxone to maintain adequate respiratory status in the emergency room after suspected carfentanil overdose. The only downside to these reported findings were that no laboratory tests were run, as both patients declined further care and left AMA. The suspected carfentanil was established based on the fact that both patients overdosed on the same unknown opioid, which they both injected, and required such high naloxone doses. In general, most street fentanyl-like products are sufficiently responsive to naloxone – however, some of these are so extremely potent that more naloxone may be required to compete for receptor occupancy.

7) The treatment of cocaine use disorder.

Kampman KM. Sci Adv. 2019 Oct 16;5(10):eaax1532. doi: 10.1126/sciadv.aax1532. eCollection 2019 Oct. Review.

Comments: Review of potential treatments- we have yet to find safe, effective medications to treat cocaine use disorder. Agents with dopamine activity are referenced as potential treatments that require further investigation, including long-acting amphetamines, modafinil or topiramate.

8) Lessons learned from ramping up a Canadian Take Home Naloxone programme during a public health emergency: a mixed-methods study.

Young S, Williams S, Otterstatter M, Lee J, Buxton J. BMJ Open. 2019 Oct 28;9(10):e030046. doi: 10.1136/bmjopen-2019-030046.

Comments: Focus groups and interviews were conducted with Take Home Naloxone program stakeholders in response to the 2016 expansion of the program. Based on the mixed method study results, authors recommended creating an online database, implementing standing orders and developing online training resources for standardized education programs for both staff and clients.

9) Sustained-release Oral Hydromorphone for the Treatment of Opioid Use Disorder.

Braithwaite V, Fairgrieve C, Nolan S. J Addict Med. 2019 Oct 25. doi: 10.1097/ADM.0000000000000585. [Epub ahead of print]

Comments: Case study of a 51 year old male with polysubstance use and opioid use disorder who transitioned from 100mg oral methadone to sustained release oral hydromorphone once daily due to a persistently elevated QTc. The study authors noted that cravings were well-controlled after the switch but due to having limited access to the abstract only, it is unclear how long the patient was followed or what other aspects of a use disorder were monitored apart from cravings.

10) Correlates of take-home naloxone kit possession among people who use drugs in British Columbia: A cross-sectional analysis.

Moustaqim-Barrette A, Papamihali K, Crabtree A, Graham B, Karamouzian M, Buxton JA. Drug Alcohol Depend. 2019 Dec 1;205:107609. doi: 10.1016/j.drugalcdep.2019.107609. Epub 2019 Oct 7.

Comments: In British Columbia, take-home naloxone programs have been in effect since 2012, distributing 147,000 naloxone kits that have been used to reverse over 40,000 opioid overdoses. Across the entire province (including rural areas along with Vancouver), the proportion of people who inject opioids who have a naloxone kit is over two times greater than the proportion of people who possess a kit who snort, smoke or inhale their opioid of choice. Of note, naloxone does not require a prescription in Canada and is available for sale over-the-counter as well.

11) CE: Implementing Guidelines for Treating Chronic Pain with Prescription Opioids.

Maloy PE, Iacocca MO, Morasco BJ. Am J Nurs. 2019 Nov;119(11):22-29. doi: 10.1097/01.NAJ.0000605344.99391.78.

Comments: Call to action for nurses working in primary care settings to partner with primary care physicians to implement many opioid safety measures.

12) Risk of death associated with kratom use compared to opioids.

Henningfield JE, Grundmann O, Babin JK, Fant RV, Wang DW, Cone EJ. Prev Med. 2019 Nov;128:105851. doi: 10.1016/j.ypmed.2019.105851. Epub 2019 Oct 21.

Comments: This commentary surveyed animal toxicology, surveys and mortality data to come up with an estimate that the risks of overdose from opioids are > 1000 times greater than from kratom, the herbal extract from Southeast Asia used recreationally for its opioid-like effects. Obviously more research is needed, as there are more and more case reports of kratom detected in opioid-related overdose deaths, though the primary alkaloid, called mitragynine, does not demonstrate the respiratory depression effects of opioids.

13) Buprenorphine.

LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-.2014 May 20.

Comments: Review of liver toxicity associated with buprenorphine. Mild transaminase elevation is seen with buprenorphine therapy, though more severe liver injuries have been observed with non-prescription sublingual or intravenous use.

14) Substance Abuse Treatment Agents.

LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-.2014 May 20.

Comments: Review of substance use disorder treatments and liver toxicity.

15) Opioids.

LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. 2019 Apr 25.

Comments: Yet another review of opioids and liver toxicity- overdose is really the only concern for acute liver injury, as prescription doses for pain relief have not been associated with significant liver disease. A special note is given to fixed-dose combination tablets of opioids and acetaminophen, which do need to be monitored to prevent acetaminophen overdose and its resulting hepatotoxicity.

16) Correlates of experiencing and witnessing non-fatal opioid overdoses among individuals accessing harm reduction services in Philadelphia, Pennsylvania.

Pizzicato LN, Johnson CC, Viner KM. Subst Abus. 2019 Oct 23:1-6. doi: 10.1080/08897077.2019.1675115. [Epub ahead of print]

Comments: Cross sectional surveys were administered at a syringe exchange site in Philadelphia. Individuals who self-identified opioid use were included in the study to determine associations for witnessing an opioid overdose and experiencing a non-fatal opioid overdose. Factors associated with experiencing an overdose included unstable housing, using both opioids and either benzos or cocaine, drug injection, witnessing an overdose in the last 12 months, and inpatient detoxification. Factors associated with witnessing an overdose included unstable housing, recent incarceration, and being trained to use naloxone.

17) Home induction and outpatient treatment of kratom use disorder with buprenorphine-naloxone: A case report in a young adult.

Schmuhl KK, Gardner SM, Cottrill CB, Bonny AE. Subst Abus. 2019 Oct 23:1-4. doi: 10.1080/08897077.2019.1671945. [Epub ahead of print]

Comments: Case report of a 20 year old male with kratom use disorder and ADHD who had a successful buprenorphine home induction to 4mg/1mg buprenorphine/naloxone. He stopped using kratom and reported improvements in sleep, mood and a return to his ADHD medications, which he had not been able to tolerate while using kratom due to tachycardia and heart palpitations.

18) A latent class analysis of drug and substance use patterns among patients treated in emergency departments for suspected drug overdose.

Liu S, Vivolo-Kantor A. Addict Behav. 2020 Feb;101:106142. doi: 10.1016/j.addbeh.2019.106142. Epub 2019 Oct 15.

Comments: Using the CDC’s Enhanced State Opioid Overdose Surveillance (ESOOS) program, over 126,000 non-fatal overdose patients were identified as being discharged from the emergency department after acute drug poisoning in 18 states. Latent class analysis categorized drugs that were identified during hospitalization and found that mostly heroin overdose (42%) followed by mostly non-heroin opioid overdose/use (27%) were responsible for non-fatal overdoses, with polysubstance use at 11%.

19) Impact of the take ACTION Train-the-Trainer model of opioid overdose education with naloxone distribution- who benefits?

Dahlem CH, Scalera M, Chen B, McCabe SE, Boyd CJ. Subst Abus. 2019 Oct 22:1-8. doi: 10.1080/08897077.2019.1671946. [Epub ahead of print]

Comments: Train the trainer model works for naloxone distribution. People trained under this model demonstrated increased knowledge and confidence to train others.

20) The nexus of opioids, pain, and addiction: Challenges and solutions.

Henningfield JE, Ashworth JB, Gerlach KK, Simone B, Schnoll SH. Prev Med. 2019 Nov;128:105852. doi: 10.1016/j.ypmed.2019.105852. Epub 2019 Oct 18.

Comments: The pendulum has swung over the years from over-prescribing opioids for pain to cutting off patients from opioids, leading to overdose and suicide risk for thousands of patients. The call for evidence-based, patient-centered policies around opioid prescribing could not be more urgent. 

21) U.S. Opioid Epidemic: Impact on Public Health and Review of Prescription Drug Monitoring Programs (PDMPs).

Boté SH. Online J Public Health Inform. 2019 Sep 19;11(2):e18. doi: 10.5210/ojphi.v11i2.10113. eCollection 2019.

Comments: These should really be called “controlled substance monitoring programs” because they – with an exception for Nebraska – only include controlled substances. If they really did include all prescriptions, I’d be able to find out if that patient who is on 4 medications for blood pressure is picking up their meds before adding a fifth medication.

22) Prescription drug monitoring programs operational characteristics and fatal heroin poisoning.

Martins SS, Ponicki W, Smith N, Rivera-Aguirre A, Davis CS, Fink DS, Castillo-Carniglia A, Henry SG, Marshall BDL, Gruenewald P, Cerdá M. Int J Drug Policy. 2019 Dec;74:174-180. doi: 10.1016/j.drugpo.2019.10.001. Epub 2019 Oct 15.

Comments: This study looked at how transitions across types of “PDMP” (better called CSMP) classes (Cooperative, Proactive, and Weak, as described in Smith et. al, 2019) over time contributed to changes in fatal heroin poisoning in counties within states from 2002 to 2016. PDMPs overall are associated with an increase in fatal heroin poisonings. There are real issues with these programs and how they have been implemented.

23) Suicidal motivations reported by opioid overdose survivors: A cross-sectional study of adults with opioid use disorder.

Connery HS, Taghian N, Kim J, Griffin M, Rockett IRH, Weiss RD, Kathryn McHugh R. Drug Alcohol Depend. 2019 Dec 1;205:107612. doi: 10.1016/j.drugalcdep.2019.107612. Epub 2019 Oct 5.

Comments: Cross sectional surveys at a private not-for-profit psychiatric hospital. Almost 60% of participants reported some suicidal motivation, falling along a continuum of severity. Intention to die from opioid overdose was not assessed, though on average, perceived risk of opioid overdose was low. Frequency of suicidal motivation in this population highlights the need to test suicide prevention interventions in addition to the standard of care. However, authors note that their sample was relatively small and predominantly white, limiting generalizability of the results. 

24) The uptake of the pharmacy-dispensed naloxone kit program in Ontario: A population-based study.

Choremis B, Campbell T, Tadrous M, Martins D, Antoniou T, Gomes T. PLoS One. 2019 Oct 18;14(10):e0223589. doi: 10.1371/journal.pone.0223589. eCollection 2019.

Comments: The Ontario government rolled out the Ontario Naloxone Program for Pharmacies (ONPP) in 2016. Among the 67,910 individuals dispensed naloxone in the one year study period, the program was most successful in providing access to prescription opioid agonist therapy (OAT) recipients, with notably less uptake among prescription opioid recipients. Only half of pharmacies eligible for ONPP did so. More efforts needed to fill this gap in naloxone access and expand pharmacy participation.

25) Differences in Naloxone Prescribing by Patient Age, Ethnicity, and Clinic Location Among Patients at High-Risk of Opioid Overdose.

Kispert D, Carwile JL, Silvia KB, Eisenhardt EB, Thakarar K. J Gen Intern Med. 2019 Oct 17. doi: 10.1007/s11606-019-05405-9. [Epub ahead of print] No abstract available.

Comments: Despite frequent clinic visits, only 6% of 1385 internal medicine clinic patients in Minnesota considered high-risk for opioid overdose received a naloxone prescription. More prescriptions for naloxone were written for younger adults, Hispanics, patients receiving care from clinics in lower-income communities, patients who met ≥ 1 CDC criterion, and those with a history of OUD.

26) Post-overdose interventions triggered by calling 911: Centering the perspectives of people who use drugs (PWUDs).

Wagner KD, Harding RW, Kelley R, Labus B, Verdugo SR, Copulsky E, Bowles JM, Mittal ML, Davidson PJ.

PLoS One. 2019 Oct 17;14(10):e0223823. doi: 10.1371/journal.pone.0223823. eCollection 2019.

Comments: Based in Reno, this study sought community feedback on the development of a machine-learning algorithm to identify opioid overdoses in 911 dispatch data and deploy post-overdose interventions. Unsurprisingly, these focus group findings emphasize the need for a way to summon EMS without involving law enforcement. Even with Good Samaritan laws in place, “calling 911” was justifiably linked with perceived fears and inevitability of police and CPS, incarceration, and threats to personal privacy. Respondents perceived benefit in peer support specialists and active follow-up, addressing holistic needs and coordinating care beyond just SUD treatment linkage. Participants were also concerned that immediately post-overdose was not an ideal time for intervention delivery, due to issues including naloxone-induced withdrawal.

27) A Laboratory Session to Prepare Pharmacy Students to Manage the Opioid Crisis Situation.

Donohoe KL, Raghavan A, Tran TT, Alotaibi FM, Powers KE, Frankart LM. Am J Pharm Educ. 2019 Sep;83(7):6988. doi: 10.5688/ajpe6988.

Comments: Most students strongly believed that pharmacists “should have an integral role in addressing the opioid crisis through patient education and direct medication reversal of an overdose”. At baseline, students had a relatively good conceptual understanding, but gained confidence in opioid overdose recognition and management after completing the laboratory session.

28) Feasibility and acceptability of a proposed pharmacy-based harm reduction intervention to reduce opioid overdose, HIV and hepatitis C.

Meyerson BE, Agley JD, Jayawardene W, Eldridge LA, Arora P, Smith C, Vadiei N, Kennedy A, Moehling T; PharmNet Research Team. Res Social Adm Pharm. 2019 Aug 9. pii: S1551-7411(19)30163-9. doi: 10.1016/j.sapharm.2019.08.026. [Epub ahead of print]

Comments: Managing pharmacists in Indiana were invited to assess the proposed intervention, using a CFIR (Consolidated Framework for Implementation Research) design framework. PharmNet would include a screening for opioid misuse and addiction, a brief motivational interviewing intervention, and referral to treatment. This integrated intervention is likely feasible, but special attention must be paid to pharmacist remuneration and further research in rural areas. Study findings led researchers to streamline procedures to minimize client and pharmacist burden.

29) Characteristics Associated with Nonmedical Methadone Use among People Who Inject Drugs in California.

Zhao JK, Kral AH, Wenger LD, Bluthenthal RN. Subst Use Misuse. 2020;55(3):377-386. doi: 10.1080/10826084.2019.1673420. Epub 2019 Oct 14.

Comments: Among a cross-sectional sample of PWID (N=777), 21% reported nonmedical methadone use in the last 30 days, almost exclusively through oral ingestion. Interviews were conducted 2011-2013, notably prior to fentanyl reaching California.

Nonmedical methadone use was associated with recent methadone maintenance treatment, which may indicate inadequate dosing at OAT clinics and self-treatment for withdrawal. Other associations included recent nonmedical buprenorphine use, higher injection frequency, schizophrenia diagnosis, recent non-injection opioid prescription use, and recent injection of prescription opioids. Nonmedical methadone use was found not to be associated with nonfatal overdose, which may support the expansion of OAT. Authors call for more research into comorbid schizophrenia among PWID to optimize treatment modalities.

30) Association between buprenorphine/naloxone and high-dose opioid analgesic prescribing in Kentucky, 2012-2017.

Luu H, Slavova S, Freeman PR, Lofwall M, Browning S, Slade E, Bush H. Drug Alcohol Depend. 2019 Dec 1;205:107606. doi: 10.1016/j.drugalcdep.2019.107606. Epub 2019 Oct 3.

Comments: As high dose opioid analgesic prescribing decreased, buprenorphine prescribing increased. Unable to view full text through Elsevier.

31) Measuring Relationships Between Proactive Reporting State-level Prescription Drug Monitoring Programs and County-level Fatal Prescription Opioid Overdoses.

Cerdá M, Ponicki WR, Smith N, Rivera-Aguirre A, Davis CS, Marshall BDL, Fink DS, Henry SG, Castillo-Carniglia A, Wintemute GJ, Gaidus A, Gruenewald PJ, Martins SS. Epidemiology. 2020 Jan;31(1):32-42. doi: 10.1097/EDE.0000000000001123.

Comments: When you stop prescribing an opioid, street opioid use and overdose mortality more than makes up for the change. This is unfortunate and frustrating – but if we don’t recognize this, we can’t start finding better ways.

32) The Role of Drugs in Alcohol Poisoning and Blackout Events: A Latent Class Analysis of a Residential Treatment Sample.

Fernandez AC, Gicquelais RE, Jannausch M, Bohnert ASB. Alcohol Clin Exp Res. 2019 Nov;43(11):2431-2437. doi: 10.1111/acer.14194. Epub 2019 Oct 9.

Comments: Alcohol overdose data (defined as alcohol poisoning, passing out, or blacking out; no validated assessment already available in literature) was collected in a residential treatment facility (N = 660). Combining drug classes with alcohol prior to overdose was common and associated with increased likelihood of hospitalization. Of note, it was unclear what would lead someone to classify a polysubstance overdose as an “alcohol overdose” as opposed to a “drug overdose”.

33) Predictors of availability of long-acting medication for opioid use disorder.

Shover CL, Humphreys K. Drug Alcohol Depend. 2019 Nov 1;204:107586. doi: 10.1016/j.drugalcdep.2019.107586. Epub 2019 Sep 25.

Comments: According to the 2017 National Survey on Substance Abuse Treatment Services, only 38% (n=5,141) of substance use treatment facilities provided any kind of MOUD. Of these, 62% provided extended-release naltrexone XR-NTX. Only 3% offered the buprenorphine implant. XR-NTX was more likely to be offered in “facilities in the East North Central, East South Central, West North Central and Mountain regions, federally-funded facilities, and facilities in states with the highest opioid overdose mortality rates.”

34) Evaluation of an interprofessional naloxone didactic and skills session with medical residents and physician assistant learners.

Hargraves D, White CC, Mauger MR, Puthota A, Pallerla H, Wigle P, Brubaker SL, Schlaudecker JD. Pharm Pract (Granada). 2019 Jul-Sep;17(3):1591. doi: 10.18549/PharmPract.2019.3.1591. Epub 2019 Sep 12.

Comments: 1 hour didactic and 1 hour live skills demonstration (syringe and ampule, nasal atomizer, branded nasal spray, and auto injector). Effective model for naloxone administration training for primary care trainees.

35) Characteristics and Receipt of Medication Treatment Among Young Adults Who Experience a Nonfatal Opioid-Related Overdose.

Bagley SM, Larochelle MR, Xuan Z, Wang N, Patel A, Bernson D, Silverstein M, Hadland SE, Land T, Samet JH, Walley AY. Ann Emerg Med. 2020 Jan;75(1):29-38. doi: 10.1016/j.annemergmed.2019.07.030. Epub 2019 Oct 4.

Comments: A retrospective cohort study (N= 15,281) of individuals aged 18 to 45 years who survived an opioid-related overdose in MA between 2012-2014. About a third of young adults received medication for OUD in the year after a nonfatal OD. Type of medication received appears to be age associated, with younger individuals more likely to receive naltrexone and older young adults more likely to receive methadone. Full text unavailable through Elsevier

36) Barriers to naloxone use and acceptance among opioid users, first responders, and emergency department providers in New Hampshire, USA.

Bessen S, Metcalf SA, Saunders EC, Moore SK, Meier A, McLeman B, Walsh O, Marsch LA. Int J Drug Policy. 2019 Dec;74:144-151. doi: 10.1016/j.drugpo.2019.09.008. Epub 2019 Oct 4.

Comments: Responders perceived that naloxone may encourage riskier opioid use, fails to address underlying causes of addiction, and results in challenging patient encounters post-administration. Reported barriers for people who use opioids included cost, legal concerns, lack of knowledge or misconceptions regarding access and use, and aversion to withdrawal symptoms.

37) It’s too much, I’m getting really tired of it’: Overdose response and structural vulnerabilities among harm reduction workers in community settings.

Kolla G, Strike C. Int J Drug Policy. 2019 Dec;74:127-135. doi: 10.1016/j.drugpo.2019.09.012. Epub 2019 Oct 4.

Comments: Ethnographic study of “Satellite Sites”, a program where PWUD are employed by a community health center to operate satellite harm reduction programs within their homes. While this type of overdose education and naloxone distribution program (OEND) is essential and effective, the workers are facing increasing structural vulnerability and stress in the context of continued criminalization of drug use. Calls for increased access to complementary interventions like supervised injection services, safer supply interventions, and protection against evictions. Full text unavailable through Elsevier

38) Evidence for state, community and systems-level prevention strategies to address the opioid crisis.

Haegerich TM, Jones CM, Cote PO, Robinson A, Ross L. Drug Alcohol Depend. 2019 Nov 1;204:107563. doi: 10.1016/j.drugalcdep.2019.107563. Epub 2019 Sep 19.

Comments: A systematic review of opioid overdose prevention intervention studies published Jan 2013- May 2018.

39) Attitudes and perceptions of naloxone dispensing among a sample of Massachusetts community pharmacy technicians.

Kurian S, Baloy B, Baird J, Burstein D, Xuan Z, Bratberg J, Tapper A, Walley A, Green TC. J Am Pharm Assoc (2003). 2019 Nov – Dec;59(6):824-831. doi: 10.1016/j.japh.2019.08.009. Epub 2019 Sep 30.

Comments: Pharmacy technicians are well-positioned, yet untapped partners in naloxone provision. This was a cross-sectional study involving 39 CVS Health pharmacies in both high and low overdose risk municipalities. Given appropriate training and possible expanded scope of authority, pharmacy technicians could extend an offer of naloxone to patients themselves or work more closely with physicians and pharmacists in the co-prescription of naloxone with other opioid medications. Qualitative themes emphasized the need for greater financial accessibility of naloxone to patients and their caregivers, as well as shifting attitudes on pharmacy-based harm reduction strategies.

40) The Contribution of Prescribed and Illicit Opioids to Fatal Overdoses in Massachusetts, 2013-2015.

Walley AY, Bernson D, Larochelle MR, Green TC, Young L, Land T. Public Health Rep. 2019 Nov/Dec;134(6):667-674. doi: 10.1177/0033354919878429. Epub 2019 Oct 2.

Comments: Out of 2916 complete postmortem opioid toxicology reports that were linked with prescription drug / controlled substance monitoring program records, “61.4% had heroin and 45.3% had fentanyl detected in postmortem toxicology reports”. Those with active opioid prescriptions, the prescribed opioids (buprenorphine, oxycodone, and methadone for OUD) were commonly not detected in the toxicology report. The authors came to the conclusion that prescribed opioids did not seem to be the proximal reason for opioid overdose deaths in Massachusetts, though may act as a “gateway drug or via diversion”.

41) Take-home naloxone possession among people who inject drugs in rural West Virginia.

Allen ST, White RH, O’Rourke A, Grieb SM, Kilkenny ME, Sherman SG. Drug Alcohol Depend. 2019 Nov 1;204:107581. doi: 10.1016/j.drugalcdep.2019.107581. Epub 2019 Sep 21.

Comments: Among PWID in Cabell County, West Virginia, slightly less than half received take-home naloxone (THN) in the past 6 months. While THN seems to be reaching high overdose risk individuals, the county only has one harm reduction program operating from a single fixed site. PWID who recently accessed clean syringes at the needle exchange program were twice as likely to have received THN, which suggests significant disparities in access for folks who live in more rural areas and less access to established services. There is an urgent need for provider and community-level efforts to destigmatize injection drug use in rural communities, as well as expanded naloxone access and overdose prevention education.

42) Patterns of non-prescribed buprenorphine and other opioid use among individuals with opioid use disorder: A latent class analysis.

Daniulaityte R, Nahhas RW, Silverstein S, Martins S, Zaragoza A, Moeller A, Carlson RG. Drug Alcohol Depend. 2019 Nov 1;204:107574. doi: 10.1016/j.drugalcdep.2019.107574. Epub 2019 Sep 22.

Comments: Latent class analysis for the participants’ 6-month non prescribed buprenorphine (NPB) use: “Heavy Heroin/Fentanyl Use” (61%), “More Formal Treatment Use” (29%) and “Intense NPB Use” (10%). 

A majority (89% of the 356 participants) reported use of NPB to self-treat withdrawal. The “Intense NPB use” class was shown to have significantly lower prevalence of injection as a primary route of heroin/fentanyl administration, cocaine use, unintentional drug overdose, and homelessness, when compared to the other latent classes over the six-month study period. The circulation of NPB may suggest a strategy of mutual aid and harm reduction in vulnerable communities in the absence of more accessible formal treatment settings.

43) Combative Treatment for Carfentanil Epidemic.

Konapur R, Searls N, Babcock CCK, Blough E, Patel I.

J Addict Nurs. 2019 Jan/Mar;30(1):2-3. doi: 10.1097/JAN.0000000000000266. No abstract available.

Comments: A guest editorial on carfentanil, a fentanyl analog that is ~100 times more potent. Generally this has been seen sporadically and has not been adopted like other fentanyl analogues, likely due to the extraordinarily high risk of death. Unable to view the full article.

44) The Opioid Epidemic in Indian Country.

Tipps RT, Buzzard GT, McDougall JA. J Law Med Ethics. 2018 Jun;46(2):422-436. doi: 10.1177/1073110518782950.

Comments: CDC data from 1999-2016 shows that opioid overdose mortality rates among American Indians and Alaska Natives (AI/AN) have followed the steady rise in rates among non-Hispanic whites. Indian Country regions in the Great Lakes and Pacific Northwest and certain urbanized tribal communities were hit especially hard. The authors acknowledge the likely under-reported statistics due to racial misclassification on death certificates and flaws in the U.S. census’ estimates of AI/AN population size. There is a thoughtful discussion on the possible legal and medical options that tribal nations have to treat OUD in their communities, with a focus on taking full advantage of federal resources and the IHS, tribal control of treatment services and integration with cultural support structures, and discouraging banishment and litigation as effective long-term solutions.

45) Improving Rural Access to Opioid Treatment Programs.

Johnson Q, Mund B, Joudrey PJ. J Law Med Ethics. 2018 Jun;46(2):437-439. doi: 10.1177/1073110518782951.

Comments:

This short report discusses barriers to medication-assisted therapy (MAT) for people with opioid use disorder (OUD) who live in rural areas.

46) Comparison of lower-dose versus higher-dose intravenous naloxone on time to recurrence of opioid toxicity in the emergency department.

Wong F, Edwards CJ, Jarrell DH, Patanwala AE. Clin Toxicol (Phila). 2019 Jan;57(1):19-24. doi: 10.1080/15563650.2018.1490420. Epub 2018 Jul 23.

Comments: This paper looked at the difference in time to re-dose for low-dose (0.4 mg) versus high-dose (1-2 mg) intravenous naloxone administration in the emergency department for 84 patients. Time to re-dose was used as a surrogate for the time to return of opioid toxicity. No association was found between dose amount and time to re-administration. For in-hospital settings, it is generally considered inappropriate to dose patients more naloxone than required to keep them safe (i.e. breathing sufficiently to sustain oxygen levels) – high dosing to fully wake somebody up is cruel.

47) Associations between pharmacotherapy for opioid dependence and clinical and criminal justice outcomes among adults with co-occurring serious mental illness.

Robertson AG, Easter MM, Lin HJ, Frisman LK, Swanson JW, Swartz MS. J Subst Abuse Treat. 2018 Mar;86:17-25. doi: 10.1016/j.jsat.2017.12.003. Epub 2017 Dec 12.

Comments: A study of 8735 adults with serious mental illness (SMI) (defined as a diagnosis of schizophrenia spectrum disorder, bipolar disorder, or major depression) with some history of jail or prison and received treatment for opioid dependence. The study compared pharmacotherapies (methadone, buprenorphine, or naltrexone) with outpatient substance use treatment without opioid-dependence pharmacotherapies. The findings likely represent differences in use disorder characteristics, rather than effects of different treatment modalities.

48) Telephone-based opioid overdose education and naloxone distribution (OEND) pharmacy consult clinic.

Szydlowski EM PharmD, Caruana SS PharmD. Subst Abus. 2018;39(2):145-151. doi: 10.1080/08897077.2018.1475317.

Comments: The VA created a telephone-based opioid education and naloxone distribution (OEND) consult clinic in Michigan to increase access to naloxone and were met with huge success- the number of patients receiving OEND more than doubled in the 3 months compared to the entire year of OEND prior. The consult would be ordered by the provider, who informed the patient that naloxone was being prescribed and a pharmacist would call them to discuss naloxone further.

49) Injectable naltrexone, oral naltrexone, and buprenorphine utilization and discontinuation among individuals treated for opioid use disorder in a United States commercially insured population.

Morgan JR, Schackman BR, Leff JA, Linas BP, Walley AY. J Subst Abuse Treat. 2018 Feb;85:90-96. doi: 10.1016/j.jsat.2017.07.001. Epub 2017 Jul 3.

Comments: Between 2010-2014, although rates of opioid use disorder OUD diagnoses increased, prescribing rates of medications for OUD decreased from a large data set of commercial insurance claims. Another disturbing finding was that many patients discontinued therapy after 30 days, with a greater hazard ratio for those patients on both oral and injectable naltrexone along with transdermal buprenorphine compared to sublingual and oralmucosal buprenorphine (these days probably sublingual films). Hopefully these trends have not continued in the last 7 years although attention needs to be given to which treatments have the best outcomes to prevent lapsed access to care and medications for OUD.

50) Healthcare utilization in adults with opioid dependence receiving extended release naltrexone compared to treatment as usual.

Soares WE 3rd, Wilson D, Rathlev N, Lee JD, Gordon M, Nunes EV, O’Brien CP, Friedmann PD. J Subst Abuse Treat. 2018 Feb;85:66-69. doi: 10.1016/j.jsat.2017.05.009. Epub 2017 May 12.

Comments: Out of a sample of 308 adults with opioid use disorder and involvement in the criminal justice system, those randomized to receive extended-release (ER) naltrexone for treatment of opioid use disorder did not utilize the healthcare system more often than adults randomized to treatment as usual (which included counseling and referral to other treatment programs like buprenorphine or methadone maintenance). Can’t access full study due to Elsevier – would be helpful to see which trial this was based on and what treatment-as-usual actually ended up being.

51) Initiation of extended release naltrexone (XR-NTX) for opioid use disorder prior to release from prison.

Friedmann PD, Wilson D, Hoskinson R Jr, Poshkus M, Clarke JG. J Subst Abuse Treat. 2018 Feb;85:45-48. doi: 10.1016/j.jsat.2017.04.010. Epub 2017 Apr 19.

Comments: Although individuals who start ER naltrexone prior to release from prison have better abstinence and more opioid-free days in the first month after release (which is a high risk period for overdose), only 22% completed 6 doses in 6 months. Loss to follow up and potential return to other opioid use is concerning and further studies would be needed to explore what happened to these participants. Correctional facilities really push ER naltrexone and it would be nice to see more studies looking at ER naltrexone vs buprenorphine initiation in prison settings and outcomes after release – we know from the X-BOT study that buprenorphine is superior on all outcomes, but that has not slowed the adoption of only ER naltrexone by criminal justice programs.

52) Extended-release naltrexone for opioid use disorder started during or following incarceration.

Lincoln T, Johnson BD, McCarthy P, Alexander E. J Subst Abuse Treat. 2018 Feb;85:97-100. doi: 10.1016/j.jsat.2017.04.002. Epub 2017 Apr 6.

Comments: In this Alkermes, Inc., supported study, 3 out of 47 patients (6%) who initiated ER naltrexone at least 7 days prior to release from jail died from overdose between 3-5 months after release and 2.5 months or more after stopping ER naltrexone. This is really concerning and again raises the question of why buprenorphine is not being offered? Offering ER naltrexone is fine, but not also offering the medication found to be superior in randomized trials is malpractice.

53) Fentanyl analogue overdose: Key lessons in management in the synthetic opioid age.

Raheemullah A, Andruska N. J Opioid Manag. 2019 Sep/Oct;15(5):428-432. doi: 10.5055/jom.2019.0531.

Comments: Fentanyl-related overdoses are becoming more common due to fentanyl’s high potency and challenges in overdose management. They cannot be a missed opportunity for opioid use disorder treatment in acute care settings and both ED and intensive care providers must be enlisted to protect the vulnerable population of people who use fentanyl, either intentionally or unintentionally.

54) Current practices in naloxone prescribing upon hospital discharge.

Punzal M, Santos P, Li X, Oyler DR, Hall AM. J Opioid Manag. 2019 Sep/Oct;15(5):357-361. doi: 10.5055/jom.2019.0524.

Comment: 90% of inpatient provider survey respondents in Kentucky agreed with CDC recommendation that naloxone be prescribed to patients with OUD, > 50 morphine milligram equivalence or history of overdose.

55) Opioid Safety and Concomitant Benzodiazepine Use in End-Stage Renal Disease Patients.

Ruchi R, Bozorgmehri S, Ozrazgat-Baslanti T, Segal MS, Shukla AM, Mohandas R, Kumar S. Pain Res Manag. 2019 Oct 20;2019:3865924. doi: 10.1155/2019/3865924. eCollection 2019. Opioid prescriptions and opioid plus benzodiazepine prescriptions are associated with possible opioid-related hospital admission rates for patients with end-stage renal disease.

56) Prolonged ethanol administration prevents the development of tolerance to

morphine-induced respiratory depression.

Hill R, Roberts J, Maclachlan J, Dewey W, Kelly E, Henderson G. Drug Alcohol Depend. 2019 Dec 1;205:107674. doi: 10.1016/j.drugalcdep.2019.107674. Epub 2019 Oct 30.

Comment: The interactions between opioids and other drugs are fascinating. Mice fed an ethanol diet who then have prolonged exposure to morphine showed decreased tolerance to morphine-induced respiratory depression compared to control mice.

57) Heroin and nonmedical prescription opioid use among high school students in urban school districts.

Jones AA, Schneider KE, Brighthaupt SC, Johnson JK, Linton SL, Johnson RM. Drug Alcohol Depend. 2019 Dec 1;205:107664. doi: 10.1016/j.drugalcdep.2019.107664. Epub 2019 Oct 25.

Comment: Trends in adolescent opioid use from 21 urban school districts that participate in the CDC’s Local Youth Risk Behavior Surveillance System are as follows: a) non-medical prescription opioid use is more prevalent than heroin use b) heroin use was higher among boys than girls, while non-prescription opioid use was highest among girls. Baltimore in Maryland and Duval County in Florida are hotspots.

58) Providers’ perceptions on barriers and facilitators to prescribing naloxone for patients at risk for opioid overdose after implementation of a national academic detailing program: A qualitative assessment.

Bounthavong M, Suh K, Christopher MLD, Veenstra DL, Basu A, Devine EB. Res Social Adm Pharm. 2019 Oct 31. pii: S1551-7411(19)30065-8. doi: 10.1016/j.sapharm.2019.10.015. [Epub ahead of print]

Comment: The U.S. Veterans Health Administration (VA) has one of the largest academic detailing programs in the nation and can perform robust academic detailing studies with large sample sizes. This study in particular demonstrates the association of implementation of academic detailing and naloxone prescriptions. Between 2014 and 2017, some, none, or all providers at 130 VA sites received academic detailing on naloxone prescribing. The number of naloxone prescriptions at each site was subsequently recorded and then compared over the same time period. Sites where all providers received academic detailing were associated with a five-fold increase in naloxone prescribing rates compared to sites where no providers received academic detailing, highlighting the potential impact academic detailing has on increasing naloxone prescribing within a health system.

59) Characteristics and circumstances of heroin and pharmaceutical opioid overdose deaths: Comparison across opioids.

Roxburgh A, Hall WD, Gisev N, Degenhardt L. Drug Alcohol Depend. 2019 Dec 1;205:107533. doi: 10.1016/j.drugalcdep.2019.06.035. Epub 2019 Oct 22.

Comment: Opioid overdose deaths in Australia were characterized from 2000-2015 and disaggregated based on each individual opioid type, including both heroin and prescription opioids. In remote areas, there was 15 times the risk of overdose death from pharmaceutical fentanyl than heroin. People with a history of chronic pain also had a 1.9-10.7 fold increased risk of death from prescription opioids compared to heroin. This trend aligns with what was seen in the U.S. around the same time frame.

60) Methadone treatment of arrestees: A randomized clinical trial.

Schwartz RP, Kelly SM, Mitchell SG, O’Grady KE, Sharma A, Jaffe JH. Drug Alcohol Depend. 2020 Jan 1;206:107680. doi: 10.1016/j.drugalcdep.2019.107680. Epub 2019 Oct 28.

Comment: Important study showing that initiating methadone treatment prior to release from jail increased retention in community-based treatment at 30 days post-release. However, by 12 months, there were no significant differences in enrollment in treatment for groups that had initiated methadone compared to enhanced treatment as usual, which involved an assessment/referral number for connecting with treatment after release. Another salient finding was that there were 5 fatal overdoses, however none occurred during methadone treatment.

61) Examining opioid-involved overdose mortality trends prior to fentanyl: New York City, 2000-2015.

Tuazon E, Kunins HV, Allen B, Paone D. Drug Alcohol Depend. 2019 Dec 1;205:107614. doi: 10.1016/j.drugalcdep.2019.107614. Epub 2019 Oct 16.

Comment: Prior to fentanyl, overdose trends in New York starting in the year 2000 deaths involving heroin without opioid analgesics decreasing from 2006 to 2010 then increasing again starting around 2010. Overdose deaths involving opioid analgesics with and without heroin increased from 2000 to 2015 across all demographic subgroups. The study postulates that tamper-proof oxycodone may have been involved with the shift back to heroin.

62) Implementation of a statewide program within community pharmacies to prevent opioid misuse and accidental overdose.

Skoy E, Eukel H, Werremeyer A, Strand M, Frenzel O, Steig J. J Am Pharm Assoc (2003). 2020 Jan – Feb;60(1):117-121. doi: 10.1016/j.japh.2019.09.003. Epub 2019 Oct 31.

Comment: Reviewed the implementation of a program called ONE Rx in North Dakota that trained 240 pharmacists and 41 pharmacy techs to screen every patient who was prescribed an opioid prescription for accidental overdose and opioid misuse. No outcome data available.

63) Pharmacogenomics and Opioid Use Disorder: Clinical Decision Support in an African American Cohort.

Ettienne EB, Ofoegbu A, Maneno MK, Briggs J, Ezeude G, Williams S, Walker C, Chapman E. J Natl Med Assoc. 2019 Dec;111(6):674-681. doi: 10.1016/j.jnma.2019.09.006. Epub 2019 Oct 31.

Comment: This was a retrospective cohort analysis on using clinical pharmacogenetics to understand genetic variation or polymorphisms in individual patient pharmacokinetics and pharmacodynamics when using opioids. Study authors did find that patients with at least one copy of the CYP3A4*1B allele exhibited more rapid metabolism of buprenorphine compared to wild type.

64) Increasing heroin, cocaine, and buprenorphine arrests reported to the Maine Diversion Alert Program.

Simpson KJ, Moran MT, McCall KL, Herbert J, Foster ML, Simoyan OM, Shah DT, Desrosiers C, Nichols SD, Piper BJ. Forensic Sci Int. 2019 Oct;303:109924. doi: 10.1016/j.forsciint.2019.109924. Epub 2019 Aug 8.

Comments: This is a followup from a 2017 article on the same program. The Diversion Alert Program (DAP) in Maine facilitates communication between law enforcement and healthcare providers with the goal of “limiting drug-related harms and criminal behavior.” Healthcare providers get information about drug arrests. Usually we in healthcare try to stay out of someone’s criminal record when providing healthcare. The reason for this is so that we provide the best healthcare possible to all-comers and do not provide worse care because the patient may have been accused of something that offends us. This is extremely important because if doctors started providing differential care based on how aligned a patient was with their own ethical standards … well, let’s just say that would be freaking horrendous.

1) Association of Take-Home Naloxone and Opioid Overdose Reversals Performed by Patients in an Opioid Treatment Program.

Katzman JG, Takeda MY, Greenberg N, Moya Balasch M, Alchbli A, Katzman WG, Salvador JG, Bhatt SR.

JAMA Netw Open. 2020 Feb 5;3(2):e200117. doi: 10.1001/jamanetworkopen.2020.0117.

Comment: 

Naloxone and opioid overdose education were provided to 395 participants in an outpatient clinic in New Mexico. 73 participants from the study performed 114 overdose reversals in the community, all of which were heroin related. Most of the reversals were performed on someone the participant knew personally. 73 out of the 395 participants (18%) performed overdose reversals in one year of follow-up – this is remarkably high.

2) Buprenorphine initiation to treat opioid use disorder in emergency rooms.

Jaeger S Jr, Fuehrlein B.

J Neurol Sci. 2020 Feb 6;411:116716. doi: 10.1016/j.jns.2020.116716. [Epub ahead of print] Review.

Comment: 

The Veteran’s Administration in Connecticut has overcome some of the challenges associated with initiating buprenorphine in the emergency room (such as needing a waivered provider). The model the VA in Connecticut established and how success was measured is unclear because the full text is not available.

3) Opioid agonist treatment and fatal overdose risk in a state-wide US population receiving opioid use disorder services.

Krawczyk N, Mojtabai R, Stuart EA, Fingerhood M, Agus D, Lyons BC, Weiner JP, Saloner B.

Addiction. 2020 Feb 24. doi: 10.1111/add.14991. [Epub ahead of print]

Comment: 

A retrospective cohort study comparing outcomes of 48,274 adults during periods of opioid agonist treatment and non-medication treatment in a specialty out-patient clinic in Maryland. There was a significant reduction in the hazard of opioid overdose deaths during medication treatment compared to non-medication treatment periods. The time after discharge for both medication and non-medication treatment was associated with an increased risk of overdose compared to non-medication treatment periods. In some contrast to other, larger cohorts from other countries, this study found a marked reduction on overdose death in medication versus abstinence-based opioid use disorder treatment, but no differential once treatment was discontinued. Either way, it remains the case that treating opioid use disorder with medications results in a significantly lower risk of death than other approaches.

4) The impact of chronic liver disease in patients receiving active pharmacological therapy for opioid use disorder: One-year findings from a prospective cohort study.

Dennis BB, Akhtar D, Cholankeril G, Kim D, Sanger N, Hillmer A, Chawar C, D’Elia A, Panesar B, Worster A, Marsh DC, Thabane L, Samaan Z, Ahmed A.

Drug Alcohol Depend. 2020 Feb 20;209:107917. doi: 10.1016/j.drugalcdep.2020.107917. [Epub ahead of print]

Comment: 

Full paper not accessible to us, but looked at the impact of chronic liver disease (CLD) on methadone treatment outcomes through a prospective cohort study of 1234 patients with opioid use disorder and receiving methadone treatment. 25% (314 patients) had CLD, which included any liver disorder present for at least 6 months. Authors discuss “dangerous opioid consumption” but not defined in abstract.

5) A pilot study to compare virtual reality to hybrid simulation for opioid-related overdose and naloxone training.

Giordano NA, Whitney CE, Axson SA, Cassidy K, Rosado E, Hoyt-Brennan AM.

Nurse Educ Today. 2020 Feb 10;88:104365. doi: 10.1016/j.nedt.2020.104365. [Epub ahead of print]

Comment: 

A quasi-experimental study evaluating nursing student knowledge about opioid overdose identification and response. Students either participated in a hybrid simulation or a virtual reality in which they had to identify the signs of an opioid overdose, administer intranasal naloxone, and provide recovery care. A pretest-posttest comparison of knowledge and attitude of nursing students found no significant difference in training type, suggesting virtual reality training is a feasible option for training nursing students about opioid-related overdose response.

6) Structure of heroin in a solution revealed by chiroptical spectroscopy.

Králík F, Fagan P, Kuchař M, Setnička V.

Chirality. 2020 Feb 20. doi: 10.1002/chir.23196. [Epub ahead of print]

Comment: 

An in-depth look at the 3D structure of heroin.

7) The Opioid Epidemic: Challenge to Military Medicine and National Security.

Dembek ZF, Chekol T, Wu A.

Mil Med. 2020 Feb 20. pii: usz487. doi: 10.1093/milmed/usz487. [Epub ahead of print]

Comment: 

This was a literature review looked at the landscape of opioid use in the military and veteran populations in the last five years. Battlefield pain management, opioid use among military and veterans, public health implications, and implemented solutions were included in the findings. While opioid overdose mortality continued to increase over the five years, there has also been several behavioral interventions and treatment programs introduced. Identifying the common issues, use behaviors, and solutions already in place is important for further addressing the high morbidity and mortality related to substance use in the military and veteran population.

8) Commentary on Park et al. (2020): Buprenorphine and benzodiazepine co-prescribing- key considerations and future directions.

Oliva EM.

Addiction. 2020 Feb 20. doi: 10.1111/add.14990. [Epub ahead of print] No abstract available.

Comment: 

Commentary on the utility of including both potentials harms and benefits when discussing buprenorphine and benzodiazepine co-prescribing as discussed in Park et al., which examined associations between prescribed benzodiazepines, overdose death, and buprenorphine discontinuation among people receiving buprenorphine.

9) Degree of Bystander-Patient Relationship and Prehospital Care for Opioid Overdose.

McCann MK, Jusko TA, Jones CMC, Seplaki CL, Cushman JT.

Prehosp Emerg Care. 2020 Feb 19:1-14. doi: 10.1080/10903127.2020.1731029. [Epub ahead of print]

Comment: 

A retrospective cohort study looking at bystander administration of pre-hospital naloxone to 545 unique individuals. Data only included patients who had prehospital naloxone delivered and had available EMS and medical record data. Spouses/family and close friends responded with naloxone more quickly and more often indicated an overdose event in 911 dispatch codes, compared to strangers or others not close to the victim.

10) Carfentanil toxicity in the African green monkey: Therapeutic efficacy of naloxone.

Langston JL, Moffett MC, Makar JR, Burgan BM, Myers TM.

Toxicol Lett. 2020 Feb 15;325:34-42. doi: 10.1016/j.toxlet.2020.02.008. [Epub ahead of print]

Comment: 

Three experiments were performed on African green monkeys to determine the toxicity of carfentanil, the amount of naloxone required to restore respiration, and the time and dosage required to completely or partially reverse the effects of carfentanil. Naloxone was effective in immediately reversing respiratory depression but a higher dose of naloxone was required for complete behavioral recovery.

11) Dihydrocodeine for detoxification and maintenance treatment in individuals with opiate use disorders.

Carney T, Van Hout MC, Norman I, Dada S, Siegfried N, Parry CD.

Cochrane Database Syst Rev. 2020 Feb 18;2:CD012254. doi: 10.1002/14651858.CD012254.pub2. Review.

Comment: 

A systematic review of randomized control trials evaluating the effectiveness of dihydrocodeine (DHC) treatment for detoxification and maintenance therapy for patients 15+ years who used illicit opioids. A total of 3 studies were included with the primary outcome being abstinence from illicit opioids post-detoxification or maintenance therapy. There was no significant difference in abstinence 6-months post detoxification for DHC compared to methadone or buprenorphine. DHC may be a low-barrier treatment but no conclusive statements can be made about its effectiveness. DHC is not an FDA approved medication for opioid use disorder, thus this study has little immediate significance for OUD treatment in the United States but may be an option in places where buprenorphine and methadone aren’t available.

12) Understanding the increase in opioid overdoses in New Hampshire: A rapid epidemiologic assessment.

Meier A, Moore SK, Saunders EC, McLeman B, Metcalf SA, Auty S, Walsh O, Marsch LA.

Drug Alcohol Depend. 2020 Feb 7;209:107893. doi: 10.1016/j.drugalcdep.2020.107893. [Epub ahead of print]

Comment: 

Using demographic surveys and semi-structured interviews, this article describes possible factors contributing to New Hampshire’s high rates of fentanyl-related overdose. The majority of participants noted they knowingly sought out fentanyl and knew that the variability of fentanyl content increased overdose risk. As fentanyl becomes more popular, additional harm reduction services, treatment efforts, and education are needed to reduce fentanyl mortality.  

13) Legal requirements and recommendations to prescribe naloxone.

Haffajee RL, Cherney S, Smart R.

Drug Alcohol Depend. 2020 Feb 6;209:107896. doi: 10.1016/j.drugalcdep.2020.107896. [Epub ahead of print]

Comment: 

This review provides an overview of the adoption of state laws and policies for naloxone co-prescribing as of September 2019.

14) Heroin-induced respiratory depression and the influence of dose variation: within-subject between-session changes following dose reduction.

Tas B, Jolley CJ, Kalk NJ, Van der Waal R, Bell J, Strang J.

Addiction. 2020 Feb 14. doi: 10.1111/add.15014. [Epub ahead of print]

Comment: 

A single-participant study, spanning five years, that examined the effect of different maintenance doses of pharmaceutical heroin on respiratory depression. Oxygen saturation, end-tidal carbon dioxide, and respiratory rate were used as indicators of respiratory depression. The inter-session variability in respiratory response support the inconsistent relationship between opioid dose and overdose risk, although this is an n of 1.

15) Is the Gender Gap in Overdose Deaths (Still) Decreasing? An Examination of Opioid Deaths in Delaware, 2013-2017.

Eeckhaut MCW, Wagner J, Neitzke-Spruill L, Walker R, Anderson TL.

J Stud Alcohol Drugs. 2020 Jan;81(1):68-73.

Comment: 

Examines if the overdose gender gap has narrowed or grown in the third wave of the opioid epidemic using toxicology reports from Delaware in 2013-2017. Overdose deaths rates increased for both men and women, but the rate increased 56% more for men than women, meaning the gender gap in overdose deaths has grown since the beginning of the opioid epidemic. Higher male-to-female opioid overdose deaths rates were found among older (45-64 years) individuals compared to younger individuals (15-44 years). 

16) Severe Hypoxemia Prevents Spontaneous and Naloxone-induced Breathing Recovery after Fentanyl Overdose in Awake and Sedated Rats.

Haouzi P, Guck D, McCann M, Sternick M, Sonobe T, Tubbs N.

Anesthesiology. 2020 Feb 7. doi: 10.1097/ALN.0000000000003156. [Epub ahead of print]

Comment: 

Hauozi et al. investigated the effects of hypoxemia after fentanyl overdose-induced apnea on sedated and unsedated rats. Outcomes were the ability to recover spontaneous breathing and the effects of naloxone. Among unsedated rats with fentanyl-induced apnea, the level of hypoxemia reached affected the ability to recover spontaneous breathing and respond to naloxone. Authors conclude that hypoxemia due to fentanyl-induced apnea can directly inhibit naloxone response and autoresuscitation. Not sure we agree with that assessment though – simple stimulation is often effective. One potential approach could be to recommend a sternal rub to confirm unresponsiveness prior to naloxone, and repeat it after naloxone.

17) Development and Clinical Validation of a Sensitive Lateral Flow Assay for Rapid Urine Fentanyl Screening in the Emergency Department.

Li Z, Chen H, Feng S, Liu K, Wang P.

Clin Chem. 2020 Feb 1;66(2):324-332. doi: 10.1093/clinchem/hvz023.

Comment: 

The Lateral Flow Assay tested in this study is able to rapidly identify fentanyl and its major metabolite, norfentanyl, with specificity and sensitivity. 

18) Buprenorphine to reverse respiratory depression from methadone overdose in opioid-dependent patients: a prospective randomized trial.

Zamani N, Buckley NA, Hassanian-Moghaddam H.

Crit Care. 2020 Feb 7;24(1):44. doi: 10.1186/s13054-020-2740-y.

Comment: 

An Iranian clinical trial in which 85 patients who had a methadone overdose were randomized to receive either titrated naloxone doses or a low or high dose of buprenorphine to reverse their overdose. Patients were enrolled when they presented to the hospital with acute respiratory depression defined as cyanosis, less than 90% oxygen saturation, and respiratory rate less than 12 breaths per minute. Patients were believed to have overdosed on methadone, and urine testing was performed for confirmation. Buprenorphine and naloxone were both administered intravenously, and both reduced respiratory depression. Intubation and withdrawal were less common among patients who received buprenorphine. Naloxone required high titrated doses for reversal of respiratory depression. This use of buprenorphine is not uncommon in the community, and potentially aligned with current efforts to start patients on buprenorphine in the emergency department.

19) Association between state Medicaid expansion status and naloxone prescription dispensing.

Sohn M, Talbert JC, Delcher C, Hankosky ER, Lofwall MR, Freeman PR.

Health Serv Res. 2020 Feb 7. doi: 10.1111/1475-6773.13266. [Epub ahead of print]

Comment: 

Medicaid expansion was associated with 38 additional naloxone prescriptions per state per quarter compared to states where Medicaid was not expanded. Expansion was also associated with an increase in the amount of naloxone prescriptions covered by Medicaid.

20) Protocol for a multi-site study of the effects of overdose prevention education with naloxone distribution program in Skåne County, Sweden.

Troberg K, Isendahl P, Blomé MA, Dahlman D, Håkansson A.

BMC Psychiatry. 2020 Feb 7;20(1):49. doi: 10.1186/s12888-020-2470-3.

Comment: 

This is a protocol paper. In June 2018, Sweden launched its first take home naloxone program in Skåne County in response to high rates of overdose deaths. The take home program consisted of a multi-site train-the-trainer model including treatment units, needle exchanges, and in-patients units that provided training, naloxone, and study recruitment. Primary outcomes include the effect of overdose education and naloxone distribution on overdose mortality.

21) Carfentanil Outbreak – Florida, 2016-2017.

Delcher C, Wang Y, Vega RS, Halpin J, Gladden RM, O’Donnell JK, Hvozdovich JA, Goldberger BA.

MMWR Morb Mortal Wkly Rep. 2020 Feb 7;69(5):125-129. doi: 10.15585/mmwr.mm6905a2.

Comment: 

Carfentanil is extremely potent. Outbreaks of carfentanil overdoses first reported in Ohio, Michigan, and Florida in 2016, and continued in Florida through 2017. Since then, overdoses due to fentanyl and fentanyl analogs have only continued to contribute to the spike in overdose deaths on both the east and west coasts of the U.S. Interestingly, carfentanil outbreaks tend to end quickly – the drug is just too potent.

22) Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder.

Wakeman SE, Larochelle MR, Ameli O, Chaisson CE, McPheeters JT, Crown WH, Azocar F, Sanghavi DM.

JAMA Netw Open. 2020 Feb 5;3(2):e1920622. doi: 10.1001/jamanetworkopen.2019.20622.

Comment: 

Wakeman et al. is an important study that clearly demonstrates the effectiveness of medication for opioid use disorder compared to nonpharmacologic treatment in treatment pathways outside of clinical trials. This is a retrospective study using data from over 40,000 patients with opioid use disorder from 2015-2017. Patients received one of six mutually exclusive treatment pathways (no treatment, inpatient detoxification or residential services, intensive behavioral health, buprenorphine or methadone, naltrexone, and nonintensive behavioral health), and outcomes included opioid-related overdose or serious acute care use 3 and 12 months after initial treatment. Only buprenorphine or methadone treatment was significantly associated with a 76% reduction in overdose risk after 3 months and 59% reduction in overdose risk at 12 months. Buprenorphine or methadone treatment was also associated with reduced risk of serious opioid-related acute care use at both 3 and 12 months. Notably, there was no reduction in overdose or acute care use associated with detoxification, intensive behavioral health, or naltrexone. This reaffirms the superiority of these medications for OUD.

23) Association of Opioid Overdose Risk Factors and Naloxone Prescribing in US Adults.

Lin LA, Brummett CM, Waljee JF, Englesbe MJ, Gunaseelan V, Bohnert ASB. J Gen Intern Med. 2020 Feb;35(2):420-427. doi: 10.1007/s11606-019-05423-7.

Comment: 

Naloxone co-prescribing (with opioids) increased and was more often provided to patients with risks factors of opioid overdose (prescription of benzodiazepines, high daily opioid dosage, etc.) between 2014-2017.

1) Commentary on Hoots et al. (2019): The gap between evidence and policy calls into question the extent of a public health approach to the opioid overdose epidemic.

Nolan ML, Allen B, Paone D.

Addiction. 2020 Jan 28. doi: 10.1111/add.14958. [Epub ahead of print] No abstract available.

Comment: Hoots et al. calls for the expansion of the opioid epidemic public health response to include stimulants given the recent rise in stimulant related overdoses. This commentary, however, asks us to evaluate and clarify what that public health approach is – and if it is a “public health” approach at all. As many of us can recall with frustration, several responses to the opioid overdose have failed to incorporate or have delayed the implementation of evidence-based practices (e.g., maintaining the x-waiver requirement to prescribe buprenorphine). Before calling for the integration of stimulants into the response to the opioid epidemic, we should reevaluate, define, and improve our current approach to be more impactful in promoting the health of individuals and communities.

2) Opioid Use Disorder.

Dydyk AM, Jain NK, Gupta M.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.

Comment: Overview of the etiology, epidemiology, and history of opioid use disorder diagnosis as well as pharmacological and nonpharmacological treatments.

3) Pharmacy leaders’ beliefs about how pharmacies can support a sustainable approach to providing naloxone to the community.

Donovan E, Bratberg J, Baird J, Burstein D, Case P, Walley AY, Green TC.

Res Social Adm Pharm. 2020 Jan 18. pii: S1551-7411(19)30590-X. doi: 10.1016/j.sapharm.2020.01.006. [Epub ahead of print]

Comment: Through qualitative interviews with pharmacy leaders, this article provides insights about pharmacists’ role in opioid epidemic. It highlights the importance of extending the spectrum of care for opioid management to pharmacies, specifically regrading naloxone. Expanding the routes of distribution of naloxone can be an important step in helping halt the increase in opioid overdose deaths.

4) One-Year Mortality and Associated Factors in Patients Receiving Out-of-Hospital Naloxone for Presumed Opioid Overdose.

Ashburn NP, Ryder CW, Angi RM, Snavely AC, Nelson RD, Bozeman WP, McGinnis HD, Winslow JT, Stopyra JP.

Ann Emerg Med. 2020 Jan 23. pii: S0196-0644(19)31422-2. doi: 10.1016/j.annemergmed.2019.11.022. [Epub ahead of print]

Comment: Non-fatal overdose is strongly associated with subsequent overdose and with subsequent fatal overdose. This study contributes to that knowledge by matching out-of-hospital naloxone receipt with death over the following 365 days. Those who got out-of-hospital naloxone with clinical improvement were 13 times more likely to have died within a year compared to the general population. As the full text was not available due to Elsevier, we were limited in our ability to assess the details of the study. For example, they do not define in the abstract how they define “improvement” after naloxone administration. The comparison of death among those who improved and did not improve after naloxone administration is likely meaningless, as naloxone administration without clinical response is not a valuable proxy for an overdose (i.e. many, if not most, of those events were probably not overdoses).

5) Known fentanyl use among clients of harm reduction sites in British Columbia, Canada.

Karamouzian M, Papamihali K, Graham B, Crabtree A, Mill C, Kuo M, Young S, Buxton JA.

Int J Drug Policy. 2020 Jan 18;77:102665. doi: 10.1016/j.drugpo.2020.102665. [Epub ahead of print]

Comment: This study gives indication about who may be more likely to be use fentanyl, (intentionally or unintentionally), and the method of consumption in British Columbia. Recent exposure to fentanyl by participants was significantly associated with urban settings as well as cannabis, methamphetamine, and heroin/morphine use.

6) Evaluation of Acetylfentanyl Following Suspected Heroin Overdose When Complicated by the Presence ) of Toxic Fentanyl and Alprazolam Concentrations.

Fagiola M, Hahn T, Avella J.

Acad Forensic Pathol. 2019 Sep;9(3-4):191-199. doi: 10.1177/1925362119892005. Epub 2020 Jan 31.

Comment: Case study of acetyl fentanyl, fentanyl, heroin, and alprazolam death. Of note, there are meaningful differences between acetyl fentanyl and fentanyl (potency and duration of action) that likely contribute to the hugely variable potency of street opioids and resultant overdose crisis.

7) Effect of State Policy Changes in Florida on Opioid-Related Overdoses.

Guy GP Jr, Zhang K.

Am J Prev Med. 2020 Jan 30. pii: S0749-3797(19)30530-6. doi: 10.1016/j.amepre.2019.11.008. [Epub ahead of print]

Comment: This study uses emergency department and inpatient databases to compare the impact of Florida’s Controlled Substance Monitoring Program (CSMP) policies to North Carolina’s (where no CSMP was implemented) between 2008-2015. Policies in Florida seemed to have an effect in reducing prescription opioid-related overdoses resulting in inpatient and ER settings, with no association with heroin related events. The biggest weakness in this analysis seems to be the limited reach of the data sources and absence of mortality analyses. Can’t access full paper due to Elsevier.

8) Routes of non-traditional entry into buprenorphine treatment programs.

Champagne-Langabeer T, Swank MW, Langabeer JR 2nd. 

Subst Abuse Treat Prev Policy. 2020 Jan 20;15(1):6. doi: 10.1186/s13011-020-0252-z. Review.

Comment: This literature review identified routes of entry to buprenorphine including criminal justice, emergency medical care, and community outreach. This is a critical element of our overdose response.

9) The impact of a pharmacist-led naloxone education and community distribution project on local use of naloxone.

Wright QE, Higginbotham S, Bunk E, Covvey JR.

J Am Pharm Assoc (2003). 2020 Jan 14. pii: S1544-3191(19)30535-7. doi: 10.1016/j.japh.2019.11.027. [Epub ahead of print]

Comment: About half of the participants in this study believed pharmacist-led naloxone education helped reduce the stigma of illicit opioid use.

10) Regional and temporal effects of naloxone access laws on opioid overdose mortality.

Cataife G, Dong J, Davis CS.

Subst Abus. 2020 Jan 17:1-10. doi: 10.1080/08897077.2019.1709605. [Epub ahead of print]

Comment: Interesting findings. Naloxone Access Laws were associated with lower fatal opioid-related overdoses in western states but had little impact in other regions. Can’t access the full article, but this definitely warrants further evaluation as the findings are impactful. The data go through 2014, while fentanyl started to emerge around 2014 in eastern states, which perhaps accounts for the lack of a benefit?

11) Developing a clinical decision support for opioid use disorders: a NIDA center for the clinical trials network working group report.

Bart GB, Saxon A, Fiellin DA, McNeely J, Muench JP, Shanahan CW, Huntley K, Gore-Langton RE.

Addict Sci Clin Pract. 2020 Jan 16;15(1):4. doi: 10.1186/s13722-020-0180-2.

Comment: A clinical decision support group from NIDA created a clinical decision support tool for OUD screening, assessment, and treatment in primary care settings.  

12) Trends in severe opioid-related poisonings and fatalities reported to the Paris poison control center – a 10-year retrospective observational study.

Caré W, Langrand J, Vodovar D, Deveaux M, Alvarez JC, Mégarbane B, Dorandeu F.

Fundam Clin Pharmacol. 2020 Jan 16. doi: 10.1111/fcp.12534. [Epub ahead of print]

Comment: Reports opioid use and overdose in Paris, France over 10-year period (2008-2017).

13) Integrating naloxone education into an undergraduate nursing course: Developing partnerships with a local department of health.

Carter G, Caudill P.

Public Health Nurs. 2020 Jan 13. doi: 10.1111/phn.12707. [Epub ahead of print]

Comment: This study reports data from pre- and post-intervention survey about nursing students’ knowledge, stigma, and efficacy of naloxone. Hopefully, with more studies like this one, naloxone and other related substance use topics may be implemented as a normal part of health care professionals’ curriculums.

14) The Rapidly Changing US Illicit Drug Market and the Potential for an Improved Early Warning System: Evidence from Ohio Drug Crime Labs.

Rosenblum D, Unick J, Ciccarone D.

Drug Alcohol Depend. 2020 Mar 1;208:107779. doi: 10.1016/j.drugalcdep.2019.107779. Epub 2020 Jan 7.

Comment: Rosenblum et al. reports a decrease in heroin but increase in fentanyl in Ohio between 2009-2018 using Ohio’s Bureau of Criminal Investigation’s crime lab data. The authors suggest that crime lab data have the potential to be used as early indicators for people who inject drugs, first responders, and law enforcement to prepare and respond to the changes in illicit opioids. How these groups should respond, and how to respond quickly, to this information, if presented as an early warning sign, is another question.

15) Potential undercounting of overdose deaths caused by specific drugs in vital statistics data: An analysis of Florida.

Quast TC.

Drug Alcohol Depend. 2020 Feb 1;207:107807. doi: 10.1016/j.drugalcdep.2019.107807. Epub 2020 Jan 7.

Comment: I’m intrigued by this report of undercounting of deaths from specific drugs to the CDC. If the data are reported as cause of death by medical examiners, that should be reflected in the CDC data. Can’t access the full article (due to Elsevier) to figure out what this is all about, but it’s definitely concerning. There are already enough issues with mortality data (lack of specifying which drugs, potential bias in selecting which drugs are causal, etc.).

16) Association of Medicaid Expansion With Opioid Overdose Mortality in the United States.

Kravitz-Wirtz N, Davis CS, Ponicki WR, Rivera-Aguirre A, Marshall BDL, Martins SS, Cerdá M.

JAMA Netw Open. 2020 Jan 3;3(1):e1919066. doi: 10.1001/jamanetworkopen.2019.19066.

Comment: Medicaid expansion was associated with a 6% reduction in total opioid overdose deaths and categories including heroin and synthetic opioids other than methadone. Unfortunately, there was an 11% increase in methadone related opioid overdoses in states that expanded Medicaid. Authors believe these improvements are related to better access to medications for opioid use disorder.

17) Opioid use disorder.

Strang J, Volkow ND, Degenhardt L, Hickman M, Johnson K, Koob GF, Marshall BDL, Tyndall M, Walsh SL.

Nat Rev Dis Primers. 2020 Jan 9;6(1):3. doi: 10.1038/s41572-019-0137-5. Review.

Comment: Strang et al. discusses the brain chemistry of OUD, individual and public burdens of OUD, and various medications for treatment.

18) Rapid Assessment of Opioid Exposure and Treatment in Cities Through Robotic Collection and Chemical Analysis of Wastewater.

Endo N, Ghaeli N, Duvallet C, Foppe K, Erickson TB, Matus M, Chai PR.

J Med Toxicol. 2020 Jan 9. doi: 10.1007/s13181-019-00756-5. [Epub ahead of print]

Comment: Wastewater analyses are increasingly fascinating.

19) Individual and county-level variation in outcomes following non-fatal opioid-involved overdose.

Lowder EM, Amlung J, Ray BR.

J Epidemiol Community Health. 2020 Jan 9. pii: jech-2019-212915. doi: 10.1136/jech-2019-212915. [Epub ahead of print]

Comment: Lowder et al. shows an increase in mortality and fatal overdoses in counties with increased naltrexone treatment providers. Further, Black patients had higher mortality rates in counties with higher-than-average naltrexone providers compared to those with lower-than-average naltrexone providers – a trend that was less notable among white patients. These results highlight important issues with extended-release naltrexone as well as equity concerns in opioid use disorder treatment.

20) Preventing opioid overdose with peer-administered naloxone: findings from a rural state.

Hanson BL, Porter RR, Zöld AL, Terhorst-Miller H.

Harm Reduct J. 2020 Jan 9;17(1):4. doi: 10.1186/s12954-019-0352-0.

Comment: This study uses qualitative interviews to give a voice to people who have used or currently use opioids and who have administered naloxone to a peer during an overdose. Participants expressed satisfaction with having received naloxone training, suggesting that naloxone should be made widely available. Notably, the authors also concluded that overdose experiences do not have a lasting impact on drug use behavior, which is in some contrast to earlier study data. Given the powerful nature of overdose events, there has been interest in leverage such events to develop safer drug use habits or consideration of therapeutic options.

21) Polysubstance use in rural West Virginia: Associations between latent classes of drug use, overdose, and take-home naloxone.

Schneider KE, O’Rourke A, White RH, Park JN, Musci RJ, Kilkenny ME, Sherman SG, Allen ST.

Int J Drug Policy. 2020 Feb;76:102642. doi: 10.1016/j.drugpo.2019.102642. Epub 2020 Jan 7.

Comment: This study examined the associated between polysubstance use, overdose, and take-home naloxone in rural West Virginia. Over 40% of the 420 individuals surveyed had experienced an overdose in the last 6 months and less than half of all participants received take-home naloxone. This is an extremely high rate of overdose, raising serious concerns! The limited coverage of naloxone is equally concerning.

22) Naloxone availability and dispensing in Indiana pharmacies 2 years after the implementation of a statewide standing order.

Eldridge LA, Agley J, Meyerson BE.

J Am Pharm Assoc (2003). 2020 Jan 6. pii: S1544-3191(19)30532-1. doi: 10.1016/j.japh.2019.11.024. [Epub ahead of print]

Comment: Indiana had a considerable increase in the number of pharmacies stocking and dispensing naloxone between 2016 and 2018 as a result of the statewide standing order.

23) Associations between prescribed benzodiazepines, overdose death and buprenorphine discontinuation among people receiving buprenorphine.

Park TW, Larochelle MR, Saitz R, Wang N, Bernson D, Walley AY.

Addiction. 2020 Jan 8. doi: 10.1111/add.14886. [Epub ahead of print]

Comment: Using a large sample of over 63,000 Massachusetts residents receiving buprenorphine between 2012 and 2015, the authors sought to understand if benzodiazepine co-prescribing with buprenorphine was associated with increased overdose risk and/or improved retention in treatment since both outcomes have been found in the literature. This study raised further questions about behaviors around buprenorphine and benzodiazepine co-prescribing. Filled benzodiazepine prescriptions during buprenorphine prescriptions were associated with an increased risk of fatal and nonfatal opioid overdose, as well as all-cause mortality – but a decreased risk of buprenorphine discontinuation. These results suggest that further studies need to examine these relationships as well as factors associated with each outcome.

24) An Inpatient Psychiatric Program Targeting Opioid Overdoses.

Mahgoub N, O’Connell K, Gevint K, Dedonatis A, Velasco J, Tham A, Cangemi S, Tai FJ, Stellman M, Radosta M, Anthony D.

J Psychiatr Pract. 2020 Jan;26(1):71-75. doi: 10.1097/PRA.0000000000000446.

Comment: A description of the implementation of a program training patients and families how to respond to an opioid overdose and administer naloxone in New York.

25) Availability of Buprenorphine Treatment in the 10 States With the Highest Drug Overdose Death Rates in the United States.

Flavin L, Malowney M, Patel NA, Alpert MD, Cheng E, Noy G, Samuelson S, Sreshta N, Boyd JW.

J Psychiatr Pract. 2020 Jan;26(1):17-22. doi: 10.1097/PRA.0000000000000437.

Comment: Flavin et al. looked at the accuracy of SAMSHA’s database of buprenorphine treatment. The authors contacted all providers listed in the SAMSHA database within a 25-mile radius of a region with a high rate of overdoses in 10 states with the highest drug related death rates to confirm if the database information was correct. In total they called 505 providers, but only 60% of the phone numbers were correct and only 40% of the providers listed provided buprenorphine. Around 60% accepted Medicaid as insurance and the average wait time was 16.8 days for those with waitlists. In total, over 70% did not have appointments available. This study demonstrates one of the many challenges associated with getting buprenorphine prescriptions. While the database is intended to be a resource, this study shows that it is only marginally useful in areas of high need.

26) Preventing Morphine Seeking Behavior through the Re-engineering of Vincamine’s Biological Activity.

Norwood VM, Brice-Tutt A, Eans SO, Stacy H, Shi G, Ratnayake R, Rocca JR, Abboud KA, Li C, Luesch H, McLaughlin JP, Huigens Iii RW.

J Med Chem. 2020 Jan 8. doi: 10.1021/acs.jmedchem.9b01924. [Epub ahead of print]

Comment: A new compound, caused by ring distortion, showed promising results in animal studies.

27) The rise in non-fatal and fatal overdoses involving stimulants with and without opioids in the United States.

Hoots B, Vivolo-Kantor A, Seth P.

Addiction. 2020 Jan 7. doi: 10.1111/add.14878. [Epub ahead of print]

Comment: Drug deaths identified by ICD-10 multiple cause of death codes for cocaine, psychostimulants, all opioids, heroin, and synthetic opioids showed the increase in cocaine involved deaths in the US since 2006 has been driven by opioids (particularly synthetic opioids). Nonfatal and fatal psychostimulant related overdoses, however, are increasing with and without opioids. Recognizing this difference can help better guide prevention and harm reduction efforts. Further exploration into regional differences in substance use and overdose trends is needed, as is, a better understanding of the role of stimulants in fatalities.

28) Availability of Medications for the Treatment of Alcohol and Opioid Use Disorder in the USA.

Abraham AJ, Andrews CM, Harris SJ, Friedmann PD.

Neurotherapeutics. 2020 Jan;17(1):55-69. doi: 10.1007/s13311-019-00814-4. Review.

Comment: This literature review highlights the limited use of opioid and alcohol use disorder medication in the United States despite an increase in availability of opioid use disorder medications over the past decade. Unfortunately, availability of alcohol use disorder medications has decreased over the past decade. Like many, Abraham et al. calls for increased substance use disorder training among health professionals, stigma reduction, policy reform for buprenorphine and methadone prescribing, among other strategies to address the ongoing opioid epidemic. 

29) Receipt of Addiction Treatment After Opioid Overdose Among Medicaid-Enrolled Adolescents and Young Adults.

Alinsky RH, Zima BT, Rodean J, Matson PA, Larochelle MR, Adger H Jr, Bagley SM, Hadland SE.

JAMA Pediatr. 2020 Jan 6:e195183. doi: 10.1001/jamapediatrics.2019.5183. [Epub ahead of print]

Comment: This study identified how and if youths received evidence-based treatments following an opioid overdose using Medicaid claims data from 2009-2015. A large majority of the youths experienced an overdose related to opioids other than heroin. Youth who previously overdosed on heroin were significantly more likely to overdose again compared to those who overdosed on other opioids. 30% of youth received behavioral health services while only 1.9% received pharmacotherapy. Youth who used heroin were significantly less likely to receive any treatment compared to those who used other opioids. The discrepancy between overdose and treatment among youth using heroin compared to other opioids signifies a significant stigma associated with heroin use. As opioid overdose rates among youth continue to rise, as has happened with fentanyl, greater accessibility of treatment, including pharmacotherapy, is essential. 

30) The cascade of care for opioid use disorder: a retrospective study in British Columbia, Canada.

Piske M, Zhou H, Min JE, Hongdilokkul N, Pearce LA, Homayra F, Socias ME, McGowan G, Nosyk B.

Addiction. 2020 Jan 3. doi: 10.1111/add.14947. [Epub ahead of print]

Comment: Using a large sample of 55,000+ people with opioid use disorder in British Columbia, Canada, this retrospective cohort study identified factors associated with increased engagement with opioid agonist treatment. This is a fantastic use of data and we desperately need to replicate and expand upon this in order to track and improve implementation of evidence-based interventions addressing substance use disorders and health sequelae.

31) The Detection of Opioid Misuse and Heroin Use From Paramedic Response Documentation: Machine Learning for Improved Surveillance.

Prieto JT, Scott K, McEwen D, Podewils LJ, Al-Tayyib A, Robinson J, Edwards D, Foldy S, Shlay JC, Davidson AJ.

J Med Internet Res. 2020 Jan 3;22(1):e15645. doi: 10.2196/15645.

Comment: As the opioid crisis continues, innovative surveillance methods, such as this one, have potential. Further research on the effectiveness as well as positive and negative implications of such work is needed.

32) Impact of the Young Adult Dependent Coverage Expansion on Opioid Overdoses and Deaths: a Quasi-Experimental Study.

Coupet E Jr, Werner RM, Polsky D, Karp D, Delgado MK.

J Gen Intern Med. 2020 Jan 2. doi: 10.1007/s11606-019-05605-3. [Epub ahead of print]

Comment: As a criticism of the ACA, some policymakers cite that the ACA expansion fueled opioid overdoses due to increased subsidization of opioid medicine. In a difference-in-difference analysis looking at emergency department encounters and out-of-hospital deaths for opioid overdoses per 100,000 US adults, Coupet et al. refute this claim. The study did find that there was an increase in non-prescription opioid related emergency department encounters, although this change could be due to a variety of other factors other than ACA expansion, as ecological analyses are problematic.

33) Importance and Approach to Manner of Death Opinions in Opioid-Related Deaths.

Abiragi M, Bauler LD, Brown T.

J Forensic Sci. 2020 Jan 2. doi: 10.1111/1556-4029.14266. [Epub ahead of print]

Comment: Most fatal opioid overdoses are accidental; however, some opioid overdose deaths are suicides, which can be difficult to determine. In the case presented by Abiragi et al., a phone call with the decedent’s family during a follow-up interview indicated the heroin overdose death was likely a suicide. There is actually a fascinating mechanism in suicide research called “psychological autopsy” that involves interviews with decedent’s friends and relatives and has also contributed critical information about heroin overdose deaths (way back in the ‘80s). While it’s unlikely to happen in all deaths, this type of ancillary information can be hugely helpful.

34) Commentary on Rhee & Rosenheck (2019): Buprenorphine prescribing for opioid use disorder in medical practice: can office-based out-patient care address the opiate crisis in the United States?

Frank JW, Binswanger IA. Commentary on Rhee & Rosenheck. Addiction. 2020 Apr;115(4):786-787. doi: 10.1111/add.14907. Epub 2020 Jan 12.

Comment: Outpatient OUD treatment should be more commonplace to help increase access to effective and possibly life-saving treatments. Other steps, such as removing the X-waiver requirement, should also be taken.

35) Incidence and predictors of drug overdoses among a cohort of >10,000 patients treated for substance use disorder.

Thylstrup B, Seid AK, Tjagvad C, Hesse M.

Drug Alcohol Depend. 2020 Jan 1;206:107714. doi: 10.1016/j.drugalcdep.2019.107714. Epub 2019 Nov 5.

Comment: Intriguing study of >10,000 people who had been treated for opioid use disorder with 10 years of follow-up data, demonstrating 28% of people with a ‘registered’ overdose (assume that means medically-attended overdose) and 6% with a fatal overdose. Risks for overdose were prior overdose, injected drug use, and benzodiazepine use.

36) The Benefits of Opioid Free Anesthesia and the Precautions Necessary When Employing It.

Bohringer C, Astorga C, Liu H.

Transl Perioper Pain Med. 2020;7(1):152-157.

Comment: This article discusses and suggests the use of non-opioid analgesic alternatives for perioperative use to avoid the negative side effects of opioids.

37) Concurrent Alcohol and Opioid Use Among Harm Reduction Clients.

Winstanley EL, Stover AN, Feinberg J.

Addict Behav. 2020 Jan;100:106027. doi: 10.1016/j.addbeh.2019.06.016. Epub 2019 Jun 20.

Comment: Over half of syringe access clients had concurrent alcohol and opioid use – this was associated with additional drug use beyond opioids… polydrug use begets polydrug use.

Thanks again to Rebecca Martinez, Cathleen Beliveau, Nataliya Karashchuk, and Laila Esfandiari at the Center on Substance Use and Health (www.csuhsf.org) for collaborating to produce these summaries!

1) Supervised injectable opioid agonist therapy in a supported housing setting for the treatment of severe opioid use disorder.

Brar R, Sutherland C, Nolan S.

BMJ Case Rep. 2019 Aug 1;12(7). pii: e229456. doi: 10.1136/bcr-2019-229456.

Comments: Desperate for such options.

2) Association of Injection Practices and Overdose With Drug Use Typologies: A Latent Class Analysis Among People Who Inject Drugs in Baltimore, 2017.

Gicquelais RE, Genberg BL, Astemborski J, Celentano DD, Kirk GD, Mehta SH.

AIDS Educ Prev. 2019 Aug;31(4):344-362. doi: 10.1521/aeap.2019.31.4.344.

Comments: Given the issue with tolerance and overdose risk, many of us used to wonder if intermittent opioid injection would be a particularly high-risk activity. This is the second study to show the opposite.

3) A Comparison of Efficacy of Treatment and Time to Administration of Naloxone by BLS and ALS Providers.

Nugent K, Matthews P, Gissendaner J, Papas M, Occident D, Patel A, Johnson M, Megargel RE, Nomura JT.

Prehosp Disaster Med. 2019 Aug;34(4):350-355. doi: 10.1017/S1049023X19004527. Epub 2019 Jul 19.

Comments: This study of EMS providers between 2014-2015 is somewhat outdated now but found that patients will receive naloxone faster if Basic Life Support (BLS) providers have the ability to provide naloxone as well as Advanced Life Support providers since BLS providers are often quicker to the scene. All Emergency Medical Services systems should allow BLS providers to carry and administer naloxone if they don’t already. 

4) Opioid-related US hospital discharges by type, 1993-2016.

Peterson C, Xu L, Florence C, Mack KA.

J Subst Abuse Treat. 2019 Aug;103:9-13. doi: 10.1016/j.jsat.2019.05.003. Epub 2019 May 10.

Comments: Assessment of the annual percentage change in the rate of opioid-related hospital discharges by type (i.e. opioid overdose, opioid use disorder with or without detoxification/rehabilitation services, etc.) from 1993 to 2016. Documentation of OUD without opioid overdose or detoxification/rehabilitation services quadrupled over the full time period and the discharge rate for heroin-related overdoses increased sharply (~23% annually) from 2010-2016. Despite this, the rate of discharges that included rehabilitation services including pharmacotherapy and counseling declined by ~2% annually from 1993-2016. Suggests that inpatient settings could be doing much more to engage patients with OUD in treatment plans.

5) Expanding low-threshold buprenorphine to justice-involved individuals through mobile treatment: Addressing a critical care gap.

Krawczyk N, Buresh M, Gordon MS, Blue TR, Fingerhood MI, Agus D.

J Subst Abuse Treat. 2019 Aug;103:1-8. doi: 10.1016/j.jsat.2019.05.002. Epub 2019 May 9.

Comments: Examines the development, patient characteristics and outcomes for Project Connections at Re-Entry, a low-threshold, mobile buprenorphine treatment program that engages with patients through a van parked outside the Baltimore City Jail. Of those who began treatment, 67.9% returned for a second visit and 31.6% were still in treatment after 30 days; 20.5% were transferred to continue buprenorphine treatment at a different site.

6) Low overdose responding self-efficacy among adults who report lifetime opioid use.

Tormohlen KN, Tobin KE, Davey-Rothwell MA, Latkin C.

Drug Alcohol Depend. 2019 Aug 1;201:142-146. doi: 10.1016/j.drugalcdep.2019.03.028. Epub 2019 Jun 7.

Comments: Assessment of overdose responding self-efficacy in a study of people who reported lifetime opioid use; 67% of people reported low self-efficacy. High self-efficacy was associated with witnessing an overdose, receiving and using naloxone, and experience with naloxone training. Full text not available through Elsevier. 

7) A predictive risk model for nonfatal opioid overdose in a statewide population of buprenorphine patients.

Chang HY, Krawczyk N, Schneider KE, Ferris L, Eisenberg M, Richards TM, Lyons BC, Jackson K, Weiner JP, Saloner B.

Drug Alcohol Depend. 2019 Aug 1;201:127-133. doi: 10.1016/j.drugalcdep.2019.04.016. Epub 2019 Jun 7.

Comments: During the study period, 3.24% of >25,000 patients prescribed buprenorphine (verified by Maryland’s controlled substance monitoring program) had a non-fatal overdose. Such an event was associated with being male, getting buprenorphine paid for through public or private insurance, and receiving more benzodiazepine prescriptions, and less likely among those on treatment for longer periods. It’s important to note that benzodiazepines are NOT a reason to not prescribe buprenorphine: the risk of overdose is far, far lower on buprenophine plus benzodiazepine compared to a full opioid agonist plus benzodiazepine. 

8) Sexual minority disparities in opioid misuse, perceived heroin risk and heroin access among a national sample of US adults.

Schuler MS, Dick AW, Stein BD.

Drug Alcohol Depend. 2019 Aug 1;201:78-84. doi: 10.1016/j.drugalcdep.2019.04.014. Epub 2019 Jun 7.

Comments: In a sample of >100,000 individuals from the National Survey of Drug Use and Health, lesbian, gay, and bisexual (LGB) subgroups had higher lifetime rates of pain reliever misuse compared to same gender heterosexuals. Bisexual women had the highest rates of high-risk injection use and OUD. Additionally, LGB women had lower perceived risk and greater access to heroin. This study does not include other groups such as people who identify as transgender, queer, intersex, and asexual who maybe also experience opioid use disparities compared to heterosexual adults. Full text not available.  

9) Patterns of polysubstance use and overdose among people who inject drugs in Baltimore, Maryland: A latent class analysis.

Schneider KE, Park JN, Allen ST, Weir BW, Sherman SG.

Drug Alcohol Depend. 2019 A  201:71-77. doi: 10.1016/j.drugalcdep.2019.03.026. Epub 2019 Jun 6.

Comments: Among three groups of people who inject drugs (PWID), using mutiple drugs through multiple routes of administration was associated with past month overdose, compared to those reporting cocaine/heroin injection or heroin injection. The heroin/cocaine group had the highest prevalence of overdose training but the groups did not differ significantly in current naloxone possession. 

Thanks again to Rebecca Martinez, Cathleen Beliveau, Nataliya Karashchuk, and Laila Esfandiari at the Center on Substance Use and Health (www.csuhsf.org) for collaborating to produce these summaries!

1) Pharmacist roles, training, and perceived barriers in naloxone dispensing: A systematic review.

Thakur T, Frey M, Chewning B.

J Am Pharm Assoc (2003). 2019 Jul 29. pii: S1544-3191(19)30320-6. doi: 10.1016/j.japh.2019.06.016. [Epub ahead of print] Review.

Comments: Legal, but underutilized. There’s an interesting difference between obtaining naloxone at syringe access programs versus pharmacies. Cost. The welcoming nature of syringe access programs (when they are run right). Stigma.

2) Opioid Overdose Hospitalization Trajectories in States With and Without Opioid-Dosing Guidelines.

Sears JM, Fulton-Kehoe D, Schulman BA, Hogg-Johnson S, Franklin GM.

Public Health Rep. 2019 Jul 31:33354919864362. doi: 10.1177/0033354919864362. [Epub ahead of print]

Comments: Tough analysis. And one that probably couldn’t be done today due to the geographic variability in fentanyl availability. They compared Colorada/Utah/Washington (as states with opioid prescribing guidelines) to Arizona/California/Michigan/New Jersey/South Carolina (as states without) from 2001-2014 to see what happened with opioid overdose hospitalizations. Of note, their state selection criteria did not include any assessment of similarity in opioid or drug use trends. Looking at the trendlines, it looks like the primary difference is that it took an extra 2 years for the curves to flatten in comparator states. Unknown if this corresponded to a decrease in overdose mortality.

3) Consideration of opioid agonist treatment in a pregnant adolescent: A case report and literature review.

Spada M, Kmiec J, Glance JB, Gopalan P.

Subst Abus. 2019 Jul 30:1-5. doi: 10.1080/08897077.2019.1635970. [Epub ahead of print]

Comments: Yes.

4) Who receives naloxone from emergency medical services? Characteristics of calls and recent trends.

Geiger C, Smart R, Stein BD.

Subst Abus. 2019 Jul 30:1-8. doi: 10.1080/08897077.2019.1640832. [Epub ahead of print]

Comments: Big increases in urban counties and among youth as fentanyl emerged. More multi-dose administrations. More refusal of transport. The West stands out in less of these trends, likely related to the delayed entrance of a significant street fentanyl market.

5) Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine.

Strang J, McDonald R, Campbell G, Degenhardt L, Nielsen S, Ritter A, Dale O.

Drugs. 2019 Jul 27. doi: 10.1007/s40265-019-01154-5. [Epub ahead of print] Review.

Comments: Review.

6) The prevalence of non-fatal overdose among people who inject drugs: A multi-stage systematic review and meta-analysis.

Colledge S, Peacock A, Leung J, Larney S, Grebely J, Hickman M, Cunningham E, Trickey A, Stone J, Vickerman P, Degenhardt L.

Int J Drug Policy. 2019 Jul 24. pii: S0955-3959(19)30208-7. doi: 10.1016/j.drugpo.2019.07.030. [Epub ahead of print] Review.

Comments: Interesting approach – they determined that 20.5% and 41.5% of PWID have had a past year and lifetime overdose, respectively. The old back-of-the-napkin estimate was about 15% and 50%, respectively. I wonder how this applies though in fentanyl areas.

7) Heroin Overdose-Related Child and Adolescent Hospitalizations: Insight on Comorbid Psychiatric and Substance Use Disorders.

Queeneth U, Bhimanadham NN, Mainali P, Onyeaka HK, Pankaj A, Patel RS.

Behav Sci (Basel). 2019 Jul 13;9(7). pii: E77. doi: 10.3390/bs9070077.

Comments: The authors report that prescription opioids led to heroin use, although the data are from 2010-2014, and more recent data suggests that’s no longer the most common pathway.

8) Legal and policy changes urgently needed to increase access to opioid agonist therapy in the United States.

Davis CS, Carr DH.

Int J Drug Policy. 2019 Jul 20;73:42-48. doi: 10.1016/j.drugpo.2019.07.006. [Epub ahead of print]

Comments: Yes – there’s an urgent need to get rid of many of the regulatory barriers – such as the only “waiver” ever required to treat a disease. This actually harkens back to the 1914 Harrison Narcotics Act and the subsequent determination by the US Supreme Court that “addiction is not a disease” … what a mess.

9) Prevalence and correlates of carrying naloxone among a community-based sample of opioid-using people who inject drugs.

Reed M, Wagner KD, Tran NK, Brady KA, Shinefeld J, Roth A.

Int J Drug Policy. 2019 Jul 20;73:32-35. doi: 10.1016/j.drugpo.2019.07.010. [Epub ahead of print]

Comments: Syringe access programs.

10) Urban, individuals of color are impacted by fentanyl-contaminated heroin.

Rhodes B, Costenbader B, Wilson L, Hershow R, Carroll J, Zule W, Golin C, Brinkley-Rubinstein L.

Int J Drug Policy. 2019 Jul 19;73:1-6. doi: 10.1016/j.drugpo.2019.07.008. [Epub ahead of print]

Comments: Yep, this is the change that is less interesting to press…

11) “They’re making it so hard for people to get help:” Motivations for non-prescribed buprenorphine use in a time of treatment expansion.

McLean K, Kavanaugh PR.

Int J Drug Policy. 2019 Jul 19;71:118-124. doi: 10.1016/j.drugpo.2019.06.019. [Epub ahead of print]

Comments: Federal policies limit access, and funds poured into expanding access may not be reaching those it needs to reach.

12) Themes in published obituaries of people who have died of opioid overdose.

Rajesh K, Crijns TJ, Ring D.

J Addict Dis. 2019 Jul 22:1-6. doi: 10.1080/10550887.2019.1639485. [Epub ahead of print]

Comments: I can’t access the full article but would love to. The themes are love, joy, and sadness. No surprise here. People love people who use drugs.

13) Misperceptions about the ‘Opioid Epidemic:’ Exploring the Facts.

Oliver JE, Carlson C.

Pain Manag Nurs. 2019 Jul 18. pii: S1524-9042(19)30072-4. doi: 10.1016/j.pmn.2019.05.004. [Epub ahead of print] Review.

Comments: I can’t access the full article. They list misperceptions.

14) One single large intramuscular dose of naloxone is effective and safe in suspected heroin poisoning.

Harris K, Page CB, Samantray S, Parker L, Brier AJ, Isoardi KZ.

Emerg Med Australas. 2019 Jul 21. doi: 10.1111/1742-6723.13344. [Epub ahead of print]

Comments: Perhaps a large (1.6mg IM in this study) IM dose reduces the likelihood of more complex management in an emergency department. It’s important to see this in the context of the old days, when paramedics would routinely given large naloxone doses, often seen as a “punishment” of a person for experiencing an overdose. The transition to 0.4mg IM was considered humane – the shift back to high dose needs to be considered seriously before being implemented because EMS has access to the means to support respiration, making immediate and full reversal of overdose less important, or – in some circumstances – undesired.

15) Impact of a pharmacist-driven intervention on the outpatient dispensing of naloxone.

Griffin S, Wishart B, Bricker K, Luebchow A.

J Am Pharm Assoc (2003). 2019 Jul – Aug;59(4S):S161-S166. doi: 10.1016/j.japh.2019.06.011.

Comments: Pharmacists were able to convince more patients to accept naloxone prescriptions.

16) Deploying science to change hearts and minds: Responding to the opioid crisis.

Walsh SL, Long KQX.

Prev Med. 2019 Jul 15:105780. doi: 10.1016/j.ypmed.2019.105780. [Epub ahead of print]

Comments: The abstract calls for increased access to evidence-based care for people with opioid use disorder and identifies some barriers to treatment. Full text not available through Elsevier. 

17) Heroin and healthcare: patient characteristics and healthcare prior to overdose.

Bohm MK, Bridwell L, Zibbell JE, Zhang K.

Am J Manag Care. 2019 Jul;25(7):341-347.

Comments: Interesting use of data from the IBM MarketScan Databases (insurance claims-based data set with millions of de-identified patient records) comparing annual heroin overdose rates between Medicaid and commercially-insured patients in the U.S. from 2010-2014. Heroin overdose was much more frequent among Medicaid compared to commercially-insured patients, with the exception of 15-24 year old persons. Over the four years, heroin overdose rates increased more rapidly for commercially-insured patients (270%) compared to Medicaid patients (94%), despite the fact that fewer commercially-insured patients had received prior opioid prescriptions in the month prior to overdose. 

18) Implementation evaluation of academic detailing on naloxone prescribing trends at the United States Veterans Health Administration.

Bounthavong M, Devine EB, Christopher MLD, Harvey MA, Veenstra DL, Basu A.

Health Serv Res. 2019 Jul 17. doi: 10.1111/1475-6773.13194. [Epub ahead of print]

Comments: Efforts to implement academic detailing on opioid overdose and naloxone distribution have not been uniform across all VA stations. This study found that VA stations where 100% of providers were exposed to an academic detailing intervention had a naloxone prescribing rate that was 5.52 times that of stations where no providers were exposed. 

19) Justice involvement patterns, overdose experiences, and naloxone knowledge among men and women in criminal justice diversion addiction treatment.

Gicquelais RE, Mezuk B, Foxman B, Thomas L, Bohnert ASB.

Harm Reduct J. 2019 Jul 16;16(1):46. doi: 10.1186/s12954-019-0317-3.

Comments: Examines overdose education and naloxone distribution (OEND) engagement of individuals diverted from the criminal justice system to addiction treatment. Just over half correctly identified naloxone as an opioid overdose treatment, while 68% had experienced an overdose and 79% had witnessed another person overdose. 

20) Supervised consumption sites: a nuanced assessment of the causal evidence.

Caulkins JP, Pardo B, Kilmer B.

Addiction. 2019 Jul 16. doi: 10.1111/add.14747. [Epub ahead of print]

Comments: Review article describing evidence around supervised consumption sites (SCS). Posits that the nature of such studies often precludes causal evidence, but that the literature generally shows associations between SCS and positive client outcomes. 

21) Pharmacist dispensed naloxone: Knowledge, availability, participation and cost in selected California counties.

Darracq MA, Lee J, Wilson T, Lasoff D, Armenian P.

Int J Drug Policy. 2019 Jul 10;71:113-117. doi: 10.1016/j.drugpo.2019.06.001. [Epub ahead of print]

Comments: Since AB1535 was signed into law in California, authorizing pharmacists to dispense naloxone without physician or mid level provider prescription, this study finds highly variable participation, availability of naloxone, charge for naloxone, and future interest at 622 pharmacies across various California counties. Unclear if there are trends or further analysis done on participating pharmacies due to lack of access to the full article.

22) Description of a pharmacist-led clinical video telehealth group clinic for opioid overdose prevention and naloxone education.

Jensen AN, Beam CM, Douglass AR, Brabson JE, Colvard M, Bean J.

Ment Health Clin. 2019 Jul 1;9(4):294-297. doi: 10.9740/mhc.2019.07.294. eCollection 2019 Jul.

Comments: Describes a video telehealth clinic led by a pharmacist to provide education about overdose and naloxone, intended to reach patients in more rural and difficult to reach areas. Seems to have reached additional people, but it is unclear how effective the education and training were at reducing overdose risk and overdose events. 

23) Public perceptions of naloxone use in the outpatient setting.

Smith JO, Malinowski SS, Ballou JM.

Ment Health Clin. 2019 Jul 1;9(4):275-279. doi: 10.9740/mhc.2019.07.275. eCollection 2019 Jul.

Comments: Among a sample of 405 participants who were reimbursed $0.10 for completing a survey through a crowdsourcing marketplace, the majority were aware that an overdose agent exists. However, although 88% of people believed naloxone is beneficial for accidental overdose, 51% still believe that naloxone enables people who misuse opioids. Public education campaigns about naloxone are still relevant to correct misconceptions and address stigma.

24) Keeping Up with Clinical Advances: Opioid Use Disorder.

Patel B, Kosten TR.

CNS Spectr. 2019 Jul 10:1-7. doi: 10.1017/S109285291900110X. [Epub ahead of print]

Comments: Overview of the various medications that treat opioid use disorder, including methadone, buprenorphine, and naltrexone. Clonidine and lofexidine, which are primarily used to manage symptoms of acute withdrawal, are also discussed. 

25) Overdose Deaths and Acute Hepatitis Infections among American Indians in North Carolina.

Cox ME, Dzialowy N, Armstrong L, Proescholdbell S.

N C Med J. 2019 Jul-Aug;80(4):197-203. doi: 10.18043/ncm.80.4.197.

Comments: Based on death certificate data, American Indians (AIs) have 1.3 times greater unintentional medication and drug overdose death rates compared to combined population rates in North Carolina, matching the rates of the white population. 

26) Factors associated with willingness to wear an electronic overdose detection device.

Ahamad K, Dong H, Johnson C, Hyashi K, DeBeck K, Milloy MJ, Wood E.

Addict Sci Clin Pract. 2019 Jul 3;14(1):23. doi: 10.1186/s13722-019-0153-5.

Comments: About half of a cohort of people who use drugs in Vancouver, Canada, said they would be willing to wear an overdose detection device, which would alert others in the case that they overdosed. Factors associated with willingness are described. 

27) Mortality and causes of death among patients with opioid use disorder receiving opioid agonist treatment: a national register study.

Bech AB, Clausen T, Waal H, Šaltytė Benth J, Skeie I.

BMC Health Serv Res. 2019 Jul 2;19(1):440. doi: 10.1186/s12913-019-4282-z.

Comments: Analysis of crude mortality rate (CMR) and causes of death in Norway’s OAT patient population from January 2014 to December 2015. 1.4% mortality rate among OAT patients in this 2-year period. Deaths were attributed to somatic disease (45%), followed by drug-induced death (42%), and violent death (12%). CMR was higher in men and in patients taking methadone compared with buprenorphine. Results may be somewhat limited by small sample size of deaths in OAT patients (n=200). 

28) Knowledge of Fentanyl and Perceived Risk of Overdose Among Persons Who Use Drugs in Vancouver, Canada.

Moallef S, Nosova E, Milloy MJ, DeBeck K, Fairbairn N, Wood E, Kerr T, Hayashi K.

Public Health Rep. 2019 Jul/Aug;134(4):423-431. doi: 10.1177/0033354919857084. Epub 2019 Jun 18.

Comments: 93.9% of participants who report drug use in this Vancouver study reported some level of fentanyl risk knowledge. 72.5% of participants (and 60% of opioid users in the sample) perceived their risk of fentanyl overdose as nonexistent or low. Participants who perceived a lower risk were also less likely to report a recent nonfatal overdose, recent injection drug use, and awareness of recent exposure to fentanyl citing never or rarely using opioids as the most common reason. Additional findings show that people who were incarcerated were less likely than those who were not incarcerated to perceive their risk of fentanyl overdose as lower. Results are limited to self-reported data.

29) Monoclonal Antibodies for Combating Synthetic Opioid Intoxication.

Smith LC, Bremer PT, Hwang CS, Zhou B, Ellis B, Hixon MS, Janda KD.

J Am Chem Soc. 2019 Jul 3;141(26):10489-10503. doi: 10.1021/jacs.9b04872. Epub 2019 Jun 25.

Comments: Study about a monoclonal antibody therapy to treat exposure to fentanyl and its analogs. The authors propose this antibody therapy as a potential alternative to naloxone; its half life is much longer and would eliminate the risk of falling back into overdose (which is actually remarkably low…). Ethical issues certainly do come up and there are real logical challenges, with which opioids are targeted, administration, prolonged withdrawal, etc.

30) Clarification re naloxone administered to study subject versus other overdose victim in the N-ALIVE pilot randomized trial.

Parmar MKB, Strang J, Choo L, Meade AM, Bird SM.

Addiction. 2019 Jul;114(7):1325. doi: 10.1111/add.14284. No abstract available.

Comments: This is clarification of the study results reported in the N-ALIVE trial of NOR (Naloxone-on-Release), which provided naloxone to former heroin users after release from prison. The committee stopped the trial early because only 5/20 of the former inmates who received naloxone on release used it on themselves and 15/20 used it on other people. This was supposed to be the definitive study of naloxone as overdose prevention, but it got beaten by the reality of naloxone as a community medication.

31) Changing Trends in Opioid Overdose Deaths and Prescription Opioid Receipt Among Veterans.

Lin LA, Peltzman T, McCarthy JF, Oliva EM, Trafton JA, Bohnert ASB.

Am J Prev Med. 2019 Jul;57(1):106-110. doi: 10.1016/j.amepre.2019.01.016. Epub 2019 May 22.

Comments: Analysis of opioid categories and receipt of prescription opioids among veterans who died from opioid overdose in the Veteran’s Health Administration.  Rates of overdose from synthetic opioids and heroin increased substantially from 2010 to 2016, while prescription opioid receipt within 3 months before death decreased from 54% in 2010 to 26% in 2016. Full text not available. 

32) Suspected Heroin Overdoses in US Emergency Departments, 2017-2018.

Vivolo-Kantor AM, Hoots B, David F, Gladden RM.

Am J Public Health. 2019 Jul;109(7):1022-1024. doi: 10.2105/AJPH.2019.305053. Epub 2019 May 16.

Comments: Analysis of suspected heroin overdoses during 2017-2018 in 23 states and jurisdictions funded by the CDC and Prevention Enhanced State Opioid Overdose Surveillance program. Results show 21.5% overall decline in heroin overdose ED visits, but significant increase in Illinois, Indiana and Utah. Limitations of the study include lack of examining other opioids such as fentanyl and limited sensitivity of ED coding. 

33) Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort.

Morgan JR, Schackman BR, Weinstein ZM, Walley AY, Linas BP.

Drug Alcohol Depend. 2019 Jul 1;200:34-39. doi: 10.1016/j.drugalcdep.2019.02.031. Epub 2019 May 3.

Comments: The Massachusetts database allows for extraordinary analyses. This one demonstrated, in a cohort of 43,846 people, that individuals receiving buprenorphine therapy following an opioid use disorder diagnosis were at a lower risk of opioid overdose (hazard ratio 0.40 [0.35-0.46]), whereas a significant risk reduction or association was not observed for naltrexone (oral [hazard ratio 0.93 {0.71-1.22}] or extended-release injectable [hazard ratio 0.74 {0.42-1.31}]). The naltrexone category is underpowered here, but does not appear likely to achieve the benefits of buprenorphine.

34) Why aren’t Australian pharmacists supplying naloxone? Findings from a qualitative study.

Olsen A, Lawton B, Dwyer R, Taing MW, Chun KLJ, Hollingworth S, Nielsen S.

Int J Drug Policy. 2019 Jul;69:46-52. doi: 10.1016/j.drugpo.2019.03.020. Epub 2019 May 9.

Comments: In Australia, over-the-counter naloxone dispensing by pharmacists is happening, though still very under-utilized. Strategies to improve pharmacist uptake are at individual (training) and system (regulation, supply) levels. 

35) Evaluation of a lateral flow immunoassay for the detection of the synthetic opioid fentanyl.

Angelini DJ, Biggs TD, Maughan MN, Feasel MG, Sisco E, Sekowski JW.

Forensic Sci Int. 2019 Jul;300:75-81. doi: 10.1016/j.forsciint.2019.04.019. Epub 2019 Apr 26.

Full text not available. There remains a huge fear of fentanyl among many first responders, irresponsibly promoted in this abstract. Fentanyl and its analogues don’t absorb well through skin. In general, to get sufficient exposure, one would have to essentially bathe in fentanyl. The cases of purported exposure commonly involve panic attacks or, in some subsequently documented circumstances, surreptitious ingestion of the drugs that were found at the scene. This fear leads to stigma against people who use drugs, dangerous legislation, and abandonment of patients in need.

36) Editorial: Prescription for Addiction.

Riggs P.

J Am Acad Child Adolesc Psychiatry. 2019 Jul;58(7):659-660. doi: 10.1016/j.jaac.2019.03.030. Epub 2019 Apr 17.

The editorial calls attention to the gap in knowledge of predictive risk factors for drug use in youth, which limits the ability to develop effective interventions. Full text not available.  

37) Pharmacokinetic Interaction between Naloxone and Naltrexone Following Intranasal Administration to Healthy Subjects.

Krieter P, Chiang CN, Gyaw S, Skolnick P, Snyder R.

Drug Metab Dispos. 2019 Jul;47(7):690-698. doi: 10.1124/dmd.118.085977. Epub 2019 Apr 16.

Comments: I’m really not clear on why we need longer acting opioid overdose reversal agents. There are rare circumstnaces where this is desirable, but that is really uncommon. Most of the time people don’t want to be in a prolonged withdrawal. Use of buprenorphine after naloxone has been done and can be effective. This is a weird research pathway. 

38) Opioid users reflect on their experiences responding to suspected opioid overdoses using take-home naloxone.

Donaghy J.

Evid Based Nurs. 2019 Jul;22(3):77. doi: 10.1136/ebnurs-2019-103072. Epub 2019 Mar 21. No abstract available.

Reflections of opioid users who have used take home naloxone on others when overdosing. Full text or abstract not available.  

39) No end to the crisis without an end to the waiver.

Frank JW, Wakeman SE, Gordon AJ.

Subst Abus. 2018;39(3):263-265. doi: 10.1080/08897077.2018.1543382. No abstract available.

Requiring a waiver to prescribe the most important medication to treat opioid use disorder is really messed up, especially since so many of these patients were provided the opioids that got them hooked by providers who didn’t need a waiver to prescribe those medications. Backwards and archaic.

40) Novel Formulations of Buprenorphine for Treatment of Opioid Use Disorder.

Rosenthal RN.

Focus (Am Psychiatr Publ). 2019 Apr;17(2):104-109. doi: 10.1176/appi.focus.20180043. Epub 2019 Apr 10.

Comments: The study aims to find novel delivery systems to improve outcomes of intermediate and long acting exposure to buprenorphine. Novel formulations are helpful to ensure buprenorphine access in circumstances that limit adherence, as well as where daily dose formulations may be perceived as problematic (such as correctional settings).

Thanks again to Rebecca Martinez, Cathleen Beliveau, Nataliya Karashchuk, and Laila Esfandiari at the Center on Substance Use and Health (www.csuhsf.org) for collaborating to produce these summaries!

_____

1) A national survey of approaches to manage the ICU patient with opioid use disorder.

Reichheld AM, Hills-Evans K, Sheehan JK, Tocci NX, Tandon M, Hsu D, Marshall J, O’Donoghue S, Stevens JP.

J Crit Care. 2019 Jun 29;54:42-47. doi: 10.1016/j.jcrc.2019.06.032. [Epub ahead of print]

Comments: Managing patients with opioid use disorder can be complicated, more so when taking methadone for treatment, and even more so when taking buprenorphine due to the partial agonist effect of that drug. I love the word “iatrogenic”, which basically means “caused by the medical system”, and pertains frequently to what happens to patients on buprenorphine treatment when they are admitted to the hospital. Buprenorphine is often stopped when it shouldn’t be, patients are in agony for prolonged periods, and end up discharged on huge doses of full agonists, like hydromorphone (Dilaudid), and relapsing to illicit opioid use. It can be extremely disruptive.

2) Reducing harm and promoting recovery through community-based mutual aid: Characterizing those who engage in a hybrid peer recovery community organization.

Ashford RD, Brown AM, Dorney G, McConnell N, Kunzelman J, McDaniel J, Curtis B.

Addict Behav. 2019 Jun 26;98:106037. doi: 10.1016/j.addbeh.2019.106037. [Epub ahead of print]

Comments: Community-based participatory research is fascinating.

3) Responding to the opioid and overdose crisis with innovative services: The recovery community center office-based opioid treatment (RCC-OBOT) model.

Ashford RD, Brown AM, McDaniel J, Neasbitt J, Sobora C, Riley R, Weinstein L, Laxton A, Kunzelman J, Kampman K, Curtis B.

Addict Behav. 2019 Jun 21;98:106031. doi: 10.1016/j.addbeh.2019.106031. [Epub ahead of print]

Comments: My university dropped Elsevier, so I can’t access this one and the abstract doesn’t give details on the model proposed, except that it involves using medications which is key to treating opioid use disorder.

4) Prescription opioid misuse among U.S. Hispanics.

Cano M.

Addict Behav. 2019 Jun 13;98:106021. doi: 10.1016/j.addbeh.2019.06.010. [Epub ahead of print]

Comments: The narrative surrounding the opioid epidemic has mostly focused on low-income white communities. However, just because the overall prevalence of opioid misuse among U.S. Hispanics is low doesn’t mean we can ignore this population. It turns out that the higher the generation of U.S. Hispanic adults, the higher the prevalence of prescription opioid misuse (e.g 6.8% prevalence 3rd generation and 6.2% for higher than 3rd generation Hispanics).  English language orientation and length of time living in the U.S. were also associated with higher odds of past-year and lifetime prescription opioid misuse.

5) State Approaches to Addressing the Overdose Epidemic: Public Health Focus Needed.

Davis C, Green T, LaSalle L, Beletsky L.

J Law Med Ethics. 2019 Jun;47(2_suppl):43-46. doi: 10.1177/1073110519857315.

Comments: Overview of the common approaches used by states to address opioid-related harm, some of which are public health-based (i.e. overdose prevention and syringe exchange programs) while others are more punitive (i.e. drug-induced homicide statutes, compulsory treatment for OUD). Article stresses that public health approaches reduce opioid-related harm while punitive approaches exacerbate it by further stigmatizing drug use and discouraging people who use drugs from seeking care after an overdose.

6) Computational Systems Pharmacology-Target Mapping for Fentanyl-laced Cocaine Overdose.

Cheng J, Wang S, Lin W, Wu N, Wang Y, Chen M, Xie XS, Feng Z.

ACS Chem Neurosci. 2019 Jun 29. doi: 10.1021/acschemneuro.9b00109. [Epub ahead of print]

Comments: This paper tries to look at overdoses from fentanyl and cocaine (most believe that it is rarely “fentanyl-laced cocaine”, but instead generally co-use or mistaken use) by looking at genes, receptors, etc., that the drugs bind through simulations. It’s an interesting concept and one that is a bit over my head, admittedly. Unfortunately, the results and discussion are one section so it’s difficult to tease out the conclusions of the authors, besides that a cannabinoid 2 agonist should be used to treat cocaine and fentanyl overdose. 

7) The Role of Pharmacists in Safe Opioid Dispensing.

Gregory T, Gregory L.

J Pharm Pract. 2019 Jun 30:897190019852803. doi: 10.1177/0897190019852803. [Epub ahead of print]

Comments: Review article that describes the role of pharmacists in the era of opioid pharmacovigilance. Mentions patient education about medications and naloxone, but focuses mostly on reduction of opioid diversion and use of non-prescription opioids through identification of “red-flag” behaviors. Missed opportunity for a discussion about the patient/pharmacist relationship as a way for patients to seek further education about their medications.

8) Characteristics of US Counties With High Opioid Overdose Mortality and Low Capacity to Deliver Medications for Opioid Use Disorder.

Haffajee RL, Lin LA, Bohnert ASB, Goldstick JE.

JAMA Netw Open. 2019 Jun 5;2(6):e196373. doi: 10.1001/jamanetworkopen.2019.6373.

Comments: In this cross-sectional study, “opioid high-risk counties” are defined by low availability of providers who can prescribe medications for OUD and high overdose mortality rate. Out of 3142 counties in the U.S., 419 were identified as opioid high-risk. Characteristics of these counties include higher rates of unemployment, micropolitan rather than metropolitan (e.g. <10,000 people), lower primary care provider density and located in East North Central, South Atlantic, or Mountain divisions.

9) Commentary on Elliot et al. (2019): How stigma shapes overdose revival and possible avenues to disrupt it.

Farrugia A.

Addiction. 2019 Jun 27. doi: 10.1111/add.14660. [Epub ahead of print] No abstract available.

Comments: Emergency medical responders can have stigmatizing attitudes and uncaring professional practices towards people they revive from overdose. Understandably, this increases the chance of conflictual encounters; however, providers are more likely to perceive these encounters as a sign of ingratitude rather than a byproduct of poor practices, thus generating a circular stigmatizing dynamic. This article posits that strategies such as addiction stigma reduction education initiatives and better naloxone administration practices are not sufficient to resolve the problem of stigma in healthcare. Accordingly, “more ambitious disruptions” to stigma must be undertaken, although what these disruptions might look like is not articulated.

10) Pain Management Strategies To Reduce Opioid Use Following Total Knee Arthroplasty.

Derogatis MJ, Sodhi N, Anis HK, Ehiorobo JO, Bhave A, Mont MA.

Surg Technol Int. 2019 Jun 25;35. pii: sti35/1156. [Epub ahead of print]

Comments: A review on the literature describing non-narcotic treatments to manage pain following total knee arthroplasty (TKA) finds conflicting evidence on prescribing acetaminophen or gabapentinoids and subsequent reduced opioid use. Multiple studies identified reductions in TKA pain with knee braces as a recommended non-invasive and non-pharmacological treatment. Full article unavailable.

11) Effect of Formulation Variables on the Nasal Permeability and Stability of Naloxone Intranasal Formulations.

Hsu HJ, Yang Y, Pavuluri V, Abraham C, Naraharisetti SB, Ashraf M, Al-Ghabeish M.

AAPS PharmSciTech. 2019 Jun 24;20(6):232. doi: 10.1208/s12249-019-1452-6.

Comments: The science of intranasal naloxone gets interesting when you try to ensure it will be absorbed – and you try to ensure it lasts a long time. Low pH helps it last longer but reduces absorption. Benzalkonium chloride improves absorption a lot, benzyl alcohol somewhat.

12) A Randomized Cross-Over Trial Comparing the Effect of Intramuscular Versus Intranasal Naloxone Reversal of Intravenous Fentanyl on Odor Detection in Working Dogs.

Essler JL, Smith PG, Berger D, Gregorio E, Pennington MR, McGuire A, Furton KG, Otto CM.

Animals (Basel). 2019 Jun 22;9(6). pii: E385. doi: 10.3390/ani9060385.

Comments: Dog’s olfactory abilities are not impacted or impaired by the administration of intranasal or intramuscular naloxone to reverse intravenous fentanyl sedation. However, the article starts out with the premise that exposure to fentanyl in first responders causes overdose. This is not true – unless they are pasting on fentanyl patches that have been designed to improve dermal absorption and then waiting 12 hours. 

13) A standardized team-based approach for identifying naloxone-eligible patients in a grocery store pharmacy.

Sexton SM, Armstrong A, Gatton O, Rhodes LA, Marciniak MW.

J Am Pharm Assoc (2003). 2019 Jun 20. pii: S1544-3191(19)30144-X. doi: 10.1016/j.japh.2019.03.015. [Epub ahead of print]df

Comments: A community pharmacy utilized a standardized team-based approach for identifying naloxone-eligible patients, which resulted in a >300% increase in naloxone orders over the course of a year in comparison to the control store (which followed standard of practice). Full text not available.

14) One-Year Mortality of Patients After Emergency Department Treatment for Nonfatal Opioid Overdose.

Weiner SG, Baker O, Bernson D, Schuur JD.

Ann Emerg Med. 2019 Jun 19. pii: S0196-0644(19)30343-9. doi: 10.1016/j.annemergmed.2019.04.020. [Epub ahead of print]

Comments: Can’t access full article so may be missing something here. Paper addresses mortality following opioid overdose cared for in emergency departments in Massachusetts. About 6.5% died within one year, which is markedly high, but they don’t describe what people died from so their conclusion that substance use interventions are needed may or may not be correct based on the data. The statistics presented in the abstract, moreover, are a bit strange, as they devote lines to basically just giving the proportion of the proportions in previous sentences. Would be nice to see a more sophisticated analysis from such a fantastic dataset.

15) Association of Naloxone Coprescription Laws With Naloxone Prescription Dispensing in the United States.

Sohn M, Talbert JC, Huang Z, Lofwall MR, Freeman PR.

JAMA Netw Open. 2019 Jun 5;2(6):e196215. doi: 10.1001/jamanetworkopen.2019.6215.

Comments: Suggests that naloxone coprescription laws are associated with increased dispensing of prescribed naloxone in pharmacies.

16) Transforming lives and empowering communities: evidence, harm reduction and a holistic approach to people who use drugs.

Southwell M, Shelly S, MacDonald V, Verster A, Maher L.

Curr Opin HIV AIDS. 2019 Jun 18. doi: 10.1097/COH.0000000000000566. [Epub ahead of print]

Comments: Harm reduction programs are still extremely underfunded and insufficiently supported, stigmatizing people who use drugs and creating barriers to care. New(ish) innovations discussed include peer distribution of naloxone, low dead space syringes, drug consumption rooms and drug-checking services.

17) Using natural language processing of clinical text to enhance identification of opioid-related overdoses in electronic health records data.

Hazlehurst B, Green CA, Perrin NA, Brandes J, Carrell DS, Baer A, DeVeaugh-Geiss A, Coplan PM.

Pharmacoepidemiol Drug Saf. 2019 Jun 19. doi: 10.1002/pds.4810. [Epub ahead of print]

Comments: Electronic health records generally don’t include fields for substance use, such as whether or not someone injects drugs. These data may exist in provider notes, although patients know that those data in health records can stigmatize them, lead providers not to care for them (e.g. orthopedic surgeons), and cause financial and legal headaches (such as losing access to life insurance) – thus patients may understandably conceal drug use from their providers as much as possible and providers, particularly in this age of open medical records, may alter their language to allow patients that confidentiality while trying not to compromise patient care.

In the mix of this, “big data” and other efforts to use existing data sources has led a lot of substance use research toward electronic health records. This study attempted to create a natural language processing algorithm to identify opioid overdoses. It did fairly well but hit some snags, particularly in the validation cohort. Intentional overdose was readily identified. About two-thirds of unintentional overdoses were identified, with about 11% of the cases identified being false positives. Identifying specific substances got much more problematic. Overall, a much needed step toward understanding how to do this – but we still need to interact with actual people.

18) In-flight opioid overdose and the availability of onboard naloxone: An international survey of commercial airlines.

Wang JJ, Poirier V, Carvalho AM, Biary R, Su MK.

Travel Med Infect Dis. 2019 Jun 16. pii: S1477-8939(19)30100-0. doi: 10.1016/j.tmaid.2019.06.003. [Epub ahead of print] No abstract available.

Comments: Abstract and full text unavailable.

19) Opioid overdose prevention education for medical students: Adopting harm reduction into mandatory clerkship curricula.

Oldfield BJ, Tetrault JM, Wilkins KM, Edelman EJ, Capurso NA.

Subst Abus. 2019 Jun 18:1-6. doi: 10.1080/08897077.2019.1621241. [Epub ahead of print]

Comments: Describes a mandatory educational intervention for medical students to provide overdose prevention information in a harm reduction framework, with a post-survey showing improved knowledge and attitudes.

20) Comprehensive Perioperative Management Considerations in Patients Taking Methadone.

Cornett EM, Kline RJ, Robichaux SL, Green JB, Anyama BC, Gennuso SA, Okereke EC, Kaye AD.

Curr Pain Headache Rep. 2019 Jun 17;23(7):49. doi: 10.1007/s11916-019-0783-z. Review.

Comments: Perioperative pain management strategies for patients on medications for opioid use disorder, including methadone, should be multimodal. Opioid-sparing techniques can be used when appropriate. Unable to access full article for more details through Elsevier.

21) Suspected involvement of fentanyl in prior overdoses and engagement in harm reduction practices among young adults who use drugs.

Goldman JE, Krieger MS, Buxton JA, Lysyshyn M, Sherman SG, Green TC, Bernstein E, Hadland SE, Marshall BDL.

Subst Abus. 2019 Jun 17:1-8. doi: 10.1080/08897077.2019.1616245. [Epub ahead of print]

Comments: In a small study of 93 participants who use drugs, those who had experienced a suspected fentanyl-related overdose (n=18) were more likely to carry and administer naloxone. This same group was more likely to have administered naloxone to someone else experiencing an overdose than those who had never overdosed or who had overdosed on substances not believed to be fentanyl.

22) Long-term tracking of opioid consumption in two United States cities using wastewater-based epidemiology approach.

Gushgari AJ, Venkatesan AK, Chen J, Steele JC, Halden RU.

Water Res. 2019 Jun 3;161:171-180. doi: 10.1016/j.watres.2019.06.003. [Epub ahead of print]

Comments: Analyzing municipal raw wastewater from two Midwestern cities for morphine, codeine, oxycodone, heroin, fentanyl, and some opioid metabolites to try to predict the number of opioid overdose deaths. Can’t access the full article so difficult to verify, but they claim to have been able to use the algorithm to fairly accurately predict the number of deaths in 2016.

23) Naloxone interventions in opioid overdoses: a systematic review protocol.

Shaw LV, Moe J, Purssell R, Buxton JA, Godwin J, Doyle-Waters MM, Brasher PMA, Hau JP, Curran J, Hohl CM.

Syst Rev. 2019 Jun 11;8(1):138. doi: 10.1186/s13643-019-1048-y.

Comments: Protocol paper for a systematic review of administration of naloxone for opioid overdose (looking at dosing, effectiveness, and adverse effects of naloxone). Not an urgent study, as naloxone is known to be safe in a wide range of doses. However, administering naloxone to an individual experiencing an overdose often causes immediate opioid withdrawal and significant discomfort in that individual. Additional research on naloxone dose administered for different opioids, especially suspected ultra-potent opioids like fentanyl, could be a useful tool in understanding how to humanely reverse opioid overdoses.

24) Pulmonary Complications of Opioid Overdose Treated With Naloxone.

Farkas A, Lynch MJ, Westover R, Giles J, Siripong N, Nalatwad A, Pizon AF, Martin-Gill C.

Ann Emerg Med. 2019 Jun 7. pii: S0196-0644(19)30309-9. doi: 10.1016/j.annemergmed.2019.04.006. [Epub ahead of print]

Comments: Unable to access full article. This retrospective, observational, cross-sectional study found that patients who had received more than 4.4mg of naloxone (in other words more than 1 dose) were 62% more likely to have a pulmonary complication like aspiration pneumonia. This is not remotely unexpected, as multiple doses are administered when someone is not responding and thus has further pulmonary compromise from their overdose.

25) [Improve the benefit/risk balance of methadone by respecting its pharmacological specificities].

Frauger E, Fouilhé Sam-Laï N, Mallaret M, Micallef J; le French Addictovigilance Network (FAN).

Therapie. 2019 Jun;74(3):383-388. doi: 10.1016/j.therap.2018.09.070. Epub 2018 Sep 27. French.

Comments: French article, full-text unavailable, describes methadone-related adverse events (overdose, diversion, death) from 2003-2017 in France.

26) Opioid use and misuse: health impact, prevalence, correlates and interventions.

Bolshakova M, Bluthenthal R, Sussman S.

Psychol Health. 2019 Jun 8:1-35. doi: 10.1080/08870446.2019.1622013. [Epub ahead of print]

Comments: A broad review and history of opioid use and misuse in recent years examining individual and environmental factors that lead to problematic use, preventative strategies, and current alternatives to pain management. This article calls for a balance of limiting access to opioids for potential misusers and ensuring that patients who need pain management do not experience additional barriers to accessing prescription opioids. However, the question remains about how this distinction could be implemented in an unbiased way. 

27) Development of vaccines to treat opioid use disorders and reduce incidence of overdose.

Pravetoni M, Comer SD.

Neuropharmacology. 2019 Jun 4:107662. doi: 10.1016/j.neuropharm.2019.06.001. [Epub ahead of print] Review.

Comments: Review article; discusses possibilities of using vaccines to treat substance use disorders, and opioid use disorders in particular. As discussed in our last release, there are both logistic (there is such a variety of opioids and the market is shifting constantly) and potential ethical issues with vaccines, particularly related to forced use in criminal justice settings and particularly relevant to opioid use disorder, for which we already have effective treatments. Unable to access full article through Elsevier.

28) The relative lethal toxicity of pharmaceutical and illicit substances; A 16-year study of the Greater Newcastle Hunter Area, Australia.

Brett J, Wylie CE, Raubenheimer J, Isbister GK, Buckley NA.

Br J Clin Pharmacol. 2019 Jun 7. doi: 10.1111/bcp.14019. [Epub ahead of print]

Comments: Interesting article. Can’t access the full text to really evaluate what they did. Seems they combined mortality data with dispensing data and data from the Hunter Area Toxicology Service (in Australia; seems to be an emergency department of sorts) to generate two data points: 1) the fatal toxicity index (FTI) = the number of fatal poisonings from a drug per year of daily dispensed drug; and (2) case fatality (CF) = the rate of fatal poisonings to total poisonings. There were 444 overdose deaths and 21,296 overdoses recorded from 2002 to 2016. Of prescribed drugs, opioids had the highest FTI (40.3 deaths per 100 years of dispensed drug) and CF (12.4% of overdoses resulted in death). Among the opioids, the highest FTI came from fentanyl, methadone and morphine (does Australia have illictly-manufactured fentanyl? That would mess up this analysis). Heroin had a CF of 26.4%. This is interesting, because heroin overdose is well established to result in death in about 4% of cases; these data suggest that, among heroin overdoses that make it to an emergency department (or toxicology unit?), 26.4% result in death. These results are quite useful for modeling on overdose prevention.

29) Availability and Cost of Naloxone Nasal Spray at Pharmacies in Philadelphia, Pennsylvania, 2017.

Guadamuz JS, Alexander GC, Chaudhri T, Trotzky-Sirr R, Qato DM.

JAMA Netw Open. 2019 Jun 5;2(6):e195388. doi: 10.1001/jamanetworkopen.2019.5388.

Comments: Evaluation of naloxone nasal spray availability at Philadelphia pharmacies following a standing order allowing pharmacies to dispense naloxone without a prescription. Findings show that only 34% of pharmacies had naloxone in stock and it was less likely to be available in areas with higher rates of opioid overdose deaths. Average out of pocket cost was $145. Results indicate that naloxone access is still restricted, especially for communities that may need it most.

30) Concerns that an opioid antidote could “make things worse”: Profiles of risk compensation beliefs using the Naloxone-Related Risk Compensation Beliefs (NaRRC-B) scale.

Winograd RP, Werner KB, Green L, Phillips S, Armbruster J, Paul R.

Subst Abus. 2019 Jun 6:1-7. doi: 10.1080/08897077.2019.1616348. [Epub ahead of print]

Comments: This study examined a way to classify concerns about naloxone distribution on a risk compensation belief scale and found that amongst service providers including police, EMS, social services and others, attending an overdose education and naloxone distribution training decreased beliefs about naloxone-related risk compensation behaviors. Education among service providers is important to reduce stigma surrounding naloxone distribution.

31) Willingness to Use Safe Consumption Spaces among Opioid Users at High Risk of Fentanyl Overdose in Baltimore, Providence, and Boston.

Park JN, Sherman SG, Rouhani S, Morales KB, McKenzie M, Allen ST, Marshall BDL, Green TC.

J Urban Health. 2019 Jun;96(3):353-366. doi: 10.1007/s11524-019-00365-1.

Comments: Study investigating trends in willingness to use safe consumption spaces among people who use drugs in the (north)east. 77% of 326 opioid users from three major cities were willing to use a safe consumption space. Female gender, racial minority status, and injecting in public spaces were associated with higher willingness to use a safe consumption space.

32) Prevention of Opioid Overdose.

Babu KM, Brent J, Juurlink DN.

N Engl J Med. 2019 Jun 6;380(23):2246-2255. doi: 10.1056/NEJMra1807054. Review. No abstract available.

Comments: Review of provider strategies for prevention of opioid overdose among patients who are initiating opioid therapy, those on long-term opioid therapy and those living with an opioid use disorder. Strategies include tapering, medication-assisted treatment, use of buprenorphine for pain management, naloxone provision, etc.

33) Modelling the combined impact of interventions in averting deaths during a synthetic-opioid overdose epidemic.

Irvine MA, Kuo M, Buxton JA, Balshaw R, Otterstatter M, Macdougall L, Milloy MJ, Bharmal A, Henry B, Tyndall M, Coombs D, Gilbert M.

Addiction. 2019 Jun 5. doi: 10.1111/add.14664. [Epub ahead of print]

Comments: Mathematical model based on British Columbia data evaluating effect of opioid overdose interventions. Take-home naloxone averted the highest number of deaths (1580 over four years), which is in line with previous studies showing the effectiveness of providing take-home naloxone. They further estimated that 230 deaths were prevented by safe consumption services and 590 by medications for opioid use disorder treatment. This occurred during a tragic opioid overdose death crisis in the region, thus authors note that the number of overdose deaths did not decline in the context of expanded overdose prevention services.

34) The role of take-home naloxone in the epidemic of opioid overdose involving illicitly manufactured fentanyl and its analogs.

Kim HK, Connors NJ, Mazer-Amirshahi ME.

Expert Opin Drug Saf. 2019 Jun;18(6):465-475. doi: 10.1080/14740338.2019.1613372. Epub 2019 May 16. Review.

Comments: Fentanyl and its analogs are coming (or already came) to dominate the street opioid supply in North America. There is concern that higher or repeated doses of naloxone may be required to reverse fentanyl. When administered in clinical settings, fentanyl is just as responsive to naloxone as other opioids. In the community, however, people may consume a substantial overdose of fentanyl which, because naloxone is a competitive antagonist, may require additional naloxone. Further, and this may be a common cause of the perceived need, fentanyl overdoses occur rapidly and can progress to cardiac arrest much more quickly than heroin overdoses. Many of the cases of fentanyl overdose are “worse” – by which I mean further along, more severe, and more likely to also involve the heart stopping – than what we are used to seeing with heroin or other opioids.

35) Stigma and drug use settings as correlates of self-reported, non-fatal overdose among people who use drugs in Baltimore, Maryland.

Latkin CA, Gicquelais RE, Clyde C, Dayton L, Davey-Rothwell M, German D, Falade-Nwulia S, Saleem H, Fingerhood M, Tobin K.

Int J Drug Policy. 2019 Jun;68:86-92. doi: 10.1016/j.drugpo.2019.03.012. Epub 2019 Apr 23.

Comments: Experiencing stigma was associated with likelihood of experiencing a non-fatal overdose, as was using drugs in a public setting. Data on these subjects and overdose risk has been mixed over the years. Unable to access full article through Elsevier.

36) U.S. National 90-Day Readmissions After Opioid Overdose Discharge.

Peterson C, Liu Y, Xu L, Nataraj N, Zhang K, Mikosz CA.

Am J Prev Med. 2019 Jun;56(6):875-881. doi: 10.1016/j.amepre.2018.12.003. Epub 2019 Apr 17.

Comments: Out of 58,850 admissions for opioid overdose in the US in 2016, 24% resulted in a readmission within 90 days; 3% (1,658) were readmitted for another overdose. Leaving against medical advice was associated with readmission (no surprise for those of us who provide inpatient care), suggesting the real benefit that addiction medicine consult services could provide.

37) Acceptability of implementing community-based drug checking services for people who use drugs in three United States cities: Baltimore, Boston and Providence.

Sherman SG, Morales KB, Park JN, McKenzie M, Marshall BDL, Green TC.

Int J Drug Policy. 2019 Jun;68:46-53. doi: 10.1016/j.drugpo.2019.03.003. Epub 2019 Apr 13.

Comments: 63% of this cohort of street-based people who use drugs had overdosed; 42% had witnessed a fatal overdose. 90% thought checking drugs with things like fentanyl strips would help then prevent overdose. Older and non-white participants were more likely to intend to use drug checking.

38) Opioid-prescribing Patterns for Pediatric Patients in the United States.

Groenewald CB.

Clin J Pain. 2019 Jun;35(6):515-520. doi: 10.1097/AJP.0000000000000707.

Comments: Narrative review noting the increasing prescribing of opioids to children since 2000 (I assume that trend has reversed in recent years, but don’t know the data). 40% of children receive opioids during hospitalization. By the age of 18, almost 20% of children in the United States report having received an opioid prescription at some point in their lifetime. 

39) Opioid overdose deaths and potentially inappropriate opioid prescribing practices (PIP): A spatial epidemiological study.

Stopka TJ, Amaravadi H, Kaplan AR, Hoh R, Bernson D, Chui KKH, Land T, Walley AY, LaRochelle MR, Rose AJ.

Int J Drug Policy. 2019 Jun;68:37-45. doi: 10.1016/j.drugpo.2019.03.024. Epub 2019 Apr 11.

Comments: Fascinating analysis in Massachusetts looking to see if clusters of potentially inappropriate opioid prescribing were associated with clusters of opioid overdoses from 2011 to 2016. They found that prescribing didn’t entirely explain overdoses. Not surprising, but useful for prioritizing prevention resources.

40) Retrospective Review of Need for Delayed Naloxone or Oxygen in Emergency Department Patients Receiving Naloxone for Heroin Reversal.

Heaton JD, Bhandari B, Faryar KA, Huecker MR.

J Emerg Med. 2019 Jun;56(6):642-651. doi: 10.1016/j.jemermed.2019.02.015. Epub 2019 Apr 5.

Comments: This study makes the case for standardizing the emergency department observation period for patients who receive naloxone after a heroin overdose. They felt a need to provide oxygen or naloxone to 4.6% of patients after two hours of observation, 1.9% after 3 hours, and 0.9% after 4 hours. 

Thanks again to Rebecca Martinez, Cathleen Beliveau, Nataliya Karashchuk, and Laila Esfandiari at the Center on Substance Use and Health (www.csuhsf.org) for collaborating to produce these summaries!

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1) Opioid overdose history and awareness of naloxone in patients seeking outpatient detoxification.

Bhardwaj SB, Cochran G, Kmiec J.

J Opioid Manag. 2019 May/Jun;15(3):253-259. doi: 10.5055/jom.2019.0508.

Comments: More than half had overdosed and 52% of the total accepted naloxone. Detox is among the most important places to have naloxone available for people to take with them, given extensive data that detox dramatically increases the risk of overdose and overdose death.

2) Free trade and opioid overdose death in the United States.

Dean A, Kimmel S.

SSM Popul Health. 2019 May 23;8:100409. doi: 10.1016/j.ssmph.2019.100409. eCollection 2019 Aug.

Comments: Important analysis using CDC and Department of Labor data to demonstrate a positive association between trade-related job loss and opioid overdose death in counties across the U.S. When fentanyl is present in heroin supply, the increase in overdose deaths from the same number of job losses is even more extreme. 

3) Methodological Complexities in Quantifying Rates of Fatal Opioid-Related Overdose.

Slavova S, Delcher C, Buchanich JM, Bunn TL, Goldberger BA, Costich JF.

Curr Epidemiol Rep. 2019;6(2):263-274. doi: 10.1007/s40471-019-00201-9. Epub 2019 May 2. Review.

Comments: This review describes how the lack of standardization in investigating, certifying, and coding drug overdose-related deaths limits the accuracy of drug overdose mortality surveillance data. Lack of routine comprehensive toxicology testing, challenges in detecting and quantifying novel synthetic opioids, and variations in the specificity and completeness of drug information listed on death certificates generates bias in the data. Based on local experience in three cities and collaboration in multi-state analyses of mortality data, there are real issues comparing one location to another – or even one location over time if the medical examiner staffing changes as well. Some particularly relevant issues include coding manner of death: some code most overdoses as “undetermined” whereas others code most as “unintentional”. More important is the variation in what specific drugs are reported, as well as if a death is attributed to drugs at all when there is an additional cause of death identified.

4) Discovering major opioid-related research themes over time: A text mining technique.

Kim YM.

AMIA Jt Summits Transl Sci Proc. 2019 May 6;2019:751-760. eCollection 2019.

Comments:  Term frequencies in PubMed publications between 2000 and 2017 show that the early 2000s were marked with research on methadone maintenance treatment  and opioid research related to managing pain for HIV and cancer. Over time, research emerged on prescription opioid misuse, associated health problems, and opioid-related deaths and ED visits. The changes within opioid research publication themes mirror the emerging health concerns over time. 

5) Rapid induction onto sublingual buprenorphine after opioid overdose and successful linkage to treatment for opioid use disorder.

Herring AA, Schultz CW, Yang E, Greenwald MK.

Am J Emerg Med. 2019 May 29. pii: S0735-6757(19)30364-X. doi: 10.1016/j.ajem.2019.05.053. [Epub ahead of print] No abstract available.

Comments Unable to access full text due to Elsevier conflicts with academia. No abstract available, so assume this is a letter discussing initiation of buprenorphine immediately after overdose. This is a really exciting emerging intervention, particularly given the impressive reduction in overdose risk among people after buprenorphine dosing. Some providers actually use rapid IV buprenorphine, which is fascinating.

6) West Virginia’s model of buprenorphine expansion: Preliminary results.

Winstanley EL, Lander LR, Berry JH, Mahoney JJ 3rd, Zheng W, Herschler J, Marshalek P, Sayres S, Mason J, Haut MW.

J Subst Abuse Treat. 2019 May 8. pii: S0740-5472(19)30059-5. doi: 10.1016/j.jsat.2019.05.005. [Epub ahead of print]

Comments: Process measures for West Virginia hub and spoke model to scale up medications for substance use disorders.

7) Preparing student pharmacists to identify opioid misuse, prevent overdose and prescribe naloxone.

Skoy E, Eukel H, Frenzel J, Werremeyer A.

Curr Pharm Teach Learn. 2019 May;11(5):522-527. doi: 10.1016/j.cptl.2019.02.013. Epub 2019 May 3.

Comments: Pre-post survey suggesting that student pharmacists’ participation in an opioid misuse and overdose training program significantly increased their knowledge, self-efficacy, and perceived value of the pharmacist’s role in preventing opioid overdose. Full text not accessible. 

8) A chemically contiguous hapten approach for a heroin-fentanyl vaccine.

Natori Y, Hwang CS, Lin L, Smith LC, Zhou B, Janda KD.

Beilstein J Org Chem. 2019 May 3;15:1020-1031. doi: 10.3762/bjoc.15.100. eCollection 2019.

Comments: Drug “vaccines” are emerging again as a major pathway to develop medications for substance use disorders. There are always ethical issues with this pathway, in particular because society has a long history of forcing treatments upon people. Nonetheless, for substance use disorders that lack other good options (e.g. stimulants), the desperate need for treatments likely justifies the risk of misuse by society. This is somewhat harder to justify for opioid use disorder, which has good medications in place already. The larger issue with opioids – and fentanyl in particular – is the fact that there is actually a wide array of analogues already on the market that may not be covered by this targeted vaccine.

9) Simple minimally-invasive automatic antidote delivery device (A2D2) towards closed-loop reversal of opioid overdose.

Dhowan B, Lim J, MacLean MD, Berman AG, Kim MK, Yang Q, Linnes J, Lee CH, Goergen CJ, Lee H.

J Control Release. 2019 May 31;306:130-137. doi: 10.1016/j.jconrel.2019.05.041. [Epub ahead of print]

Comments: It’s been a real challenge to address overdoses that occur when people are alone. Closed-loop devices that alert emergency help or even administer naloxone have been considered for year.s It’s nice to see something start to move through the stages, although there is a LOT more to do before this were to make it to the real world – it’s an implant that likely requires an outpatient surgery and I’d be concerned about the need for (frequent) refill. Unable to access the full paper so may be missing some details.

10) The opioid epidemic in rural northern New England: An approach to epidemiologic, policy, and legal surveillance.

Stopka TJ, Jacque E, Kelso P, Guhn-Knight H, Nolte K, Hoskinson R Jr, Jones A, Harding J, Drew A, VanDonsel A, Friedmann PD.

Prev Med. 2019 May 31:105740. doi: 10.1016/j.ypmed.2019.05.028. [Epub ahead of print]

Comments: Geographic analysis of opioid overdose rates, HCV rates and harm reduction access in rural areas of New Hampshire, Vermont and Massachusetts. 

11) Effect of pill mill laws on opioid overdose deaths in Ohio & Tennessee: A mixed-methods case study.

Brighthaupt SC, Stone EM, Rutkow L, McGinty EE.

Prev Med. 2019 May 29;126:105736. doi: 10.1016/j.ypmed.2019.05.024. [Epub ahead of print]

Comments: Examined the impact of pill mill laws–regulations that prevent the issuing of opioid prescriptions without medical indication–on overall opioid overdose death rate and drug-specific opioid overdose death rates (prescription opioids, heroin, and synthetic opioids) in Ohio and Tennessee. Pill mill laws, even when robustly implemented, neither reduced nor increased overdose death. Full text not available. 

12) Dancing with Deterrents: Understanding the Role of Abuse-Deterrent Opioid Formulations and Naloxone in Managing Cancer Pain.

Mitchell MT.

Oncologist. 2019 May 31. pii: theoncologist.2019-0340. doi: 10.1634/theoncologist.2019-0340. [Epub ahead of print]

Comments:  Examines the use of novel “abuse-deterrent” formulas for managing cancer pain. This article acknowledges the economic barriers to patients using these more expensive formulas and warns that the novel formulas are no less prone to misuse by taking larger doses or switching to heroin. Additionally, use of naloxone as a means of harm-reduction in patients with end-stage cancer is controversial due to symptoms associated with imminent death being similar to opioid overdose; naloxone has the potential to exacerbate emotional and physical pain in this population. 

13) Naloxone urban legends and the opioid crisis: what is the role of public health?

Crabtree A, Masuda JR.

BMC Public Health. 2019 May 30;19(1):670. doi: 10.1186/s12889-019-7033-5.

Comments: This article describes and discredits sensationalized media reports about naloxone kits being used not as intended. These stories are discussed in a sociological framework of urban legends, wherein these reports incite a fear-based response against stigmatized activities and communities (there’s a long history of this related to drug use – see, for example, this excellent piece discussing a Pulitzer Prize-winning series by Washington Post journalist Janet Cooke, which led to massive manhunts for a drug dealing child, and was later determined to be entirely fraudulent). This article posits that these naloxone urban legends can be a useful tool to the public health field in understanding and addressing the underlying anxieties of the opioid crisis. 

14) Street fentanyl use: Experiences, preferences, and concordance between self-reports and urine toxicology.

Daniulaityte R, Carlson RR, Juhascik MP, Strayer KE, Sizemore IE.

Int J Drug Policy. 2019 May 27;71:3-9. doi: 10.1016/j.drugpo.2019.05.020. [Epub ahead of print]

Comments: In a sample of 60 people who self-reported heroin and non-prescription fentanyl use, nearly 90% tested positive for non-prescription fentanyl. Participants were not able to accurately identify when they were using heroin compared to when they were using non-prescription fentanyl. Study sampling and methodology were somewhat unclear from the abstract only (full text unavailable), since it does not speak to whether participants intentionally used both substances. This study took place in Dayton, Ohio, which had one of the highest overdose death rates in the country in 2017.

15) A gender-based analysis of nonmedical prescription opioid use among people who use illicit drugs.

Cheng T, Nosova E, Small W, Hogg RS, Hayashi K, DeBeck K.

Addict Behav. 2019 Oct;97:42-48. doi: 10.1016/j.addbeh.2019.05.022. Epub 2019 May 21.

Comments: Analyzed factors associated with nonmedical prescription opioid use among 1,459 people in Vancouver who use illicit drugs. There were no differences between men and women with regards to accessing prescription opioids for non-medical purposes. Those who used heroin, had overdosed, and had difficulty accessing health and social services were more likely to use prescription opioids for non-medical purposes. Unable to access full text. 

16) Opioid maintenance, weaning and detoxification techniques; where we have been, where we are now and what the future holds: an update.

Plunkett AR, Peden RM.

Pain Manag. 2019 May;9(3):297-306. doi: 10.2217/pmt-2018-0046. Epub 2019 May 29.

Comments: A review of the literature surrounding opioid use amidst changing sociological and political environments. Full text unavailable.

17) Comparing rates and characteristics of ambulance attendances related to extramedical use of pharmaceutical opioids in Australia: a protocol for a retrospective observational study.

Nielsen S, Crossin R, Middleton M, Martin C, Wilson J, Lam T, Scott D, Smith K, Lubman D.

BMJ Open. 2019 May 27;9(5):e029170. doi: 10.1136/bmjopen-2019-029170.

Comments: This article outlines the protocol for an upcoming study of non-prescription pharmaceutical opioid use in Australia using data from ambulance clinical records. Funded by a pharmaceutical company that makes tapentadol, the study outlines a particular focus on non-prescription use of tapentadol and oxycodone. 

Thanks to Rebecca Martinez, Cathleen Beliveau, Nataliya Karashchuk, and Laila Esfandiari at the Center on Substance Use and Health (www.csuhsf.org) for these summaries!

______

1) The opioid crisis: Origins, trends, policies, and the roles of pharmacists.

Chisholm-Burns MA, Spivey CA, Sherwin E, Wheeler J, Hohmeier K.

Am J Health Syst Pharm. 2019 Mar 19;76(7):424-435. doi: 10.1093/ajhp/zxy089.

Comments: Pharmacist-focused history. 

2) Heroin body-packing and naloxone.

Vahabzadeh M, Banagozar Mohammadi A.

Lancet. 2019 Mar 23;393(10177):e35. doi: 10.1016/S0140-6736(19)30502-1. No abstract available.

Comments: In this case, 82 packets of heroin packed into the stomach and bowels- each weighing 20 grams and encased in 2 condoms- necessitated multiple large doses of naloxone prior to gastrotomy. Of note, naloxone is well-tolerated even at markedly high doses. While naloxone is generally administered as tenths of a milligram to a few milligrams, animal toxicity data suggest multiple grams could hypothetically be given.

3) Identification and Description of Non-Fatal Opioid Overdoses using Rhode Island EMS Data, 2016-2018.

Lasher L, Rhodes J, Viner-Brown S.

R I Med J (2013). 2019 Mar 1;102(2):41-45.

Comments: Identification of overdoses in EMS data — overview of overdose trends in RI.

4) Prescription Drug Monitoring Programs and Opioid Overdoses: Exploring Sources of Heterogeneity.

Castillo-Carniglia A, Ponicki WR, Gaidus A, Gruenewald PJ, Marshall BDL, Fink DS, Martins SS, Rivera-Aguirre A, Wintemute GJ, Cerdá M.

Epidemiology. 2019 Mar;30(2):212-220. doi: 10.1097/EDE.0000000000000950.

Comments: There have been multiple efforts to quantify the potential benefit of controlled substance monitoring programs (CSMPs). First, CSMPs are commonly and erroneously referred to as “prescription drug monitoring programs” when they do not, in fact, allow tracking of prescriptions. CSMPs are often managed by law enforcement and medical providers are mandated to use them. CSMPs are often used in a punitive rather than therapeutic manner, both for patients and providers. If CSMPs were actually “PDMPs”, then all prescription data would be available, providers would enthusiastically crave that information because it would help them manage the multiple conditions most patients have, and privacy protections would be superior because it would be vaster health data.

On to the paper. This paper found that, in places where most people were using prescribed opioids, CSMP implementation seemed to be associated with reduced prescription opioid hospitalizations. This is presumably because fewer prescription opioids were available. However, CSMPs were also associated with increased heroin hospitalizations, particularly in areas that didn’t have high rates of opioids prescribed for chronic pain. The conclusion of the authors – that CSMPs are most effective in areas with high rates of prescribed opioids – fails to account for the fact that many of these opioids were landing in those neighborhoods without as much prescribing – the very same people that turned to heroin (and then fentanyl) when they could no longer find oxycodone on the street. 

We needed vast improvements in our prescribing of opioids – there’s no doubt about that. However, it is critical to understand and admit to the unintended harms of CSMPs and other opioid stewardship efforts. If we don’t, then we will ultimately land in just as bad of a place as we started.

5) Exposures to Opioids Among Wisconsin Children and Adolescents, 2002-2016.

Creswell PD, Gibson C, Theobald J, Meiman JG.

WMJ. 2019 Apr;118(1):9-15.

Comments: Overdose rates among youth are rising in Wisconsin. Among adolescents age 13-19, the majority of hospital encounters involved prescription opioids. However, the proportion of encounters involving heroin-related overdose also increased from 10% in 2002 to 36% in 2016. 

6) Practices and concerns related to naloxone use among emergency medical service providers in a rural state: A mixed-method examination.

Kilwein TM, Wimbish LA, Gilbert L, Wambeam RA.

Prev Med Rep. 2019 Apr 28;14:100872. doi: 10.1016/j.pmedr.2019.100872. eCollection 2019 Jun.

Comments: EMS providers in remote rural areas of Wyoming report titrating naloxone more often than those in populated areas due to longer average transport times to the hospital and less law enforcement backup. Some rural EMS providers see increased naloxone use as an insufficient solution to the rise in opioid misuse, and would like to see greater efforts towards improving access to treatment and harm reduction strategies within their communities. 

7) Buprenorphine charges to uninsured patients at top-ranked U.S. hospitals.

Niforatos JD, Dorner SC, Pescatore RM, Raja AS.

Am J Emerg Med. 2019 Apr 24. pii: S0735-6757(19)30266-9. doi: 10.1016/j.ajem.2019.04.041. [Epub ahead of print] No abstract available.

Comments: An examination of the financial burden of buprenorphine prescribed in the ED setting for opioid use disorders. Full article and results were unavailable.

8) Gender differences in acute recreational drug toxicity: a case series from Oslo, Norway.

Syse VL, Brekke M, Grimsrud MM, Persett PS, Heyerdahl F, Hovda KE, Vallersnes OM.

BMC Emerg Med. 2019 Apr 29;19(1):29. doi: 10.1186/s12873-019-0244-3.

Comments: In patients treated for drug toxicity, gender differences were not pronounced. Despite relatively worse physical and mental health among women who use drugs noted in previous studies, there was no indication that this resulted in a difference in clinical manifestation or treatment when presenting with drug toxicity.

9) Rural-Urban Trends in Opioid Overdose Discharges in Missouri Emergency Departments, 2012-2016.

Coffey W, Hunter A, Mobley E, Vivolo-Kantor A.

J Rural Health. 2019 Apr 25. doi: 10.1111/jrh.12368. [Epub ahead of print]

Comments: Missouri’s overdose death rate increased by 36% from 2015 to 2016 and urban counties had both higher rates and a larger percentage increase of overdose than rural counties, including heroin overdose rates. Statewide, all rural and urban counties experienced an increase in heroin overdose morbidity. 

10) Identifying and classifying opioid-related overdoses: A validation study.

Green CA, Perrin NA, Hazlehurst B, Janoff SL, DeVeaugh-Geiss A, Carrell DS, Grijalva CG, Liang C, Enger CL, Coplan PM.

Pharmacoepidemiol Drug Saf. 2019 Apr 24. doi: 10.1002/pds.4772. [Epub ahead of print]

Comments: Code-based algorithms that detect opioid-related overdoses and classify them according to heroin involvement work well. Algorithms for classifying suicide/suicide attempts and unintentional opioid overdoses work less well, but were improved when natural language processing (NLP) was used. 

11) Should we worry that take-home naloxone availability may increase opioid use?

Tas B, Humphreys K, McDonald R, Strang J.

Addiction. 2019 Apr 23. doi: 10.1111/add.14637. [Epub ahead of print] No abstract available.

Comments: Naloxone distribution remains beneficial despite perceived negative unintended consequences.

12) Do electronic health record prompts increase take-home naloxone administration for emergency department patients after an opioid overdose?

Marino R, Landau A, Lynch M, Callaway C, Suffoletto B.

Addiction. 2019 Apr 23. doi: 10.1111/add.14635. [Epub ahead of print]

Comments: Real-time prompts from the electronic health record may increase distribution of take-home naloxone to patients following an overdose and correct racial biases in prescribing. However, as clinicians know, prompts in electronic records are ubiquitous, a point of frustration while trying to address multiple issues in limited time, and usually ignored.

13) Progress in agonist therapy for substance use disorders: Lessons learned from methadone and buprenorphine.

Jordan CJ, Cao J, Newman AH, Xi ZX.

Neuropharmacology. 2019 Apr 19. pii: S0028-3908(19)30001-2. doi: 10.1016/j.neuropharm.2019.04.015. [Epub ahead of print] Review.

Comments: Need a succinct review of the pharmacological rationale for agonist replacement therapy in the treatment of opioid and nicotine dependence? Also delves into the application of what we’ve learned about agonist therapies for potential cocaine use disorder treatment modalities like classical and atypical DAT inhibitors. 

14) Demystifying buprenorphine misuse: Has fear of diversion gotten in the way of addressing the opioid crisis?

Doernberg M BA, Krawczyk N BA, Agus D JD, Fingerhood M MD.

Subst Abus. 2019 Apr 22:1-6. doi: 10.1080/08897077.2019.1572052. [Epub ahead of print]

Comments: Policies that restrict access to buprenorphine in criminal justice and other settings due to fear of diversion constitute an unnecessary barrier to care for vulnerable populations.

15) Community Pharmacist Utilization of Legislation That Allows Impact on the Opioid Crisis in the State of Minnesota: A Mixed-Methods Approach.

Palombi L, Hawthorne AN, Lunos S, Melgaard K, Dahly A, Blue H.

J Pharm Pract. 2019 Apr 14:897190019841747. doi: 10.1177/0897190019841747. [Epub ahead of print]

Comments: Minnesota-licensed pharmacists underutilize harm reduction tools and opioid-related legislation (88.64% of respondents reported not dispensing naloxone in the past month using a protocol and 59.69% reported no naloxone distribution by any method). 

16) The impact of expanded Medicaid eligibility on access to naloxone.

Frank RG, Fry CE.

Addiction. 2019 Apr 14. doi: 10.1111/add.14634. [Epub ahead of print]

Comments: Medicaid expansion contributed to increases in naloxone prescriptions. This seems to indicate increased accessibility to those for whom cost was a barrier. 

17) A conceptual model for understanding post-release opioid-related overdose risk.

Joudrey PJ, Khan MR, Wang EA, Scheidell JD, Edelman EJ, McInnes DK, Fox AD.

Addict Sci Clin Pract. 2019 Apr 15;14(1):17. doi: 10.1186/s13722-019-0145-5. Review.

Comments: Prevention of overdose for people released from jails and prisons is multifactorial and extremely complex, and this article presents an impressive conceptual framework to better understand factors at play. Ideally, reducing overdose risks starts with reducing people’s exposure to incarceration in the first place. This article also calls for increased access to OUD treatment across the continuum of care along with better coordination between the criminal justice, healthcare and community-based systems to prevent overdose deaths. 

18) Methadone and buprenorphine pharmacokinetics and pharmacodynamics when co-administered with fostemsavir to opioid-dependent, human immunodeficiency virus seronegative participants.

Moore K, Magee M, Sevinsky H, Chang M, Lubin S, Myers E, Ackerman P, Llamoso C.

Br J Clin Pharmacol. 2019 Apr 13. doi: 10.1111/bcp.13964. [Epub ahead of print]

Comments: This study looks at the interaction between fostemsavir (FTR)–an oral prodrug of tamsavir that prevents initial HIV attachment and entry into host immune cells–and methadone/buprenorphine treatment. They found that FTR did not significantly impact MET and BUP pharmacokinetics, and thus can be administered with MET or BUP without dose adjustment. 

19) Losing the uphill battle? Emergent harm reduction interventions and barriers during the opioid overdose crisis in Canada.

Strike C, Watson TM.

Int J Drug Policy. 2019 Apr 8. pii: S0955-3959(19)30057-X. doi: 10.1016/j.drugpo.2019.02.005. [Epub ahead of print]

Comments: Harm reductions interventions are emerging in Canada and the authors argue that although this is promising, Canada needs political environments at all levels to foster innovation and drug policy experimentation to address the escalating opioid crisis.

20) Chronic pain management among people who use drugs: A health policy challenge in the context of the opioid crisis.

Dassieu L, Kaboré JL, Choinière M, Arruda N, Roy É.

Int J Drug Policy. 2019 Apr 8. pii: S0955-3959(19)30089-1. doi: 10.1016/j.drugpo.2019.03.023. [Epub ahead of print]

Comments: Patients with chronic pain who use drugs experienced frustration navigating the medical system, desired non-pharmacological therapies for their pain but often couldn’t afford them, and sometimes turned to street drugs to manage pain, resulting in a higher risk of exposure to fentanyl and overdose. Full article not available.

21) Learning from the past, looking to the future – Is there a place for injectable opioid treatment among Australia’s responses to opioid misuse?

Belackova V, Salmon AM, Jauncey M, Bell J.

Int J Drug Policy. 2019 Apr 8. pii: S0955-3959(19)30094-5. doi: 10.1016/j.drugpo.2019.01.026. [Epub ahead of print]

Comments: Yes. Arguments for piloting supervised injectable opioid treatment are: aging populations of opioid-dependent patients have not benefitted from existing treatment modalities, prescription opioids continue to be misused, and overdose rates are climbing. Developing strategies to improve sustainability of programs involve addressing patient exit strategies and cost. 

22) Overdose Risk and Client Characteristics Associated With the Injection of Buprenorphine at a Medically Supervised Injecting Center in Sydney, Australia.

Power J, Salmon AM, Latimer J, Jauncey M, Day CA.

Subst Use Misuse. 2019;54(10):1646-1653. doi: 10.1080/10826084.2019.1600147. Epub 2019 Apr 11.

Comments: This study found that risk of overdose was low for buprenorphine injection compared to other substances and no overdoses occurred when buprenorphine/naloxone was injected. Additionally, injection of mono-formulated buprenorphine and co-formulated buprenorphine-naloxone was associated with male gender, homelessness, no income/reliance upon government payments, and prior imprisonment.

23) Drug overdose deaths at work, 2011-2016.

Tiesman HM, Konda S, Cimineri L, Castillo DN.

Inj Prev. 2019 Apr 10. pii: injuryprev-2018-043104. doi: 10.1136/injuryprev-2018-043104. [Epub ahead of print]

Comments: Workplace overdose fatalities in the US were the highest in transportation and mining industries; heroin was the single most frequent drug documented in workplace overdose deaths. Deaths were low but increased 24% annually between 2011-2016 implicating that workplaces are impacted by the national opioid overdose epidemic directly.

24) Inhibitory transmission in the bed nucleus of the stria terminalis in male and female mice following morphine withdrawal.

Luster BR, Cogan ES, Schmidt KT, Pati D, Pina MM, Dange K, McElligott ZA.

Addict Biol. 2019 Apr 9. doi: 10.1111/adb.12748. [Epub ahead of print]

Comments: Mouse model comparing response to opioid withdrawal by sex in mice- some differences exist in GABAergic signaling between males and females. 

25) Management of opioid use disorder in the USA: present status and future directions.

Blanco C, Volkow ND.

Lancet. 2019 Apr 27;393(10182):1760-1772. doi: 10.1016/S0140-6736(18)33078-2. Epub 2019 Mar 14. Review.

Comments: Medications for opioid use disorder (OUD) have the potential to significantly improve OUD outcomes, however barriers to care at diagnosis, entry into treatment, and retention in treatment limit their efficacy. 

26) Real-world misuse, abuse, and dependence of abuse-deterrent versus non-abuse-deterrent extended-release morphine in Medicaid non-cancer patients.

Cicero TJ, Mendoza M, Cattaneo M, Dart RC, Mardekian J, Polson M, Roland CL, Schnoll SH, Webster LR, Park PW.

Postgrad Med. 2019 Apr;131(3):225-229. doi: 10.1080/00325481.2019.1585688. Epub 2019 Mar 19.

Comments:

This is an industry funded-trial to bolster the case for novel opioid products designed to try to discourage injection. They found that problematic use increase over time among those receiving either the standard opioid or their “abuse-deterrent” formulation. The analysis is, oddly, limited to confidence intervals, although these do overall suggest a greater increase in poor outcomes among the recipients of standard opioids. 

Of note, the novel formulation was the formulary choice in this clinic system. As this is not a randomized trial, there are likely differences between the two groups of people – e.g. the recipients of standard opioids may have been requesting those because of an intent to inject or insufflate the product.

1) Fighting fire with fire: development of intranasal nalmefene to treat synthetic opioid overdose.

Krieter P, Gyaw S, Crystal R, Skolnick P.

J Pharmacol Exp Ther. 2019 Apr 2. pii: jpet.118.256115. doi: 10.1124/jpet.118.256115. [Epub ahead of print]

Comments: Nalmefene has high affinity and >7h duration of effect. But not at all clear that we need a more potent opioid antagonist, as the high mortality with fentanyl is likely due to rapid progression to cardiac arrest.

2) The Affordable Care Act In The Heart Of The Opioid Crisis: Evidence From West Virginia.

Saloner B, Landis R, Stein BD, Barry CL.

Health Aff (Millwood). 2019 Apr;38(4):633-642. doi: 10.1377/hlthaff.2018.05049.

Comments: The ACA is really one of the best tools we have for the health system to approach this crisis appropriately.

3) News Media Reporting On Medication Treatment For Opioid Use Disorder Amid The Opioid Epidemic.

Kennedy-Hendricks A, Levin J, Stone E, McGinty EE, Gollust SE, Barry CL.

Health Aff (Millwood). 2019 Apr;38(4):643-651. doi: 10.1377/hlthaff.2018.05075.

Comments: Addiction experts aren’t so great at pitching their story.

4) Trends in and correlates of tranquilizer misuse among adults who misuse opioids in the United States, 2002-2014.

Boggis JS, Feder K.

Drug Alcohol Depend. 2019 Feb 16;198:158-161. doi: 10.1016/j.drugalcdep.2019.01.014. [Epub ahead of print]

Comments: 28% of those reporting opioid misuse also report tranquilizer misuse.

5) How prepared are pharmacists to provide over-the-counter naloxone? The role of previous education and new training opportunities.

Lai Joyce Chun K, Olsen A, Taing MW, Clavarino A, Hollingworth S, Dwyer R, Middleton M, Nielsen S.

Res Social Adm Pharm. 2019 Mar 22. pii: S1551-7411(18)30328-0. doi: 10.1016/j.sapharm.2019.03.003. [Epub ahead of print]

Comments: 81% of pharmacists in Australia were willing to be trained in opioid overdose prevention.

6) Evidence-Based Guidelines for EMS Administration of Naloxone.

Williams K, Lang ES, Panchal A, Gasper JJ, Taillac P, Gouda J, Hedges M.

Prehosp Emerg Care. 2019 Mar 29:1-41. doi: 10.1080/10903127.2019.1597955. [Epub ahead of print]

Comments: It makes sense that intranasal is preferred over intramuscular, but why would intravenous be preferred over other routes of administration when it’s challenging and risky to place an IV in emergency settings? This really doesn’t make sense.

7) Opioid agonist treatment and the process of injection drug use initiation.

Mittal ML, Jain S, Sun S, DeBeck K, Milloy MJ, Hayashi K, Hadland SE, Werb D.

Drug Alcohol Depend. 2019 Apr 1;197:354-360. doi: 10.1016/j.drugalcdep.2018.12.018. Epub 2019 Jan 22.

Comments: People who inject drugs but are in opioid agonist treatment were half as likely (0.52) to report recently helping someone else start injecting, compared to those not in treatment. This is a very compelling reason to expand treatment access. 

8) Microfluidic analysis of fentanyl-laced heroin samples by surface-enhanced Raman spectroscopy in a hydrophobic medium.

Salemmilani R, Moskovits M, Meinhart CD.

Analyst. 2019 Mar 28. doi: 10.1039/c9an00168a. [Epub ahead of print]

Comments: This looks like a qualitative way to identify fentanyl in heroin samples. While that is interesting, what is more needed is quantitative assessment / relative concentration.

9) Unintentional drug overdose deaths involving cocaine among middle-aged and older adults in New York City.

Han BH, Tuazon E, Kunins HV, Mantha S, Paone D.

Drug Alcohol Depend. 2019 Mar 14;198:121-125. doi: 10.1016/j.drugalcdep.2019.01.042. [Epub ahead of print]

Comments: “Characteristics of decedents of cocaine-involved overdose overlap with populations with high [cardiovascular disease] burden…”

10)Trends in fentanyl and fentanyl analogue-related overdose deaths – Montgomery County, Ohio, 2015-2017.

Daniulaityte R, Juhascik MP, Strayer KE, Sizemore IE, Zatreh M, Nahhas RW, Harshbarger KE, Antonides HM, Martins SS, Carlson RG.

Drug Alcohol Depend. 2019 Mar 18;198:116-120. doi: 10.1016/j.drugalcdep.2019.01.045. [Epub ahead of print]

Comments: Solid data on the emergency of fentanyl and analogues in Ohio.

11)The association between county-level safety net treatment access and opioid hospitalizations and mortality in New York.

Haley SJ, Maroko AR, Wyka K, Baker MR.

J Subst Abuse Treat. 2019 May;100:52-58. doi: 10.1016/j.jsat.2019.02.004. Epub 2019 Feb 22.

Comments: Geographic proximity to opioid treatment programs/buprenorphine providers is associated with less of an increase in opioid overdose mortality.

12)Medications for Opioid Use Disorder Save Lives.

Leshner AI, Mancher M; Committee on Medication-Assisted Treatment for Opioid Use Disorder, Board on Health Sciences Policy, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine.

Washington (DC): National Academies Press (US); 2019 Mar 20.

Comments: Review of medications.

13)US Emergency Department Visits for Acute Harms From Prescription Opioid Use, 2016-2017.

Lovegrove MC, Dowell D, Geller AI, Goring SK, Rose KO, Weidle NJ, Budnitz DS.

Am J Public Health. 2019 May;109(5):784-791. doi: 10.2105/AJPH.2019.305007. Epub 2019 Mar 21.

Comments: Fascinating data on opioids in 267,020 ED visits. 38.9% were therapeutic use, 30.4% of which were due to gastrointestinal effects (e.g. constipation). 47.6% were due to nonmedical use, 30.0% of which were due to unresponsiveness or cardiorespiratory failure and 35.7% of which were due to altered mental status. 13.5% were due to self-harm. These are very useful data.

14)Opioid Use Disorders in Adolescents-Updates in Assessment and Management.

Yule AM, Lyons RM, Wilens TE.

Curr Pediatr Rep. 2018 Jun;6(2):99-106. doi: 10.1007/s40124-018-0161-z. Epub 2018 Apr 25.

Comments: Buprenorphine use is supported.

15)Comparative Human Factors Evaluation of Two Nasal Naloxone Administration Devices: NARCAN_®Nasal Spray and Naloxone Prefilled Syringe with Nasal Atomizer.

Tippey KG, Yovanoff M, McGrath LS, Sneeringer P.

Pain Ther. 2019 Mar 15. doi: 10.1007/s40122-019-0118-0. [Epub ahead of print]

Comments: No surprise here – the manufactured device is easier to use, particularly for untrained bystanders.

16)Development and evaluation of a standardized research definition for opioid overdose outcomes.

Binswanger IA, Narwaney KJ, Gardner EM, Gabella BA, Calcaterra SL, Glanz JM.

Subst Abus. 2019 Mar 15:1-9. doi: 10.1080/08897077.2018.1546263. [Epub ahead of print]

Comments: An important first step, but there’s a lot left to figure out.

17)At-a-glance – Supervised Injection Services: a community-based response to the opioid crisis in the City of Ottawa, Canada.

DelVillano S, de Groh M, Morrison H, Do MT.

Health Promot Chronic Dis Prev Can. 2019 Mar;39(3):112-115. doi: 10.24095/hpcdp.39.3.03. English, French. 

Comments: As title describes.

18)Intranasal naloxone rapidly occupies brain mu-opioid receptors in human subjects.

Johansson J, Hirvonen J, Lovró Z, Ekblad L, Kaasinen V, Rajasilta O, Helin S, Tuisku J, Sirén S, Pennanen M, Agrawal A, Crystal R, Vainio PJ, Alho H, Scheinin M.

Neuropsychopharmacology. 2019 Mar 13. doi: 10.1038/s41386-019-0368-x. [Epub ahead of print]

Comments: It’s long been thought that there would be other potential benefits to intranasal naloxone. Authors suggest gambling and alcohol use disorder. Others have suggested eating disorders.

19)Managing Opioid Use in Orthopaedic Patients Through Harm Reduction Strategies.

Worley J.

Orthop Nurs. 2019 Mar/Apr;38(2):129-135. doi: 10.1097/NOR.0000000000000524.

Comments: Targeting orthopedic providers.

20)Comparison of the Pharmacokinetic Properties of Naloxone Following the Use of FDA-Approved Intranasal and Intramuscular Devices Versus a Common Improvised Nasal Naloxone Device.

Krieter PA, Chiang CN, Gyaw S, McCann DJ.

J Clin Pharmacol. 2019 Mar 12. doi: 10.1002/jcph.1401. [Epub ahead of print]

Comments: We’ve known this for awhile and nobody has used the improvised device in years, so … 

21)Provider perceptions of system-level opioid prescribing and addiction treatment policies.

Haffajee RL, French CA.

Curr Opin Psychol. 2019 Feb 4;30:65-73. doi: 10.1016/j.copsyc.2019.01.018. [Epub ahead of print] Review.

Comments: Awareness is increasing.

22)Life after opioid-involved overdose: survivor narratives and their implications for ER/ED interventions.

Elliott L, Bennett AS, Wolfson-Stofko B.

Addiction. 2019 Mar 9. doi: 10.1111/add.14608. [Epub ahead of print]

Comments: A really important element of medicine is not to blame patients for their disease. This gets difficult in emergency settings – and not just for substance use disorders. Recurrent visits for unmanaged diabetes, noncompliance with congestive heart failure regimens, etc., can lead to judgmental care and lack of empathy. Nonetheless, the stigma for substance use disorders comes far more readily.

23)Prescription Drug and Alcohol Use Disorders: Safe Prescribing of Opioids.

Shin T.

FP Essent. 2019 Mar;478:11-18.

Comments: The important element to the CDC guidelines described here is that they were not designed for people already on opioids. The guidelines don’t say you should automatically taper people to the levels identified in the CDC guidelines, and increasing data shows that can be hazardous (including a recent FDA statement on the issue)

24)Evaluation and optimization of take-home naloxone in an academic medical center.

Cooler J, Ross CA, Robert S, Linder L, Ruhe AM, Philip A.

Ment Health Clin. 2019 Mar 1;9(2):105-109. doi: 10.9740/mhc.2019.03.105. eCollection 2019 Mar.

Comments: Use of educational videos.

25)From Substance Use Disorders in Life to Autopsy Findings: A Combined Case-Record and Medico-Legal Study.

Brådvik L, Löwenhielm P, Frank A, Berglund M.

Int J Environ Res Public Health. 2019 Mar 5;16(5). pii: E801. doi: 10.3390/ijerph16050801.

Comments: Great idea, but this study lumped suicide with undetermined with accidental overdose. Not sure what to do with such results.

26)Potential uses of naltrexone in emergency department patients with opioid use disorder.

Bradley ES, Liss D, Carriero SP, Brush DE, Babu K.

Clin Toxicol (Phila). 2019 Mar 4:1-7. doi: 10.1080/15563650.2019.1583342. [Epub ahead of print]

Comments: In the context of an overdose after prolonged abstinence, this might be reasonable. Again, while important to have as an option, the applications of naltrexone for opioid use disorder are limited.

27)Successful treatment with slow-release oral morphine following afentanyl-related overdose: A case report.

Prinsloo G, Ahamad K, Socías ME MD, MSc.

Subst Abus. 2019 Mar 4:1-3. doi: 10.1080/08897077.2019.1576086. [Epub ahead of print]

Comments: There are many options for treating opioid use disorder, beyond the three options available in the U.S.

28)An evaluation of Take Home Naloxone program implementation in British Columbian correctional facilities.

Pearce LA, Mathany L, Rothon D, Kuo M, Buxton JA.

Int J Prison Health. 2019 Mar 11;15(1):46-57. doi: 10.1108/IJPH-12-2017-0058. Epub 2019 Feb 20.

Comments: Focus groups.

29)Scotland’s National Naloxone Programme.

Bird SM, McAuley A.

Lancet. 2019 Jan 26;393(10169):316-318. doi: 10.1016/S0140-6736(18)33065-4. No abstract available. 

Comments: Review of some of the estimates produced in Scotland.

30)Trends and correlates of perceived access to heroin among young adults in the United States, 2002-2016.

Salas-Wright CP, Oh S, Vaughn MG, Muroff J, Amodeo M, Delva J.

Drug Alcohol Depend. 2018 Dec 1;193:169-176. doi: 10.1016/j.drugalcdep.2018.09.009. Epub 2018 Oct 18.

Comments: “probably impossible” to obtain heroin.

31)Characterizing fentanyl-related overdoses and implications for overdose response: Findings from a rapid ethnographic study in Vancouver, Canada.

Mayer S, Boyd J, Collins A, Kennedy MC, Fairbairn N, McNeil R.

Drug Alcohol Depend. 2018 Dec 1;193:69-74. doi: 10.1016/j.drugalcdep.2018.09.006. Epub 2018 Oct 12.

Comments: Rapid onset, chest rigidity, etc.

32)Utilization of opioid agonist therapy among incarcerated persons with opioid use disorder in Vancouver, Canada.

Bozinoff N, DeBeck K, Milloy MJ, Nosova E, Fairbairn N, Wood E, Hayashi K.

Drug Alcohol Depend. 2018 Dec 1;193:42-47. doi: 10.1016/j.drugalcdep.2018.09.003. Epub 2018 Oct 6.

Comments: It reduces illicit use and overdose.

33)The Impact of Patient Characteristics and Postoperative Opioid Exposure on Prolonged Postoperative Opioid Use: An Integrative Review.

Lanzillotta JA, Clark A, Starbuck E, Kean EB, Kalarchian M.

Pain Manag Nurs. 2018 Oct;19(5):535-548. doi: 10.1016/j.pmn.2018.07.003. Epub 2018 Aug 29. Review.

Comments: Unclear how much the actual act of prescribing for prolonged periods has on post-operative opioid use, as there are many other predictors of prolonged post-operative use that may be outside of the surgeon’s control.

34)Addressing the Fentanyl Analogue Epidemic by Multiplex UHPLC-MS/MS Analysis of Whole Blood.

Bergh MS, Bogen IL, Wilson SR, Øiestad ÅML.

Ther Drug Monit. 2018 Dec;40(6):738-748. doi: 10.1097/FTD.0000000000000564.

Comments: Identifying fentanyl analogues in blood.

35)Young Man After Overdose.

Lebin JA, Wu EH, McCoy AM, Gross JA.

J Emerg Med. 2018 Oct;55(4):e109-e110. doi: 10.1016/j.jemermed.2018.07.002. Epub 2018 Aug 16. No abstract available. 

Comments: Undigested pasta mistaken for drug packing materials.

36)Reducing the opioid overdose death toll in North America.

Hall WD, Farrell M.

PLoS Med. 2018 Jul 31;15(7):e1002626. doi: 10.1371/journal.pmed.1002626. eCollection 2018 Jul.

Comments: Review of strategies including medications, naloxone, and supervised injection sites.

37)Reframing the Prevention Strategies of the Opioid Crisis: Focusing on Prescription Opioids, Fentanyl, and Heroin Epidemic.

Manchikanti L, Sanapati J, Benyamin RM, Atluri S, Kaye AD, Hirsch JA.

Pain Physician. 2018 Jul;21(4):309-326.

Comments: A review of the crisis and education, increased access to non-opioid pain management options, and use of medications for opioid use disorder.

38)Unit-Dose Packaging and Unintentional Buprenorphine-Naloxone Exposures.

Wang GS, Severtson SG, Bau GE, Dart RC, Green JL.

Pediatrics. 2018 Jun;141(6). pii: e20174232. doi: 10.1542/peds.2017-4232. Epub 2018 May 3.

Comments: Appears to have reduced pediatric exposures.

39)Scene Safety and Force Protection in the Era of Ultra-Potent Opioids.

Lynch MJ, Suyama J, Guyette FX.

Prehosp Emerg Care. 2018 Mar-Apr;22(2):157-162. doi: 10.1080/10903127.2017.1367446. Epub 2017 Sep 28.

Comments: As the article describes, this is media craziness. The “overdose” events from touching fentanyl are consistent with panic attacks, not opioid toxicity. If transdermal exposure to fentanyl was a concern, there would be no way to distribute it to people who use drugs. Some serious education is needed.

40)Death From Opioid Overdose After Deep Brain Stimulation: A Case Report.

Zhang C, Huang Y, Zheng F, Zeljic K, Pan J, Sun B.

Biol Psychiatry. 2018 Jan 1;83(1):e9-e10. doi: 10.1016/j.biopsych.2017.07.018. Epub 2017 Aug 1. No abstract available. 

Comments: This is a death during a clinical trial of deep brain stimulation for treatment of opioid use disorder. A patient relapsed and died from heroin overdose.

41)Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts.

Rose ME.

Pain Med. 2018 Apr 1;19(4):793-807. doi: 10.1093/pm/pnx048. Review.

Comments: This is a more complex issue than this article makes it out to be.

42)Pharmacist-led health-system approaches to reduce opioid overdose and death.

Saldaña SN, Weaver N, Stanford B.

J Am Pharm Assoc (2003). 2017 Mar – Apr;57(2S):S8-S9. doi: 10.1016/j.japh.2016.09.005. Epub 2016 Nov 16. No abstract available. 

Comments: Encouraging.

43)Bringing naloxone to ground zero: Huntington, West Virginia.

Babcock C, Rockich-Winston N, Booth C.

J Am Pharm Assoc (2003). 2017 Mar – Apr;57(2S):S9-S10. doi: 10.1016/j.japh.2016.09.006. Epub 2016 Nov 9. No abstract available. 

Comments: West Virginia. Oh West Virginia. If there were a place more in need…

1) Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2011-2016.

Hedegaard H, Bastian BA, Trinidad JP, Spencer M, Warner M.

Natl Vital Stat Rep. 2018 Dec;67(9):1-14.

Comment: Nice summary of the data demonstrating the shift from prescribed opioids to heroin to fentanyl, with rising methamphetamine and persistent cocaine presence.

2) Enhanced Intranasal Absorption of Naltrexone by Dodecyl Maltopyranoside: Implications for the Treatment of Opioid Overdose.

Krieter P, Gyaw S, Chiang CN, Crystal R, Skolnick P.

J Clin Pharmacol. 2019 Jan 30. doi: 10.1002/jcph.1384. [Epub ahead of print]

Comment: Fascinating that the half-life of naltrexone is only 2.2 hours when administered intranasally … would be great to see that for managing alcohol use.

3) Emergency department physicians’ and pharmacists’ perspectives on take-home naloxone.

Holland TJ, Penm J, Dinh M, Aran S, Chaar B.

Drug Alcohol Rev. 2019 Jan 29. doi: 10.1111/dar.12894. [Epub ahead of print]

Comment: Qualitative assessment of opinions.

4) Take-home naloxone: a life saver in opioid overdose.

The Lancet.

Lancet. 2019 Jan 26;393(10169):296. doi: 10.1016/S0140-6736(19)30153-9. No abstract available. 

Comment: Editorial supporting take-home naloxone.

5) Feasibility and Acceptability of a Checklist and Learning Collaborative to Promote Quality and Safety in the Perinatal Care of Women with Opioid Use Disorders.

Goodman D, Zagaria AB, Flanagan V, Deselle FS, Hitchings AR, Maloney R, Small TA, Vergo AV, Bruce ML.

J Midwifery Womens Health. 2019 Jan;64(1):104-111. doi: 10.1111/jmwh.12943.

Comment: Some good changes – more naloxone provided, more counseling regarding breastfeeding, and more nicotine-replacement therapy initiated.

6) Correlates of seeking emergency medical help in the event of an overdose in British Columbia, Canada: Findings from the Take Home Naloxone program.

Karamouzian M, Kuo M, Crabtree A, Buxton JA.

Int J Drug Policy. 2019 Jan 25. pii: S0955-3959(19)30014-3. doi: 10.1016/j.drugpo.2019.01.006. [Epub ahead of print]

Comment: Great analysis of naloxone programmatic data. 55.7% of lay naloxone administrations were followed by a call for emergency medical services, again demonstrating that we do not have data showing a reduction in calling 911 when naloxone is administered. 

7) Seizures in tramadol overdoses reported in the ToxIC registry: predisposing factors and the role of naloxone.

Murray BP, Carpenter JE, Dunkley CA, Moran TP, Alfaifi M, Alsukaiti WS, Kazzi Z.

Clin Toxicol (Phila). 2019 Jan 24:1-5. doi: 10.1080/15563650.2018.1547826. [Epub ahead of print]

Comment: Tramadol is a weird drug. This analysis found that when it caused an opioid-like overdose, seizures were less likely, and that naloxone use was not associate with tramadol seizures.

8) “You Never Know What You’re Getting”: Opioid Users’ Perceptions of Fentanyl in Southwest Pennsylvania.

McLean K, Monnat SM, Rigg K, Sterner GE 3rd, Verdery A.

Subst Use Misuse. 2019 Jan 24:1-12. doi: 10.1080/10826084.2018.1552303. [Epub ahead of print]

Comment: Fentanyl use patterns are evolving – it seems to be here to stay this time.

9) Development of a Cascade of Care for responding to the opioid epidemic.

Williams AR, Nunes EV, Bisaga A, Levin FR, Olfson M.

Am J Drug Alcohol Abuse. 2019 Jan 24:1-10. doi: 10.1080/00952990.2018.1546862. [Epub ahead of print]

Comment: Nice to see this development.

10) Blockade of the human ether a-go-go related gene (hERG) potassium channel by fentanyl.

Tschirhart JN, Li W, Guo J, Zhang S.

Mol Pharmacol. 2019 Jan 21. pii: mol.118.114751. doi: 10.1124/mol.118.114751. [Epub ahead of print]

Comment: First, you gotta love the naming culture for these genes. Now the human ether a-go-go gene potassium channel effects could prolong the QT interval, which could result in ventricular arrhythmias and, ultimately, cardiac arrest. Is this playing a role in fentanyl-related deaths? Not sure. 

11) Changing risk and presentation of overdose associated with consumption of street drugs at a supervised injection site in Vancouver, Canada.

Notta D, Black B, Chu T, Joe R, Lysyshyn M.

Drug Alcohol Depend. 2019 Jan 15;196:46-50. doi: 10.1016/j.drugalcdep.2018.12.016. [Epub ahead of print]

Comment: Great use of these data. As fentanyl entered the heroin supply in Vancouver, the rate of “heroin” overdoses rose 4.8 fold. This is interesting, as fentanyl knowingly used at the Sydney injection facility was 4 times more likely than heroin to result in overdose – honestly I would have expected an even more substantial increase in “heroin” overdose events in the context of heroin contaminated with fentanyl. Notably, there was a several fold increase in overdose events for all drugs being injected in Vancouver over the period studied. They also saw an increase in rigidity (a potential complication of fentanyl) from 10.4% of “heroin” overdoses in 2010/11 to 18.9% in 2017.

12) High Prevalence of Self-Reported Exposure to Adulterated Drugs Among People Who Experienced an Opioid Overdose in Canada: A Cohort Study.

Prangnell A, Fairgrieve C, Nosova E, DeBeck K, Milloy MJ, Hayashi K.

Subst Use Misuse. 2019 Jan 20:1-6. doi: 10.1080/10826084.2018.1555257. [Epub ahead of print]

Comment: Two-thirds of people who overdosed believed their drugs had been adulterated. While the current drug supply is very dynamic, I suspect this finding would hold for overdoses in areas not heavily affected by fentanyl; that is, this is a common perception among people who have overdosed, explained by the actor-observer bias.

13) Associations between implementation of Project Lazarus and opioid analgesic dispensing and buprenorphine utilization in North Carolina, 2009-2014.

Alexandridis AA, Dasgupta N, McCort AD, Ringwalt CL, Rosamond WD, Chelminski PR, Marshall SW.

Inj Epidemiol. 2019 Jan 21;6(1):2. doi: 10.1186/s40621-018-0179-2.

Comment: Limited effects.

14) What should clinicians do as fentanyl replaces heroin?

Bisaga A.

Addiction. 2019 Jan 20. doi: 10.1111/add.14522. [Epub ahead of print] No abstract available. 

Comment: Be creative, be innovative, don’t be shy.

15) Twenty years of the methadone treatment protocol in Ireland: reflections on the role of general practice.

Delargy I, Crowley D, Van Hout MC.

Harm Reduct J. 2019 Jan 17;16(1):5. doi: 10.1186/s12954-018-0272-4. Review.

Comment: 20 years and 10,000 patients later.

16) Overdose Deaths Involving Fentanyl and Fentanyl Analogs – New York City, 2000-2017.

Colon-Berezin C, Nolan ML, Blachman-Forshay J, Paone D.

MMWR Morb Mortal Wkly Rep. 2019 Jan 18;68(2):37-40. doi: 10.15585/mmwr.mm6802a3.

Comment: It’s always tricky to use toxicology results in overdose mortality surveillance because there are many substances found on toxicology which may not have contributed to the death (e.g. something the patient takes medically that was at a low or appropriately therapeutic level and doesn’t interact with likely causal drugs, or something that is a by-product of decomposition). In this circumstance, however, it made sense.

17) Changes in Buprenorphine-Naloxone and Opioid Pain Reliever Prescriptions After the Affordable Care Act Medicaid Expansion.

Saloner B, Levin J, Chang HY, Jones C, Alexander GC.

JAMA Netw Open. 2018 Aug 3;1(4):e181588. doi: 10.1001/jamanetworkopen.2018.1588.

Comment: Buprenorphine treatment increased and opioid pain reliever prescriptions did not. That makes solid sense.

18) Pharmacokinetics of a novel, approved, 1.4 mg intranasal naloxone formulation for reversal of opioid overdose- a randomised controlled trial.

Skulberg AK, Åsberg A, Khiabani HZ, Røstad H, Tylleskar I, Dale O.

Addiction. 2019 Jan 14. doi: 10.1111/add.14552. [Epub ahead of print]

Comment: Intranasal 1.4mg was ~50% bioavailable, which is half as good as intramuscular, and the pharmacokinetics were similar to 0.8mg intramuscular, although the time to peak effect was about 5 minutes slower.

19) Overdose mortality rates in Croatia and factors associated with self-reported drug overdose among persons who inject drugs in three Croatian cities.

Handanagic S, Bozicevic I, Sekerija M, Rutherford GW, Begovac J.

Int J Drug Policy. 2019 Jan 11;64:95-102. doi: 10.1016/j.drugpo.2018.11.017. [Epub ahead of print]

Comment: Polydrug injection.

20) Increased Presence of Fentanyl in Cocaine-Involved Fatal Overdoses: Implications for Prevention.

Nolan ML, Shamasunder S, Colon-Berezin C, Kunins HV, Paone D.

J Urban Health. 2019 Jan 11. doi: 10.1007/s11524-018-00343-z. [Epub ahead of print]

Comment: These data suggest that fentanyl is responsible for a good amount of the increase in cocaine deaths in NYC. Was that intentionally consumed or contaminating cocaine? Given that the demographics of cocaine related deaths have historically been fairly distinct from opioid deaths in NYC, I wonder if comparing demographics would help to elucidate which is the case.

21) Non-Medical Use of Novel Synthetic Opioids: A New Challenge to Public Health.

Lovrecic B, Lovrecic M, Gabrovec B, Carli M, Pacini M, Maremmani AGI, Maremmani I.

Int J Environ Res Public Health. 2019 Jan 9;16(2). pii: E177. doi: 10.3390/ijerph16020177. Review.

Comment: Yup, we’re in a mess.

22) Primary Care for Persons Who Inject Drugs.

Visconti AJ, Sell J, Greenblatt AD.

Am Fam Physician. 2019 Jan 15;99(2):109-116.

Comment: Love this topic, which drove me into medicine in the first place. Excellent to see physicians, scientists, and academic publications take on this need.

23) Reversal of Pediatric Opioid Toxicity with Take-Home Naloxone: a Case Report.

Lebin JA, Chen BC, Valento MJ.

J Med Toxicol. 2019 Jan 10. doi: 10.1007/s13181-018-0695-z. [Epub ahead of print]

Comment: This may be the first journal report of pediatric reversal with take-home naloxone, but it’s not the first story … it’s been happening in the community for decades.

24) Drug Overdose Deaths Among Women Aged 30-64 Years – United States, 1999-2017.

VanHouten JP, Rudd RA, Ballesteros MF, Mack KA.

MMWR Morb Mortal Wkly Rep. 2019 Jan 11;68(1):1-5. doi: 10.15585/mmwr.mm6801a1.

Comment: Increased overdose mortality across the board among women.

25) Increasing Naloxone Access and Use to Prevent Opioid Overdose Death and Disability.

White ND.

Am J Lifestyle Med. 2018 Oct 20;13(1):33-35. doi: 10.1177/1559827618803874. eCollection 2019 Jan-Feb. Review.

Comment: Legislation and pronouncements have only done so much.

26) Opioid overdose detection using smartphones.

Nandakumar R, Gollakota S, Sunshine JE.

Sci Transl Med. 2019 Jan 9;11(474). pii: eaau8914. doi: 10.1126/scitranslmed.aau8914.

Comment: This is a fascinating topic. We can saturate the world with naloxone, but it still won’t prevent overdose events from becoming fatal among people who are isolated from others (e.g. marginally housed, living in hotel rooms). In San Francisco, about one-third of deaths occurred in single-room occupancy hotel units – a number that is unlikely to be significantly affected by responder interventions. To have non-invasive tools that can detect concerning vital signs could be hugely beneficial if implemented well.

27) Intravenous Misuse of Methadone, Buprenorphine and Buprenorphine-Naloxone in Patients Under Opioid Maintenance Treatment: A Cross-Sectional Multicentre Study.

Lugoboni F, Zamboni L, Cibin M, Tamburin S; Gruppo InterSERT di Collaborazione Scientifica (GICS).

Eur Addict Res. 2019;25(1):10-19. doi: 10.1159/000496112. Epub 2019 Jan 9.

Comment: People who inject drugs frequently try to inject other drugs.

28) Predictive Factors of Treatment Outcomes for Hospital Care in Children with Acute Methadone Poisoning.

Atighi Y, Eizadi-Mood N, Mansourian M, Zamani A, Saffaei A, Sabzghabaee AM.

J Res Pharm Pract. 2018 Oct-Dec;7(4):200-204. doi: 10.4103/jrpp.JRPP_16_141.

Comment: Accidental opioid poisoning amoung children at home is always tragic. While our first effort has to be avoiding such events, an earlier manuscript today showed that having naloxone at home can help mitigate when they do occur.

29) Perspectives on rapid fentanyl test strips as a harm reduction practice among young adults who use drugs: a qualitative study.

Goldman JE, Waye KM, Periera KA, Krieger MS, Yedinak JL, Marshall BDL.

Harm Reduct J. 2019 Jan 8;16(1):3. doi: 10.1186/s12954-018-0276-0.

Comment: People use them and often implement some overdose prevention or management strategies when results are positive.

30) Legally Lethal Kratom: A Herbal Supplement with Overdose Potential.

Palasamudram Shekar S, Rojas EE, D’Angelo CC, Gillenwater SR, Martinez Galvis NP.

J Psychoactive Drugs. 2019 Jan 8:1-3. doi: 10.1080/02791072.2018.1562591. [Epub ahead of print]

Comment: Kratom’s another “weird” drug with some opioid properties. Took 10 days to recover – wow!

31) The importance of buprenorphine research in the opioid crisis.

Pendergrass SA, Crist RC, Jones LK, Hoch JR, Berrettini WH.

Mol Psychiatry. 2019 Jan 7. doi: 10.1038/s41380-018-0329-5. [Epub ahead of print]

Comment: Yep. Although I’d say implementation is more important.

32) Implementation of a collaborative model for opioid overdose prevention on campus.

Hill LG, Holleran Steiker LK, Mazin L, Kinzly ML.

J Am Coll Health. 2019 Jan 7:1-4. doi: 10.1080/07448481.2018.1549049. [Epub ahead of print]

Comment: Further expansion of naloxone.

33) Divergence In Recent Trends In Deaths From Intentional And Unintentional Poisoning.

Hempstead K, Phillips J.

Health Aff (Millwood). 2019 Jan;38(1):29-35. doi: 10.1377/hlthaff.2018.05186.

Comment: Notwithstanding a huge increase in unintentional opioid deaths and a shift in the causal opioids, poisoning suicide deaths have not changed during this period, again suggesting that suicide and unintentional overdose are distinct processes.

34) Medication Treatment For Opioid Use Disorders In Substance Use Treatment Facilities.

Mojtabai R, Mauro C, Wall MM, Barry CL, Olfson M.

Health Aff (Millwood). 2019 Jan;38(1):14-23. doi: 10.1377/hlthaff.2018.05162.

Comment: Uh … yeah. Please.

35) Changes in Pharmacists’ Perceptions After a Training in Opioid Misuse and Accidental Overdose Prevention.

Eukel HN, Skoy E, Werremeyer A, Burck S, Strand M.

J Contin Educ Health Prof. 2019 Jan 3. doi: 10.1097/CEH.0000000000000233. [Epub ahead of print]

Comment: More training pharmacists.

36) Commentary on Stam et al. (2019): Drugs, death and statistics.

Darke S.

Addiction. 2019 Jan 6. doi: 10.1111/add.14520. [Epub ahead of print] No abstract available. 

Comment: As usual, the author has insightful comments on overdose research and surveillance. Heroin deaths are often miscoded as morphine (or codeine?) deaths and stimulant deaths are often missed because the immediate medical cause of a cerebral hemorrhage or cardiac arrest is sufficient for the cause of death field.

37) On-site identification of psychoactive drugs by portable Raman spectroscopy during drug-checking service in electronic music events.

Gerace E, Seganti F, Luciano C, Lombardo T, Di Corcia D, Teifel H, Vincenti M, Salomone A.

Drug Alcohol Rev. 2019 Jan;38(1):50-56. doi: 10.1111/dar.12887. Epub 2019 Jan 6.

Comment: Portable drug detection is very exciting.

38) An age-based analysis of nonmedical prescription opioid use among people who use illegal drugs in Vancouver, Canada.

Cheng T, Small W, Dong H, Nosova E, Hayashi K, DeBeck K.

Subst Abuse Treat Prev Policy. 2018 Nov 27;13(1):41. doi: 10.1186/s13011-018-0180-3.

Comment: No age differences.

39) Utilizing Buprenorphine in the Emergency Department after Overdose.

Johns SE, Bowman M, Moeller FG.

Trends Pharmacol Sci. 2018 Dec;39(12):998-1000. doi: 10.1016/j.tips.2018.10.002. Review.

Comment: Good idea, when patients want it.

40) Pharmacological Research as a Key Component in Mitigating the Opioid Overdose Crisis.

Baumann MH, Kopajtic TA, Madras BK.

Trends Pharmacol Sci. 2018 Dec;39(12):995-998. doi: 10.1016/j.tips.2018.09.006. Review.

Comment: Review with focus on what new medications could provide.

41) At-a-glance – What can paramedic data tell us about the opioid crisis in Canada?

Do MT, Furlong G, Rietschlin M, Leyenaar M, Nolan M, Poirier P, Field B, Thompson W.

Health Promot Chronic Dis Prev Can. 2018 Sep;38(9):339-342. doi: 10.24095/hpcdp.38.9.06. English, French. 

Comment: It’s tricky to track opioid overdose with paramedic calls for several reasons (e.g. diagnosis codes are preliminary in this triage service, using naloxone administration as a marker misses a lot of events that aren’t “typical” heroin overdoses, the impact of naloxone programming is unclear, etc). Nonetheless, if you can access the data in a useful way, exploring this data source is irresistible.

42) Review of Case Narratives from Fatal Overdoses Associated with Injectable Naltrexone for Opioid Dependence.

Saucier R, Wolfe D, Dasgupta N.

Drug Saf. 2018 Oct;41(10):981-988. doi: 10.1007/s40264-018-0653-3. Erratum in: Drug Saf. 2018 May 24. 

Comment: It is concerning that in overdose deaths the manufacturer placed the blame on opioid use disorder and did not consider elevated risk for overdose after treatment discontinuation. I would agree that a registry is in order.