Wow. 64 this month. Lots going on. Of note, several articles on pharmacists and on extended-release naltrexone. Plus the usual naloxone, buprenorphine, methadone papers.
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.
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.
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.
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.
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.
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.
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%.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.”
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.