In March 2015, SAMHSA updated Opioid Treatment Program guidelines, including new guidance on discussing overdose:

“Overdose prevention, including prescribing or dispensing naloxone, is an essential complement to both detoxification services as well as medically supervised withdrawal. Patients should be advised of the risks of relapse following detoxification and offered a relapse prevention program that includes counseling, naloxone and opioid antagonist therapy.”

We provide some sample documents that may facilitate the process.

Example: State rules and regulations for licensure requires universal Overdose Prevention and Education (Section 46.0, p 140)

(see Section 46.0 Overdose Prevention and Education on pg. 140)

Sample state guidance to substance use disorder treatment providers

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) 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 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) Infant and Youth Mortality Trends by Race/Ethnicity and Cause of Death in the United States.

Khan SQ, Berrington de Gonzalez A, Best AF, Chen Y, Haozous EA, Rodriquez EJ, Spillane S, Thomas DA, Withrow D, Freedman ND, Shiels MS.

JAMA Pediatr. 2018 Oct 1:e183317. doi: 10.1001/jamapediatrics.2018.3317. [Epub ahead of print]

Comment: U.S. is not looking so good due to drug overdose deaths.

2) 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:  This study compares young to older cohorts of people in Vancouver who use prescription opioids non-medically, although the two cohorts may have some qualitative differences that make them challenging to compare. 

3) Evaluating opioid overdose using the National Violent Death Reporting System, 2016.

Clinton HA, Hunter AA, Logan SB, Lapidus GD.

Drug Alcohol Depend. 2018 Nov 15;194:371-376. doi: 10.1016/j.drugalcdep.2018.11.002. [Epub ahead of print]

Comment:  People who die of prescription opioid overdose tend to be relatively older and include more women, compared to deaths from illicit opioid toxicity.

4) How competent are people who use opioids at responding to overdoses? Qualitative analyses of actions and decisions taken by lay first-responders during overdose emergencies.

Neale J, Brown C, Campbell ANC, Jones JD, Metz VE, Strang J, Comer SD.

Addiction. 2018 Nov 26. doi: 10.1111/add.14510. [Epub ahead of print]

Comment:  Very.

5) Development and evaluation of a pilot overdose education and naloxone distribution program for hospitalized general medical patients.

Jakubowski A, Pappas A, Isaacsohn L, Castillo F, Masyukova M, Silvera R, Holaday L, Rausch E, Farooq S, Veltri KT, Cunningham CO, Bachhuber MA.

Subst Abus. 2018 Nov 26:1-5. doi: 10.1080/08897077.2018.1518836. [Epub ahead of print]

Comment:  Providing naloxone in inpatient settings works well and reaches many individuals who don’t access naloxone from distribution programs.

6) Generational trends and patterns in readmission within a statewide cohort of clients receiving heroin use disorder treatment in Maryland, 2007-2013.

Rezai-Zadeh KP, Engstrom RN, Sharma A, Chen Y, Chu J, Cox RP, Lee MT.

J Subst Abuse Treat. 2019 Jan;96:82-91. doi: 10.1016/j.jsat.2018.10.010. Epub 2018 Nov 2.

Comment:  Autors suggest that millennials are frequently readmitted for treatment of heroin use disorder and generally resistant to treatment.

7) Fentanyl exposure among patients seeking opioid treatment.

Ochalek TA, Parker MA, Higgins ST, Sigmon SC.

J Subst Abuse Treat. 2019 Jan;96:23-25. doi: 10.1016/j.jsat.2018.10.007. Epub 2018 Oct 17.

Comment:  People coming in for opioid use disorder treatment are frequently positive for both heroin and fentanyl.

8) Using Network and Spatial Data to Better Target Overdose Prevention Strategies in Rural Appalachia.

Rudolph AE, Young AM, Havens JR.

J Urban Health. 2018 Nov 21. doi: 10.1007/s11524-018-00328-y. [Epub ahead of print]

Comment:  Great to see network data applied to overdose in a manner that moves both fields forward. 

9) Reversal and prevention of the respiratory-depressant effects of heroin by the novel µ opioid receptor antagonist methocinnamox in rhesus monkeys.

Gerak LR, Maguire DR, Woods JH, Husbands SM, Disney A, France CP.

J Pharmacol Exp Ther. 2018 Nov 21. pii: jpet.118.253286. doi: 10.1124/jpet.118.253286. [Epub ahead of print]

Comment:  Opioid antagonist that lasts many days – I’m not clear that this is an improvement over the short-term antagonism of naloxone. Would it be ethical to administer a long-term opioid antagonist in an emergency situation without the consent of a patient? Would it be safe given possible subsequent drug use behaviors?

10) 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.

Comment:  Lots of work going on in this domain.

11) 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.

Comment:  Still not sure we need new opioid antagonists.

12) Prevalent misconceptions about opioid use disorders in the United States produce failed policy and public health responses.

Heimer R, Hawk K, Vermund SH.

Clin Infect Dis. 2018 Nov 17. doi: 10.1093/cid/ciy977. [Epub ahead of print]

Comment:  A nice review of recent history.

13) Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia.

Stam NC, Gerostamoulos D, Smith K, Pilgrim JL, Drummer OH.

Clin Toxicol (Phila). 2018 Nov 17:1-6. doi: 10.1080/15563650.2018.1529319. [Epub ahead of print]

Comment:  Authors correctly note that most fatal overdose events are unwitnessed and that the availability of naloxone would only be expected to improve the outcome of events that are witnessed (17% of cases in this study – and about half of those involved a witness who may not have been able to effectively respond). This is consistent with prior modeling of naloxone and the anticipated modest effect on mortality.

14) Assessing pharmacy student experience with, knowledge of and attitudes towards harm reduction: illuminating barriers to pharmacist-led harm reduction.

Mahon LR, Hawthorne AN, Lee J, Blue H, Palombi L.

Harm Reduct J. 2018 Nov 16;15(1):57. doi: 10.1186/s12954-018-0262-6.

Comment:  Survey of incoming first-year pharmacy students shows excellent opportunities for education.

15) The Emergency Department as an Opportunity for Naloxone Distribution.

Gunn AH, Smothers ZPW, Schramm-Sapyta N, Freiermuth CE, MacEachern M, Muzyk AJ.

West J Emerg Med. 2018 Nov;19(6):1036-1042. doi: 10.5811/westjem.2018.8.38829. Epub 2018 Sep 10. Review.

Comment:  Systematic review of 5 studies of naloxone distribution from EDs showing that uptake is very challenging.

16) [The American opioid overdose crisis: A threat for France?]

Vodovar D, Langrand J, Tournier N, Mégarbane B.

Rev Med Interne. 2018 Nov 11. pii: S0248-8663(18)31164-0. doi: 10.1016/j.revmed.2018.10.389. [Epub ahead of print] French. 

Comment:  Situation “worrying”, but nothing like the U.S. crisis.

17) A Public Health Strategy for the Opioid Crisis.

Saloner B, McGinty EE, Beletsky L, Bluthenthal R, Beyrer C, Botticelli M, Sherman SG.

Public Health Rep. 2018 Nov/Dec;133(1_suppl):24S-34S. doi: 10.1177/0033354918793627.

Comment:  Nice review of strategies. 

18) Blocking drug activation as a therapeutic strategy to attenuate acute toxicity and physiological effects of heroin.

Zhang T, Zheng X, Kim K, Zheng F, Zhan CG.

Sci Rep. 2018 Nov 13;8(1):16762. doi: 10.1038/s41598-018-35196-8.

Comment:  Using antagonists for heroin use disorder treatment. Always risky, sometimes has a benefit.

19) Provision of Naloxone Without a Prescription by California Pharmacists 2 Years After Legislation Implementation.

Puzantian T, Gasper JJ.

JAMA. 2018 Nov 13;320(18):1933-1934. doi: 10.1001/jama.2018.12291. No abstract available. 

Comment:  Limited.

20) Historical Review: Opiate Addiction and Opioid Receptors.

Wang S.

Cell Transplant. 2018 Nov 13:963689718811060. doi: 10.1177/0963689718811060. [Epub ahead of print]

Comment:  Neurobiology of opioid use disorder.

21) Postmortem Toxicology of New Synthetic Opioids.

Concheiro M, Chesser R, Pardi J, Cooper G.

Front Pharmacol. 2018 Oct 26;9:1210. doi: 10.3389/fphar.2018.01210. eCollection 2018. Review.

Comment:  Determining which drugs are responsible for death is always challenging, particularly as new symthetic drugs enter the market.

22) Opioid Overdose Hospitalizations among Medicare-Disability Beneficiaries.

Peters JL, Durand WM, Monteiro KA, Dumenco L, George P.

J Am Board Fam Med. 2018 Nov-Dec;31(6):881-896. doi: 10.3122/jabfm.2018.06.180152.

Comment: The link between the U.S. shift from welfare to disability for support of those in need and the opioid crisis is well established. In this study, disability recipients accounted for 11.7% of hospitalizations for opioid overdose. Of note, most opioid overdose events don’t result in hospitalization, so this proportion may be more representative of complicated overdose events rather than overdose events outright.

23) Vaccination reduces fentanyl distribution to the brain and fentanyl-induced toxicity in mice and rats: a potential role for a prophylactic vaccine against fentanyl-induced overdose.

Raleigh MD, Baruffaldi F, Peterson SJ, Le Naour M, Harmon TM, Vigliaturo JR, Pentel PR, Pravetoni M.

J Pharmacol Exp Ther. 2018 Nov 8. pii: jpet.118.253674. doi: 10.1124/jpet.118.253674. [Epub ahead of print]

Comment: A fentanyl vaccine. Interesting.

24) Routine opioid outcome monitoring in community pharmacy: Pilot implementation study protocol.

Nielsen S, Kowalski M, Wood P, Larney S, Bruno R, Shanahan M, Lenton S, Dietze P, Green T, Murnion B, Ritter A.

Res Social Adm Pharm. 2018 Oct 22. pii: S1551-7411(18)30285-7. doi: 10.1016/j.sapharm.2018.10.024. [Epub ahead of print]

Comment: Study protocol for intervention for pharmacists working on overdose and naloxone.

25) Non-fatal opioid-related overdoses among adolescents in Massachusetts 2012-2014.

Chatterjee A, Larochelle MR, Xuan Z, Wang N, Bernson D, Silverstein M, Hadland SE, Land T, Samet JH, Walley AY, Bagley SM.

Drug Alcohol Depend. 2018 Oct 25;194:28-31. doi: 10.1016/j.drugalcdep.2018.09.020. [Epub ahead of print]

Comment: Great study from a fantastic dataset proving critical to developing comprehensive public health responses to the overdose crisis. Adolescents were less likely than adults to be prescribed opioids or to receive medications for opioid use disorder before or after the overdose event – only 8% of adolescents got medications after the overdose, compared to 29% of adults. Interestingly, the majority of adolescent overdose events were among females.

26) 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.

Comment: Many adolescents think it impossible to obtain heroin – that proportion rose from 31% in 2002 to 41% in 2016.

27) Case Report: 28-year-old Woman With Opioid Use Disorder Delivers Healthy Baby While in Custody: Addressing Forced Detox.

Gray J, Saia K, Walley AY.

J Addict Med. 2018 Oct 30. doi: 10.1097/ADM.0000000000000468. [Epub ahead of print]

Comment: Medications for opioid use disorder are critical, even more so for the vulnerable populations often inappropriately denied such access – including incarcerated persons and pregnant women.

28) Pharmacologic Treatment of Opioid Use Disorder: a Review of Pharmacotherapy, Adjuncts, and Toxicity.

Toce MS, Chai PR, Burns MM, Boyer EW.

J Med Toxicol. 2018 Dec;14(4):306-322. doi: 10.1007/s13181-018-0685-1. Epub 2018 Oct 30. Review.

Comment: Review of medications used in opioid use disorder, including treatment agents (buprenorphine, methadone) and medications to manage symptoms / alternative therapies such as clonidine, kratom, loperamide, lofexidine, akuamma seeds, kava, and gabapentin.

29) Risk factors for discontinuation of buprenorphine treatment for opioid use disorders in a multi-state sample of Medicaid enrollees.

Samples H, Williams AR, Olfson M, Crystal S.

J Subst Abuse Treat. 2018 Dec;95:9-17. doi: 10.1016/j.jsat.2018.09.001. Epub 2018 Sep 7.

Comment: Those more likely to discontinue were started on a lower dose of buprenorphine, male, younger, Black or Latinx, or had capitated insurance, other substance use disorders, HCV, prior overdose, or prior inpatient care. Besides the lower initial dose of buprenorphine and minority race/ethnicity, the other factors appear consistent well known barriers to treatment.

30) Trends in Overdose-Related Out-of-Hospital Cardiac Arrests in Arizona.

Smith G, Beger S, Vadeboncoeur T, Chikani V, Walter F, Bobrow B.

Resuscitation. 2018 Oct 20. pii: S0300-9572(18)31014-1. doi: 10.1016/j.resuscitation.2018.10.019. [Epub ahead of print]

Comment: Evaluating out-of-hospital cardiac arrests for cardiac versus drug toxicity as the etiology is fascinating and extremely important for national guidelines – including American Heart Association guidelines and training. The proportion of arrests due to drug overdose increased from 4.7% in 2010 to 6.6% in 2015.

31) Use of rapid fentanyl test strips among young adults who use drugs.

Krieger MS, Goedel WC, Buxton JA, Lysyshyn M, Bernstein E, Sherman SG, Rich JD, Hadland SE, Green TC, Marshall BDL.

Int J Drug Policy. 2018 Oct 12. pii: S0955-3959(18)30246-9. doi: 10.1016/j.drugpo.2018.09.009. [Epub ahead of print]

Comment: People used fentanyl test strips and reported improved overdose risk behaviors after getting a positive fentanyl result.

32) 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.

Comment: At this stage, fentanyl is well-established to result in more rapid overdose and some cases of chest wall rigidity.

33) Safety of a Modified Community Trailer to Manage Patients with Presumed Fentanyl Overdose.

Scheuermeyer FX, Grafstein E, Buxton J, Ahamad K, Lysyshyn M, DeVlaming S, Prinsloo G, Van Veen C, Kestler A, Gustafson R.

J Urban Health. 2018 Oct 15. doi: 10.1007/s11524-018-0321-z. [Epub ahead of print]

Comment: I recall about 20 years ago walking through the Lower East Side of NYC and observing paramedics treat a person for overdose. They then put the man in the ambulance. The man walked out of the side door while the paramedics climbed in the rear. They came out and put the man back in the ambulance. While they walked out of the side door, the man walked out the back of the ambulance. This went in circles for some time, until the man eventually escaped and ran down the street. That is a failure to provide the care that people want.

34) Cost-effectiveness of naloxone kits in secondary schools.

Cipriano LE, Zaric GS.

Drug Alcohol Depend. 2018 Nov 1;192:352-361. doi: 10.1016/j.drugalcdep.2018.08.003. Epub 2018 Sep 17.

Comment: Unlikely to meet any standard of cost-effectiveness.

35) Pharmacists’ knowledge, support, and perceived roles associated with providing naloxone in the community.

Stewart B, Thomas RL, Tutag-Lehr V.

Curr Pharm Teach Learn. 2018 Aug;10(8):1013-1021. doi: 10.1016/j.cptl.2018.05.016. Epub 2018 Jun 7.

Comment: Some pharmacists are very much on top of these issues.

36) Commentary: The opioid overdose epidemic: Evidence-based interventions.

Barglow P.

Am J Addict. 2018 Oct 12. doi: 10.1111/ajad.12823. [Epub ahead of print]

Comment: Authors note that sharp opioid dose restrictions result in increased heroin and fentanyl use. I haven’t read the full paper, but am unclear if they have solid data for this, although it is likely true.

37) Cognitive and socio-cognitive functioning of chronic non-medical prescription opioid users.

Kroll SL, Nikolic E, Bieri F, Soyka M, Baumgartner MR, Quednow BB.

Psychopharmacology (Berl). 2018 Dec;235(12):3451-3464. doi: 10.1007/s00213-018-5060-z. Epub 2018 Oct 11.

Comment: Morphine hair concentrations were related to deficits in recognizing emotion from faces, bodies, and complex scenes, in a dose-dependent fashion.

38) Opioid Overdose Prevention in Family Medicine Clerkships: A CERA Study.

Gano L, Renshaw SE, Hernandez RH, Cronholm PF.

Fam Med. 2018 Oct;50(9):698-701. doi: 10.22454/FamMed.2018.757385.

Comment: 50% of family medicine clerkships addressed providing naloxone – that’s pretty good given the novelty of the intervention for medical systems.

39) The Fentanyl Epidemic and Evolution of Fentanyl Analogs in the United States and the European Union.

Jannetto PJ, Helander A, Garg U, Janis GC, Goldberger B, Ketha H.

Clin Chem. 2018 Oct 10. pii: clinchem.2017.281626. doi: 10.1373/clinchem.2017.281626. [Epub ahead of print] Review.

Comment: This is a global crisis.

40) The Opioid Epidemic and the Role of the Occupational Health Nurse.

Higgins SA, Simons J.

Workplace Health Saf. 2018 Oct 10:2165079918796242. doi: 10.1177/2165079918796242. [Epub ahead of print]

Comment: Occupational health and management of opioid use disorder.

41) Characteristics of Patients With Opioid Use Disorder Associated With Performing Overdose Reversals in the Community: An Opioid Treatment Program Analysis.

Katzman JG, Greenberg NH, Takeda MY, Moya Balasch M.

J Addict Med. 2018 Oct 9. doi: 10.1097/ADM.0000000000000461. [Epub ahead of print]

Comment: Interesting analysis. The first such analysis was a study of naloxone recipients from a naloxone distribution program. That study found that those who had previously witnessed an overdose or used heroin or methamphetamine were most likely to use naloxone to reverse an overdose. This study, among patients seeking treatment for opioid use disorder, finds such an association with having previously witnessed an overdose and testing positive for 2 or more illicit drugs, but also accessing emergency medical care for their own overdose, being younger, and being Latinx.

42) Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States.

Peiper NC, Clarke SD, Vincent LB, Ciccarone D, Kral AH, Zibbell JE.

Int J Drug Policy. 2018 Oct 3. pii: S0955-3959(18)30213-5. doi: 10.1016/j.drugpo.2018.08.007. [Epub ahead of print]

Comment: Second study from this update finding that use of fentanyl test strips was associated with fewer overdose risk behaviors.

43) “Feeling confident and equipped”: Evaluating the acceptability and efficacy of an overdose response and naloxone administration intervention to service industry employees in New York City.

Wolfson-Stofko B, Gwadz MV, Elliott L, Bennett AS, Curtis R.

Drug Alcohol Depend. 2018 Nov 1;192:362-370. doi: 10.1016/j.drugalcdep.2018.08.001. Epub 2018 Sep 21.

Comment: Training service industry workers in overdose response / naloxone administration.

44) Understanding an emerging treatment population: Protocol for and baseline characteristics of a prospective cohort of people receiving treatment for pharmaceutical opioid dependence.

Nielsen S, Lintzeris N, Murnion B, Degenhardt L, Bruno R, Haber P, Johnson J, Hardy M, Ling S, Saddler C, Dunlop A, Demirkol A, Silsbury C, Phung N, Houseman J, Larance B.

Drug Alcohol Rev. 2018 Nov;37(7):887-896. doi: 10.1111/dar.12859. Epub 2018 Oct 2.

Comment: Most had commenced opioids for pain – and these were older than the others.

45) Implementing peer recovery services for overdose prevention in Rhode Island: An examination of two outreach-based approaches.

Waye KM, Goyer J, Dettor D, Mahoney L, Samuels EA, Yedinak JL, Marshall BDL.

Addict Behav. 2019 Feb;89:85-91. doi: 10.1016/j.addbeh.2018.09.027. Epub 2018 Sep 25.

Comment: Peer services at the emergency department appears to be highly effective at getting naloxone into the hands of patients and establishing future outreach contact.

46) Commentary. Fentanyl-related death and the underreporting risk.

D’Errico S.

J Forensic Leg Med. 2018 Nov;60:35-37. doi: 10.1016/j.jflm.2018.09.007. Epub 2018 Sep 21.

Comment: More forensic work needed.

46) EMS naloxone administration as non-fatal opioid overdose surveillance: 6-year outcomes in Marion County, Indiana.

Ray BR, Lowder EM, Kivisto AJ, Phalen P, Gil H.

Addiction. 2018 Dec;113(12):2271-2279. doi: 10.1111/add.14426. Epub 2018 Sep 26.

Comment: Of 4726 patients administered naloxone in Marion County, Indiana, 9.4% died in about a year on average. The 13.4% with repeated non-fatal overdose events were twice as likely to die and 3 times as likely to die from a drug-related cause.

47) Delay-Dependent Impairments in Memory and Motor Functions After Acute Methadone Overdose in Rats.

Ahmad-Molaei L, Hassanian-Moghaddam H, Farnaghi F, Tomaz C, Haghparast A.

Front Pharmacol. 2018 Sep 10;9:1023. doi: 10.3389/fphar.2018.01023. eCollection 2018.

Comment: Methadone overdose as a cause of delayed neurologic/cognitive disorders.

48) Detection and Quantitation of Trace Fentanyl in Heroin by Surface-Enhanced Raman Spectroscopy.

Haddad A, Comanescu MA, Green O, Kubic TA, Lombardi JR.

Anal Chem. 2018 Nov 6;90(21):12678-12685. doi: 10.1021/acs.analchem.8b02909. Epub 2018 Oct 8.

Comment: More forensics.

49) Buprenorphine treatment formulations: Preferences among persons in opioid withdrawal management.

Kenney SR, Anderson BJ, Bailey GL, Stein MD.

J Subst Abuse Treat. 2018 Nov;94:55-59. doi: 10.1016/j.jsat.2018.08.011. Epub 2018 Aug 28.

Comment: Past overdose was associated with willingness to start buprenorphine – that’s an important result. About half preferred a sublingual formulation, while the others would opt for an injection or buccal implant.

50) Factors associated with methadone maintenance therapy discontinuation among people who inject drugs.

Lo A, Kerr T, Hayashi K, Milloy MJ, Nosova E, Liu Y, Fairbairn N.

J Subst Abuse Treat. 2018 Nov;94:41-46. doi: 10.1016/j.jsat.2018.08.009. Epub 2018 Aug 23.

Comment: Lack of financial support, incarceration, and homelessness were associated with stopping methadone therapy.

51) Methadone maintenance treatment among patients exposed to illicit fentanyl in Rhode Island: Safety, dose, retention, and relapse at 6 months.

Stone AC, Carroll JJ, Rich JD, Green TC.

Drug Alcohol Depend. 2018 Nov 1;192:94-97. doi: 10.1016/j.drugalcdep.2018.07.019. Epub 2018 Aug 25.

Comment: Methadone still works in the context of fentanyl.

52) Acceptability of prison-based take-home naloxone programmes among a cohort of incarcerated men with a history of regular injecting drug use.

Curtis M, Dietze P, Aitken C, Kirwan A, Kinner SA, Butler T, Stoové M.

Harm Reduct J. 2018 Sep 21;15(1):48. doi: 10.1186/s12954-018-0255-5.

Comment: Yes, prisoners will accept naloxone. Just give it to them!!!

53) Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016.

Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS.

Science. 2018 Sep 21;361(6408). pii: eaau1184. doi: 10.1126/science.aau1184.

Comment: Fascinating look at the opioid crisis as just the latest wave in a 38+ year trend of increasing drug overdose mortality.

54) Near-fatal Intoxication with the “New” Synthetic Opioid U-47700: The First Reported Case in the Czech Republic.

Židková M, Horsley R, Hloch O, Hložek T.

J Forensic Sci. 2018 Sep 19. doi: 10.1111/1556-4029.13903. [Epub ahead of print]

Comment: Bummer.

55) The Opioid Crisis in Missouri: A Call to Action for Physicians, Legislators, and Society.

Lewis L, Carpenter CR, Schwarz ES, Jotte RS, Waller C, Winograd R, Williams R, Stenger S, Rehder H, Governick S, Giuffra L.

Mo Med. 2017 Nov-Dec;114(6):440-446.

Comment: Why are there barriers to accessing medications for opioid use disorder treatment?

56) Emerging Evidence for Cannabis’ Role in Opioid Use Disorder.

Wiese B, Wilson-Poe AR.

Cannabis Cannabinoid Res. 2018 Sep 1;3(1):179-189. doi: 10.1089/can.2018.0022. eCollection 2018. Review.

Comment: Cannabis effects seem to be highly dependent upon set and setting (i.e. expected effects and environment). I wonder if there is a way to leverage cannabis toward treatment ends by adding a counseling component to medical cannabis recommendations.

57) Correlations between population-levels of prescription opioid dispensing and related deaths in Ontario (Canada), 2005-2016.

Fischer B, Jones W, Varatharajan T, Malta M, Kurdyak P.

Prev Med. 2018 Nov;116:112-118. doi: 10.1016/j.ypmed.2018.09.001. Epub 2018 Sep 11.

Comment: Yes, there are correlations.

58) Evaluation of a fentanyl drug checking service for clients of a supervised injection facility, Vancouver, Canada.

Karamouzian M, Dohoo C, Forsting S, McNeil R, Kerr T, Lysyshyn M.

Harm Reduct J. 2018 Sep 10;15(1):46. doi: 10.1186/s12954-018-0252-8.

Comment: Another fentanyl test paper.- this one showing that most didn’t want drugs checked.

59) State Unintentional Drug Overdose Reporting Surveillance: Opioid Overdose Deaths and Characteristics in Rhode Island.

Jiang Y, McDonald JV, Goldschmidt A, Koziol J, McCormick M, Viner-Brown S, Alexander-Scott N.

R I Med J (2013). 2018 Sep 4;101(7):25-30.

Comment: Most decedents had substance use disorder diagnoses, multiple drugs attributed to death, and fentanyl as one contributing drug.

60) Acceptability of Naloxone Dispensing Among Pharmacists.

Do V, Behar E, Turner C, Geier M, Coffin P.

J Pharm Pract. 2018 Sep 4:897190018798465. doi: 10.1177/0897190018798465. [Epub ahead of print]

Comment: This paper on pharmacist acceptability of naloxone was done prior to FDA-approval of formulations intended for lay administration. It is likely that a similar study today would show even greater acceptability – and fewer concerns.

61) Evaluation of an Opiate Overdose Educational Intervention and Naloxone Prescribing Program in Homeless Adults Who Use Opiates.

Pietrusza LM, Puskar KR, Ren D, Mitchell AM.

J Addict Nurs. 2018 Jul/Sep;29(3):188-195. doi: 10.1097/JAN.0000000000000235.

Comment: Only 33% of patients picked up the naloxone at the pharmacy. Once again, it is clear that we have to reach outside of the established healthcare system in order to properly care for those patients most in need.

62) Naloxone Effectiveness: A Systematic Review.

Chimbar L, Moleta Y.

J Addict Nurs. 2018 Jul/Sep;29(3):167-171. doi: 10.1097/JAN.0000000000000230.

Comment: Unable to access the full paper and the abstract lacks key details needed to evaluate the quality of the study.

63) Opioid Overdose and Naloxone Kit Distribution: A Quality Assurance Educational Program in the Primary Care Setting.

Lockett TL, Hickman KL, Fils-Guerrier BJ, Lomonaco M, Maye JP, Rossiter AG.

J Addict Nurs. 2018 Jul/Sep;29(3):157-162. doi: 10.1097/JAN.0000000000000231.

Comment: Basic education can improve patient management.

64) Being “hooked up” during a sharp increase in the availability of illicitly manufactured fentanyl: Adaptations of drug using practices among people who use drugs (PWUD) in New York City.

McKnight C, Des Jarlais DC.

Int J Drug Policy. 2018 Oct;60:82-88. doi: 10.1016/j.drugpo.2018.08.004. Epub 2018 Aug 31.

Comment: Interview study. “PWUD utilized test shots, a consistent drug dealer, fentanyl test strips, naloxone, getting high with or near others and reducing drug use to protect from overdose.”

65) An overview of take-home naloxone programs in Australia.

Dwyer R, Olsen A, Fowlie C, Gough C, van Beek I, Jauncey M, Lintzeris N, Oh G, Dicka J, Fry CL, Hayllar J, Lenton S.

Drug Alcohol Rev. 2018 May;37(4):440-449. doi: 10.1111/dar.12812.

Comment: Evaluation data of naloxone programs in Australia.

66) Addressing the growing opioid and heroin abuse epidemic: a call for medical school curricula.

Ratycz MC, Papadimos TJ, Vanderbilt AA.

Med Educ Online. 2018 Dec;23(1):1466574. doi: 10.1080/10872981.2018.1466574.

Comment: Agreed.

67) America’s Opioid Epidemic: a Comprehensive Review and Look into the Rising Crisis.

Ostling PS, Davidson KS, Anyama BO, Helander EM, Wyche MQ, Kaye AD.

Curr Pain Headache Rep. 2018 Apr 4;22(5):32. doi: 10.1007/s11916-018-0685-5. Review.

Comment: Authors note restrictions on opioid prescribing and costs of naloxone as contributing to the crisis and controlled substance monitoring programs and abuse-deterrent opioid formulations as solutions. Hmm. First, we use the term “controlled substance monitoring programs” because the commonly-used “prescription drug monitoring program” is a misnomer – these systems only track controlled substances. If they tracked all prescription drugs, you can be certain they would be limited to healthcare rather than emphasizing law enforcement access as they currently do. We would also probably have something closer to universal healthcare in the country. Second, I’m not convinced that these interventions have much of an impact on the crisis. 

68) Opioid use and harms associated with a sustained-release tapentadol formulation: a postmarketing study protocol.

Peacock A, Larance B, Farrell M, Cairns R, Buckley N, Degenhardt L.

BMJ Open. 2018 Mar 23;8(3):e020006. doi: 10.1136/bmjopen-2017-020006.

Comment: Study protocol (I’ve noticed that Australian investigators seem to be publishing protocols prior to conducting studies).

69) Assessment of potential opioid toxicity and response to naloxone by rapid response teams at an urban Melbourne hospital.

Gunasekaran B, Weil J, Whelan T, Santamaria J, Boughey M.

Intern Med J. 2018 Feb;48(2):198-200. doi: 10.1111/imj.13692.

Comment: Wide variations in naloxone use and dose, consistent with other studies.

70) Newly Emerging Drugs of Abuse and Their Detection Methods: An ACLPS Critical Review.

Liu L, Wheeler SE, Venkataramanan R, Rymer JA, Pizon AF, Lynch MJ, Tamama K.

Am J Clin Pathol. 2018 Jan 29;149(2):105-116. doi: 10.1093/ajcp/aqx138. Review.

Comment: Still more forensics!

71) Diagnosis of Heroin Overdose in an 8-Year-Old Boy: Reliable Contribution of Toxicological Investigations.

Soichot M, Julliand S, Filatriau J, Hurbain A, Bourgogne E, Mihoubi A, Gourlain H, Delhotal-Landes B.

J Anal Toxicol. 2018 May 1;42(4):255-264. doi: 10.1093/jat/bkx111.

Comment: Accidental drug poisonings among children are really tragic. This brings to mind a separate, but fascinating, story that contributed to the 1980s War on Drugs. That story involved a journalist for the Washington Post who won the Pulitzer Prize for a story on child heroin use that led to a huge citywide search for the subject of the story … and was later established to be entirely fraudulent, long after additional anti-drug legislation was passed in response.

72) Knowledge and possession of take-home naloxone kits among street-involved youth in a Canadian setting: a cohort study.

Goldman-Hasbun J, DeBeck K, Buxton JA, Nosova E, Wood E, Kerr T.

Harm Reduct J. 2017 Dec 22;14(1):79. doi: 10.1186/s12954-017-0206-6.

Comment: This study of naloxone among youth in Vancouver was done in the early days of naloxone in Canada. They have since vastly expanded distribution and I suspect the data would look different today.

73) Opiate agonist treatment to improve health of individuals with opioid use disorder in Lebanon.

Ghaddar A, Abbas Z, Haddad R.

Harm Reduct J. 2017 Dec 8;14(1):78. doi: 10.1186/s12954-017-0204-8.

Comment: People do better in multiple aspects of life.

74) Housing and overdose: an opportunity for the scale-up of overdose prevention interventions?

Bardwell G, Collins AB, McNeil R, Boyd J.

Harm Reduct J. 2017 Dec 6;14(1):77. doi: 10.1186/s12954-017-0203-9.

Comment: Totally.

75) Hypoglycemia and Sudden Death During Treatment With Methadone for Opiate Detoxification.

Plescia CJ, Manu P.

Am J Ther. 2018 Mar/Apr;25(2):e267-e269. doi: 10.1097/MJT.0000000000000692.

Comment: Methadone overdose has been associated with hypoglycemia on many occasions. 

76) Overdose prevention training with naloxone distribution in a prison in Oslo, Norway: a preliminary study.

Petterson AG, Madah-Amiri D.

Harm Reduct J. 2017 Nov 21;14(1):74. doi: 10.1186/s12954-017-0200-z.

Comment: Give naloxone to prisoners prior to release.

77) A Cross-sectional Survey Using Clinical Vignettes to Examine Overdose Risk Assessment and Willingness to Prescribe Naloxone.

Deanna Wilson J, Berk J, Matson P, Spicyn N, Alvanzo A, Adger H, Feldman L.

J Gen Intern Med. 2018 Nov 7. doi: 10.1007/s11606-018-4733-y. [Epub ahead of print] No abstract available. 

Comment: Survey of resident physicians in Baltimore regarding naloxone prescribing. Authors felt they underestimated overdose risk among patients prescribed opioids – and noted that they didn’t prescribe naloxone to a lot of patients who they felt were at risk for overdose. 

78) Managing the opioid epidemic: back to the basics with resuscitation.

Hung O, Stewart RD, Malpas G, Phipps S, Hung D.

CJEM. 2018 Nov 8:1-2. doi: 10.1017/cem.2018.453. [Epub ahead of print] No abstract available. 

Comment: Authors argue that naloxone should come after establishing rescue breathing and/or chest compressions.

79) Commentary on Rege et al. (2018): Naloxone reports to US poison centers highlight overdose prevention opportunities.

Oliva EM, Bounthavong M.

Addiction. 2018 Dec;113(12):2316-2317. doi: 10.1111/add.14443. Epub 2018 Oct 21. No abstract available. 

Comment: As above.

80) The changing landscape of naloxone availability in the United States, 2011 – 2017.

Freeman PR, Hankosky ER, Lofwall MR, Talbert JC.

Drug Alcohol Depend. 2018 Oct 1;191:361-364. doi: 10.1016/j.drugalcdep.2018.07.017. Epub 2018 Aug 30.

Comment: Big increase in prescribed naloxone since nasal approved by FDA.

81) Peer navigation and take-home naloxone for opioid overdose emergency department patients: Preliminary patient outcomes.

Samuels EA, Bernstein SL, Marshall BDL, Krieger M, Baird J, Mello MJ.

J Subst Abuse Treat. 2018 Nov;94:29-34. doi: 10.1016/j.jsat.2018.07.013. Epub 2018 Aug 1. No abstract available. 

Comment: People who land in the ED with opioid overdose have high rates of mortality in the subsequent year, women and older patients are less likely to be provided with naloxone, and recovery coaches may reduce time to treatment uptake. 

82) Pregnancy and Naltrexone Pharmacotherapy.

Jones CW, Terplan M.

Obstet Gynecol. 2018 Oct;132(4):923-925. doi: 10.1097/AOG.0000000000002864.

Comment: Data do not support naltrexone during pregnancy at this time.

83) Potential Risk Window for Opioid Overdose Related to Treatment with Extended-Release Injectable Naltrexone.

Binswanger IA, Glanz JM.

Drug Saf. 2018 Oct;41(10):979-980. doi: 10.1007/s40264-018-0705-8. No abstract available. 

Comment: There are some data suggesting increased overdose risk in the 1-month after ending injectable naltrexone treatment.

1)Using routinely collected data to understand and predict adverse outcomes in opioid agonist treatment: Protocol for the Opioid Agonist Treatment Safety (OATS) Study.

Larney S, Hickman M, Fiellin DA, Dobbins T, Nielsen S, Jones NR, Mattick RP, Ali R, Degenhardt L.

BMJ Open. 2018 Aug 5;8(8):e025204. doi: 10.1136/bmjopen-2018-025204.

Comment: Methods paper for another amazing data linkage study – this one in Australia. Color me jealous.

2)The impact of medically supervised injectioncentres on drug-related harms: A meta-analysis.

May T, Bennett T, Holloway K.

Int J DrugPolicy. 2018 Aug 2;59:98-107. doi: 10.1016/j.drugpo.2018.06.018. [Epub ahead of print] Review.

Comment: I’m not clear there are enough data for a useful meta-analysis.

3)Determining the effective dose of street-level heroin: A new way to consider fluctuations in heroinpurity, mass and potential contribution to overdose.

Stam NC, Gerostamoulos D, Gerstner-Stevens J, Scott N, Smith K, Drummer OH, Pilgrim JL.

Forensic Sci Int. 2018 Jul 19;290:219-226. doi: 10.1016/j.forsciint.2018.07.009. [Epub ahead of print]

Comment: Interesting way to look at heroin dose – always a challenge in detailed research.

4)Development and implementation of procedures for outpatient naloxoneprescribing at a large academic medical center.

Zschoche JH, Nesbit S, Murtaza U, Sowell A, Waldfogel JM, Arwood N, Rush J, McNamara L, Swarthout M, Nesbit T, Ortmann M.

Am J Health Syst Pharm. 2018 Aug 3. pii: ajhp170759. doi: 10.2146/ajhp170759. [Epub ahead of print]

Comment: Streamlined process utilizing pharmacists in large medical center. Neat.

5)Rx for addiction and medication safety: An evaluation of teen education for opioid misuse prevention.

Patry E, Bratberg JP, Buchanan A, Paiva AL, Balestrieri S, Matson KL.

Res Social Adm Pharm. 2018 Jul 7. pii: S1551-7411(18)30287-0. doi: 10.1016/j.sapharm.2018.07.006. Comment: Fascinating curriculum, including naloxone training, for high school students.

6)Awareness and access to naloxonenecessary but not sufficient: Examining gaps in the naloxonecascade.

Tobin K, Clyde C, Davey-Rothwell M, Latkin C.

Int J DrugPolicy. 2018 Jul 31;59:94-97. doi: 10.1016/j.drugpo.2018.07.003. [Epub ahead of print]

Comment: 90% were aware of naloxone, of whom 69% had ever received it, of whom 26% always carried it. 45% of those who had ever received naloxone had used it to reverse an overdose. Women and those who had used naloxone before were more likely to carry it on their person. Great data in a cohort of 353 adults who have used heroin.

7)Adoption and Utilization of an Emergency Department NaloxoneDistribution and Peer Recovery Coach Consultation Program.

Samuels EA, Baird J, Yang ES, Mello M.

Acad Emerg Med. 2018 Aug 3. doi: 10.1111/acem.13545. [Epub ahead of print]

Comment: Naloxone increased from none to over a third, while referrals to treatment more than doubled.

8)Addressing Intersecting Housing and OverdoseCrises in Vancouver, Canada: Opportunities and Challenges from a Tenant-Led OverdoseResponse Intervention in Single Room Occupancy Hotels.

Bardwell G, Fleming T, Collins AB, Boyd J, McNeil R.

J Urban Health. 2018 Aug 2. doi: 10.1007/s11524-018-0294-y. [Epub ahead of print]

Comment: This is super cool. A tenant-led naloxone training and overdose response program in SROs. So so important to reach that population.

9)Initial results of a drugchecking pilot program to detect fentanyl adulteration in a Canadian setting.

Tupper KW, McCrae K, Garber I, Lysyshyn M, Wood E.

DrugAlcohol Depend. 2018 Sep 1;190:242-245. doi: 10.1016/j.drugalcdep.2018.06.020. Epub 2018 Jul 24.

Comment: 90.6% of “heroin” samples contained fentanyl; 5.9% of speed/meth contained fentanyl.

10)Methadonemaintenance treatment and mortality in people with criminal convictions: A population-based retrospective cohort study from Canada.

Russolillo A, Moniruzzaman A, Somers JM.

PLoS Med. 2018 Jul 31;15(7):e1002625. doi: 10.1371/journal.pmed.1002625. eCollection 2018 Jul.

Comment: Methadone prevents death.

11)MakingNaloxoneRescue Part of Basic Life Support Training for Medical Students.

Jack HE, Warren KE, Sundaram S, Gheihman G, Weems J, Raja AS, Miller ES.

AEM Educ Train. 2018 Mar 30;2(2):174-177. doi: 10.1002/aet2.10095. eCollection 2018 Apr.

Comment: Nice.

12)[Interest of take-home naloxonefor opioidoverdose].

Frauger E, Kheloufi F, Boucherie Q, Monzon E, Jupin L, Richard N, Mallaret M, Micallef J.

Therapie. 2018 Jul 7. pii: S0040-5957(18)30119-7. doi: 10.1016/j.therap.2018.07.001. [Epub ahead of print] French.

Comment: French authorities authorized lay use of naloxone nasal spray.

13)Integrating Public Health and Health Care Strategies to Address the Opioid Epidemic: The Oregon Health Authority’s Opioid Initiative.

Hedberg K, Bui LT, Livingston C, Shields LM, Van Otterloo J.

J Public Health Manag Pract. 2018 Jul 18. doi: 10.1097/PHH.0000000000000849. [Epub ahead of print]

Comment: This is a good example of how not to report on interventions and overdose outcomes. Opioid prescribing went down and prescription opioid overdose deaths went down … for one year. How can you report on death “trends” from two years of data? Overdose is not a stable outcome – it varies from year-to-year. To base conclusions on a drop from one year to the next is unwise to say the least. And not to mention that heroin deaths went up is disingenuous.

14)Reframing the Prevention Strategies of the Opioid Crisis: Focusing on Prescription Opioids, Fentanyl, and HeroinEpidemic.

Manchikanti L, Sanapati J, Benyamin RM, Atluri S, Kaye AD, Hirsch JA.

Pain Physician. 2018 Jul;21(4):309-326.

Comment: Education, expanding non-opioid pain options, and expanding buprenorphine for pain and opioid use disorder. Interesting.

15)Comparison of lower-dose versus higher-dose intravenous naloxoneon time to recurrence of opioid toxicity in the emergency department.

Wong F, Edwards CJ, Jarrell DH, Patanwala AE.

Clin Toxicol (Phila). 2018 Jul 23:1-6. doi: 10.1080/15563650.2018.1490420. [Epub ahead of print]

Comment: Initial dose of IV naloxone does not affect time to opioid effect recurrence. Good to know. Likely the story is different for nasal.

16)Moving opioid misuse prevention upstream: A pilot study of community pharmacists screening for opioid misuse risk.

Strand MA, Eukel H, Burck S.

Res Social Adm Pharm. 2018 Jul 17. pii: S1551-7411(18)30219-5. doi: 10.1016/j.sapharm.2018.07.011. [Epub ahead of print]

Comment: I remain reluctant to recommend such screening tools in practice. They generally don’t do well prospectively (if they have been evaluated at all), can lead to stigma/discrimination, and can also raise medico-legal concerns about patient management.

17)Implementation and assessment of a naloxone-training program for first-year student pharmacists.

Schartel A, Lardieri A, Mattingly A, Feemster AA.

Curr Pharm Teach Learn. 2018 Jun;10(6):717-722. doi: 10.1016/j.cptl.2018.03.016. Epub 2018 Apr 5.

Comment: Short training helps.

18)Student pharmacist perceptions of participation in hands-on naloxonecounseling.

Hines J, Deja E, Black EP.

Curr Pharm Teach Learn. 2018 Jun;10(6):712-716. doi: 10.1016/j.cptl.2018.03.002. Epub 2018 Apr 9.

Comment: I like this survey. To me it supports the notion that the more providers feel they have to offer people who use drugs, the less stigma they will bring to the table.

19)OpioidOverdoseMortality Among Former North Carolina Inmates: 2000-2015.

Ranapurwala SI, Shanahan ME, Alexandridis AA, Proescholdbell SK, Naumann RB, Edwards D Jr, Marshall SW.

Am J Public Health. 2018 Sep;108(9):1207-1213. doi: 10.2105/AJPH.2018.304514. Epub 2018 Jul 19.

Comment: Risk in the first two weeks post-release was 40 fold higher than the general population for opioid overdose death and 74 fold for heroin death.

20)Spatial Methods to Enhance Public Health Surveillance and Resource Deployment in the Opioid Epidemic.

Dodson ZM, Enki Yoo EH, Martin-Gill C, Roth R.

Am J Public Health. 2018 Sep;108(9):1191-1196. doi: 10.2105/AJPH.2018.304524. Epub 2018 Jul 19.

Comment: Geocoding work is always intriguing.

21)Geospatial Clustering of Opioid-Related Emergency Medical Services Runs for Public Deployment of Naloxone.

Dworkis DA, Weiner SG, Liao VT, Rabickow D, Goldberg SA.

West J Emerg Med. 2018 Jul;19(4):641-648. doi: 10.5811/westjem.2018.4.37054. Epub 2018 May 15.

Comment: Again, the idea of putting naloxone boxes around in communities with lots of overdose events. The challenge is maintaining them, of course.

22)Public attitudes and beliefs about Virginia community pharmacists dispensing and administering naloxone.

Haggerty LC, Gatewood SS, Goode JKR.

J Am Pharm Assoc (2003). 2018 Jul – Aug;58(4S):S73-S77.e1. doi: 10.1016/j.japh.2018.04.034.

Comment: About two-thirds of respondents liked the idea of pharmacists providing naloxone.

23)Identifying barriers to dispensing naloxone: A survey of community pharmacists in North Carolina.

Rudolph SE, Branham AR, Rhodes LA, Hayes HH Jr, Moose JS, Marciniak MW.

J Am Pharm Assoc (2003). 2018 Jul – Aug;58(4S):S55-S58.e3. doi: 10.1016/j.japh.2018.04.025.

Comment: Over half of the pharmacists were not comfortable providing naloxone, but most were interested in learning more.

24)Increased use of heroinas an initiating opioid of abuse: Further considerations and policy implications.

Cicero TJ, Kasper ZA, Ellis MS.

Addict Behav. 2018 May 31. pii: S0306-4603(18)30467-2. doi: 10.1016/j.addbeh.2018.05.030. [Epub ahead of print]

Comment: Use of heroin as the opioid of initiation grew from 8.7% in 2005 to 31.6% in 2015.

25)Risks of fatal opioid overdoseduring the first year following nonfatal overdose.

Olfson M, Wall M, Wang S, Crystal S, Blanco C.

DrugAlcohol Depend. 2018 Sep 1;190:112-119. doi: 10.1016/j.drugalcdep.2018.06.004. Epub 2018 Jul 4.

Comment: Ok – fascinating study. Important to note that it represents people who had a non-fatal overdose that reached the medical system, which is not more than half of overdose events and generally represents a more serious event. Among those individuals 64% had filled an opioid prescription in the preceding 6 months. In the ensuing 12 months, the rate of repeat overdose was 295/1000 person-years (so ~29.5%) and fatal overdose was 1154/100k person years (so ~1.2%). These figures are pretty consistent with longstanding overdose epidemiology and more recent prospective work.

26)Fatal and Nonfatal OverdoseAmong Pregnant and Postpartum Women in Massachusetts.

Schiff DM, Nielsen T, Terplan M, Hood M, Bernson D, Diop H, Bharel M, Wilens TE, LaRochelle M, Walley AY, Land T.

Obstet Gynecol. 2018 Aug;132(2):466-474. doi: 10.1097/AOG.0000000000002734.

Comment: Great data on overdose in pregnancy and post-partum period. Highest risk is 7-12 months after delivery. Medication treatment of course lowers risk.

27)Trends and characteristics of naloxonetherapy reported to US poison centers.

Rege SV, Ngo DA, Ait-Daoud N, Sharma S, Verplancken E, Holstege CP.

Addiction. 2018 Jul 10. doi: 10.1111/add.14378. [Epub ahead of print]

Comment: Increasing use.

28)Grievable lives? Death by opioid overdosein Australian newspaper coverage.

Fraser S, Farrugia A, Dwyer R.

Int J DrugPolicy. 2018 Jun 30;59:28-35. doi: 10.1016/j.drugpo.2018.06.004. [Epub ahead of print]

Comment: This is a powerful construct from Australia. “Until the lives of opioid consumers come to be considered grievable, the measures known to reduce overdose deaths may struggle to find support.”

29)Trauma Trainees’ Multiple Competing Goals in Opioid Prescription Communication.

Adams ET, Cohen EL, Bernard A, Darnell W, Helme DW.

Qual Health Res. 2018 Jul 1:1049732318784896. doi: 10.1177/1049732318784896. [Epub ahead of print]

Comment: It’s tough for surgeons to address opioid prescribing. I mean, it’s tough across the board. But surgeons really aren’t in a good position for this practice change.

30)Sociodemographic factors, prescription history and opioid overdosedeaths: a statewide analysis using linked PDMP and mortality data.

Nechuta SJ, Tyndall BD, Mukhopadhyay S, McPheeters ML.

DrugAlcohol Depend. 2018 Sep 1;190:62-71. doi: 10.1016/j.drugalcdep.2018.05.004. Epub 2018 Jun 13.

Comment: 55% of prescribed opioid, 39.2% of fentanyl, and 20.7% of heroin overdoses had an active opioid prescription at the time of overdose death.

31)Primary Care and the Opioid-OverdoseCrisis – BuprenorphineMyths and Realities.

Wakeman SE, Barnett ML.

N Engl J Med. 2018 Jul 5;379(1):1-4. doi: 10.1056/NEJMp1802741. No abstract available.

Comment: Nice article! Good read.

32)Moving Addiction Care to the Mainstream – Improving the Quality of BuprenorphineTreatment.

Saloner B, Stoller KB, Alexander GC.

N Engl J Med. 2018 Jul 5;379(1):4-6. doi: 10.1056/NEJMp1804059. No abstract available.

Comment: Yes, please.

33)Abuse of fentanyl: An emerging problem to face.

Kuczyńska K, Grzonkowski P, Kacprzak Ł, Zawilska JB.

Forensic Sci Int. 2018 Aug;289:207-214. doi: 10.1016/j.forsciint.2018.05.042. Epub 2018 Jun 2. Review.

Comment: Fentanyl review.

34)As Overdoses Climb, Emergency Departments Begin Treating Opioid Use Disorder.

Rubin R.

JAMA. 2018 Jun 5;319(21):2158-2160. doi: 10.1001/jama.2018.4648. No abstract available.

Comment: Review of addressing OUD in the emergency department.

The following papers continue from our last PubMed update on North Carolina experiences:

35)Running the Numbers: County Level Dynamics of HeroinMortality in North Carolina.

Gunn AH, Bartlett B, Feng G, Gayed M, Kanter K, Onuoha E, Thornton M, Muzyk A, Schramm-Sapyta N.

N C Med J. 2018 May-Jun;79(3):195-200. doi: 10.18043/ncm.79.3.195. No abstract available.

36)Meeting Opioid Users Where They Are: A Service Referral Approach to Law Enforcement.

Paul L.

N C Med J. 2018 May-Jun;79(3):172-173. doi: 10.18043/ncm.79.3.172. No abstract available.

37)The Opioid Epidemic in NC: Progress, Challenges, and Opportunities.

Kansagra SM, Cohen MK.

N C Med J. 2018 May-Jun;79(3):157-162. doi: 10.18043/ncm.79.3.157.

26 naloxone papers:

1) Naloxone prescriptions from the emergency department: An initiative in evolution.

Verdier M, Routsolias JC, Aks SE.

Am J Emerg Med. 2018 May 22. pii: S0735-6757(18)30422-4. doi: 10.1016/j.ajem.2018.05.044. [Epub ahead of print] No abstract available.

Comments: 18% got filled. More likely to get filled if sent with other Rx’s.

2) “Once I’d done it once it was like writing your name”: Lived experience of take-home naloxone administration by people who inject drugs.

McAuley A, Munro A, Taylor A.

Int J Drug Policy. 2018 May 23;58:46-54. doi: 10.1016/j.drugpo.2018.05.002. [Epub ahead of print]

Comments: Qualitative study with 8 PWID who have administered naloxone.

3) Characterizing peer roles in an overdose crisis: Preferences for peer workers in overdose response programs in emergency shelters.

Bardwell G, Kerr T, Boyd J, McNeil R.

Drug Alcohol Depend. 2018 Jun 26;190:6-8. doi: 10.1016/j.drugalcdep.2018.05.023. [Epub ahead of print]

Comments: Peers are hugely important in service provision.

4) Successful bystander-administered intranasal naloxone reversal of opioid overdose between two veterans: A case report.

Ouyang S, Moore T.

Ment Health Clin. 2018 Mar 23;7(6):287-289. doi: 10.9740/mhc.2017.11.287. eCollection 2017 Nov.

Comments: There are hundreds to thousands of successful lay reversals in the US daily.

5) At-a-glance – Lessons learned from launching the Manitoba Take-Home Naloxone Program.

Bozat-Emre S, Marshall SG, Zhong C, Reimer J.

Health Promot Chronic Dis Prev Can. 2018 Jun;38(6):252-255. doi: 10.24095/hpcdp.38.6.06. English, French.

Comments: Standard programmatic data, noting that the program gives valuable information about street opioids.

6) Acceptability and feasibility of naloxone prescribing in primary care settings: A systematic review.

Behar E, Bagnulo R, Coffin PO.

Prev Med. 2018 Jun 15;114:79-87. doi: 10.1016/j.ypmed.2018.06.005. [Epub ahead of print] Review.

Comments: Systematic review of literature on naloxone prescribing from primary care.

7) Yes, not now, or never: an analysis of reasons for refusing or accepting emergency department-based take-home naloxone.

Kestler A, Giesler A, Buxton J, Meckling G, Lee M, Hunte G, Wilkins J, Marks D, Scheuermeyer F.

CJEM. 2018 May 23:1-9. doi: 10.1017/cem.2018.368. [Epub ahead of print]

Comments: Those refusing naloxone felt they weren’t at risk of overdose or that the ED wasn’t the place to get the prescription. Those accepting felt they could help others.

8) Naloxone Use Among Emergency Department Patients with Opioid Overdose.

Marco CA, Trautman W, Cook A, Mann D, Rasp J, Perkins O, Ballester M.

J Emerg Med. 2018 May 16. pii: S0736-4679(18)30360-3. doi: 10.1016/j.jemermed.2018.04.022. [Epub ahead of print]

Comments: Ohio study of overdoses in the ED. Lots of repeated visits. Only 31% had home access to naloxone. Among those who had naloxone, 33% reported less opioid usage, 4% reported more, and 63% reported no change.

9) An overview of take-home naloxone programs in Australia.

Dwyer R, Olsen A, Fowlie C, Gough C, van Beek I, Jauncey M, Lintzeris N, Oh G, Dicka J, Fry CL, Hayllar J, Lenton S.

Drug Alcohol Rev. 2018 May;37(4):440-449. doi: 10.1111/dar.12812.

Comments: Peer programs!

10) Knowledge of naloxone and take-home naloxone programs among a sample of people who inject drugs in Australia: Variations across capital cities.

Dietze PM, Stare M, Cogger S, Nambiar D, Olsen A, Burns L, Lenton S.

Drug Alcohol Rev. 2018 May;37(4):457-463. doi: 10.1111/dar.12644. Epub 2017 Dec 21.

Comments: Half of PWID were aware of take-home naloxone. Good start, ways to go.

11) Facilitators and Barriers to Naloxone Kit Use Among Opioid-Dependent Patients Enrolled in Medication Assisted Therapy Clinics in North Carolina.

Khatiwoda P, Proeschold-Bell RJ, Meade CS, Park LP, Proescholdbell S.

N C Med J. 2018 May-Jun;79(3):149-155. doi: 10.18043/ncm.79.3.149.

Comments: Smaller kits more likely to be carried.

12)Feasibility of Bystander Administration of Public-Access Naloxone for Opioid Overdose.

Goldberg SA, Dworkis DA, Liao VT, Eyre AJ, Albert J, Fawcett MM, Narovec CM, DiClemente J, Weiner SG.

Prehosp Emerg Care. 2018 May 3:1-7. doi: 10.1080/10903127.2018.1461284. [Epub ahead of print]

Comments: Public access naloxone stations is an idea that’s been batted about for decades without much in terms of implementation.

13)Pharmacokinetic properties of intranasal and injectable formulations of naloxone for community use: a systematic review.

Ryan SA, Dunne RB.

Pain Manag. 2018 Apr 23. doi: 10.2217/pmt-2017-0060. [Epub ahead of print]

Comments: Intranasal works well.

14) [Temporary approval for intranasal naloxone: Setting up in a French addiction center].

Barré T, Vorspan F, Fortias M, Veyrier M, Cavagna P, Azuar J, Nicolas L, Naccache F, Barreteau H, Bellivier F, Bloch V.

Therapie. 2018 Mar 29. pii: S0040-5957(18)30060-X. doi: 10.1016/j.therap.2018.03.003. [Epub ahead of print] French.

Comments: Pilot naloxone prescribing in France.

15) Cost-Effectiveness of Take-Home Naloxone for the Prevention of Overdose Fatalities among HeroinUsers in the United Kingdom.

Langham S, Wright A, Kenworthy J, Grieve R, Dunlop WCN.

Value Health. 2018 Apr;21(4):407-415. doi: 10.1016/j.jval.2017.07.014. Epub 2018 Feb 4.

Comments: Remarkably similar outcomes as the 2012 naloxone model in the United States.

16) Distribution of take-home opioid antagonist kits during a synthetic opioid epidemic in British Columbia, Canada: a modelling study.

Irvine MA, Buxton JA, Otterstatter M, Balshaw R, Gustafson R, Tyndall M, Kendall P, Kerr T, Gilbert M, Coombs D.

Lancet Public Health. 2018 Apr 17. pii: S2468-2667(18)30044-6. doi: 10.1016/S2468-2667(18)30044-6. [Epub ahead of print]

Comments: Authors conclude that rapid expansion of naloxone access helped to reverse the increasing trend of opioid overdose deaths during the fentanyl crisis.

17) Prescribing naloxone for opioid overdose intervention.

Dunne RB.

Pain Manag. 2018 Apr 18. doi: 10.2217/pmt-2017-0065. [Epub ahead of print]

Comments: A review, although it is incorrect that screening for patients at risk of opioid overdose is required. The majority of US states allow for third party prescribing to those who might witness an opioid overdose. Moreover, the use of “overdose” when speaking to patients prescribed opioids can sabotage efforts to get naloxone to where the opioids are.

18) The feasibility of employing a home healthcare model for education and treatment of opioid overdoseusing a naloxone auto-injector in a private practice pain medicine clinic.

Dragovich A, Brason F, Beltran T, McCoart A, Plunkett AR.

Curr Med Res Opin. 2018 Apr 18:1-11. doi: 10.1080/03007995.2018.1466698. [Epub ahead of print]

Comments: Home health approach to training on overdose response.

19) Emergency physician resistance to a take-home naloxone program led by community harm reductionists.

Barbour K, McQuade M, Somasundaram S, Chakravarthy B.

Am J Emerg Med. 2018 Mar 17. pii: S0735-6757(18)30228-6. doi: 10.1016/j.ajem.2018.03.036. [Epub ahead of print] No abstract available.

Comments: A study of providing naloxone in an emergency department, in which the attending physician refused to prescribe naloxone to 37% of the patients who wanted it. Really unclear why someone would refuse to provide a naloxone prescription to a patient who wanted one. And few of the patients filled the prescription – again consistent with what we know about naloxone and any other preventive intervention like flu shots: it has to be free and convenient.

20) Pharmacokinetics and -dynamics of intramuscular and intranasal naloxone: an explorative study in healthy volunteers.

Skulberg AK, Tylleskar I, Nilsen T, Skarra S, Salvesen Ø, Sand T, Loftsson T, Dale O.

Eur J Clin Pharmacol. 2018 Mar 22. doi: 10.1007/s00228-018-2443-3. [Epub ahead of print]

Comments: Intranasal naloxone was 0.75 as bioavailable as intramuscular.

21) Implementation and evaluation of an opioid overdose education and naloxone distribution (OEND) program at a Veterans Affairs Medical Center.

Pauly JB, Vartan CM, Brooks AT.

Subst Abus. 2018 Mar 22:1-17. doi: 10.1080/08897077.2018.1449174. [Epub ahead of print]

Comments: 30% of veterans referred for naloxone completed education and most were at low risk for opioid overdose.

22) Naloxone reversal of clonidine toxicity: dose, dose, dose.

Seger DL, Loden JK.

Clin Toxicol (Phila). 2018 Mar 16:1-7. doi: 10.1080/15563650.2018.1450986. [Epub ahead of print]

Comments: 10mg of naloxone in pediatric patients worked very well. Fascinating.

23) Effects of naloxone distribution to likely bystanders: Results of an agent-based model.

Keane C, Egan JE, Hawk M.

Int J Drug Policy. 2018 Mar 7;55:61-69. doi: 10.1016/j.drugpo.2018.02.008. [Epub ahead of print]

Comments: I have a fair amount of experience with models (created several Markov and decision tree-based models) and, while I’ve never constructed an agent-based model, the absence of a table of parameters for this paper is highly concerning to me. I cannot evaluate if this paper has value.

24) Naloxone access for Emergency Medical Technicians: An evaluation of a training program in rural communities.

Zhang X, Marchand C, Sullivan B, Klass EM, Wagner KD.

Addict Behav. 2018 Mar 5. pii: S0306-4603(18)30109-6. doi: 10.1016/j.addbeh.2018.03.004. [Epub ahead of print]

Comments: EMTs can be trained to administer naloxone.

25) Naloxone formulation for overdose reversal preference among patients receiving opioids for pain management.

Dunn KE, Barrett FS, Bigelow GE.

Addict Behav. 2018 Mar 28. pii: S0306-4603(18)30131-X. doi: 10.1016/j.addbeh.2018.03.011. [Epub ahead of print]

Comments: They prefer non-injectable. No surprise there.

26) Utilizing risk index for overdose or serious opioid-induced respiratory depression (RIOSORD) scores to prioritize offer of rescue naloxone in an outpatient veteran population: A telephone-based project.

Yates D, Frey T, Montgomery JC.

Subst Abus. 2018 Mar 26:1-12. doi: 10.1080/08897077.2018.1449171. [Epub ahead of print]

Comments: 63.4% of those contacted accepted the naloxone prescription.

Plus 6 papers on naloxone and Good Samaritan laws:

27) Naloxone laws facilitate the establishment of overdose education and naloxone distribution programs in the United States.

Lambdin BH, Davis CS, Wheeler E, Tueller S, Kral AH.

Drug Alcohol Depend. 2018 May 12. pii: S0376-8716(18)30238-2. doi: 10.1016/j.drugalcdep.2018.04.004. [Epub ahead of print]

Comments: As title says.

28) Do naloxone access laws increase outpatient naloxone prescriptions? Evidence from Medicaid.

Gertner AK, Domino ME, Davis CS.

Drug Alcohol Depend. 2018 Jun 22;190:37-41. doi: 10.1016/j.drugalcdep.2018.05.014. [Epub ahead of print]

Comments: Naloxone access laws are associated with increased outpatient prescriptions.

29) Opioid-overdose laws association with opioid use and overdose mortality.

McClellan C, Lambdin BH, Ali MM, Mutter R, Davis CS, Wheeler E, Pemberton M, Kral AH.

Addict Behav. 2018 Mar 19. pii: S0306-4603(18)30138-2. doi: 10.1016/j.addbeh.2018.03.014. [Epub ahead of print]

Comments: Laws supporting naloxone programming were associated with less opioid overdose mortality and no increase in non-medical opioid use.

30) Assessing the effectiveness of New York’s 911 Good Samaritan Law-Evidence from a natural experiment.

Nguyen H, Parker BR.

Int J Drug Policy. 2018 Jun 29;58:149-156. doi: 10.1016/j.drugpo.2018.05.013. [Epub ahead of print]

Comments: Interesting comparison between New York and New Jersey, although this could have been influenced by market forces as well.

31) Lay responder naloxone access and Good Samaritan law compliance: postcard survey results from 20 Indiana counties.

Watson DP, Ray B, Robison L, Huynh P, Sightes E, Walker S, Brucker K, Duwve J.

Harm Reduct J. 2018 Apr 6;15(1):18. doi: 10.1186/s12954-018-0226-x.

Comments: Knowing someone who overdosed predicts getting naloxone. If people know about Good Sam protections they are more likely to call emergency medical services after the overdose.

32) State naloxone access laws are associated with an increase in the number of naloxone prescriptions dispensed in retail pharmacies.

Xu J, Davis CS, Cruz M, Lurie P.

Drug Alcohol Depend. 2018 Aug 1;189:37-41. doi: 10.1016/j.drugalcdep.2018.04.020. Epub 2018 May 29.

Comments: See title.

And 6 papers on pharmacies and naloxone/opioids:

33) Predicting pharmacy naloxone stocking and dispensing following a statewide standing order, Indiana 2016.

Meyerson BE, Agley JD, Davis A, Jayawardene W, Hoss A, Shannon DJ, Ryder PT, Ritchie K, Gassman R.

Drug Alcohol Depend. 2018 Apr 26;188:187-192. doi: 10.1016/j.drugalcdep.2018.03.032. [Epub ahead of print]

Comments:  Bigger pharmacies and chains stocked naloxone more.

34) Reviewing state-mandated training requirements for naloxone-dispensing pharmacists.

Roberts AW, Carpenter DM, Smith A, Look KA.

Res Social Adm Pharm. 2018 Apr 5. pii: S1551-7411(17)30915-4. doi: 10.1016/j.sapharm.2018.04.002. [Epub ahead of print]

Comments: The state requirements are silly. Why do we always create barriers to providers taking care of people with substance use disorders and related issues?

35) Chronic pain medication management of older populations: Key points from a national conference and innovative opportunities for pharmacy practice.

Gilmartin-Thomas JF, Bell JS, Liew D, Arnold CA, Buchbinder R, Chapman C, Cicuttini F, Dobbin M, Gibson SJ, Giummarra MJ, Gowan J, Katz B, Lubman DI, McCrone M, Pilgrim J, Synnot A, van Dyk E, Workman B, McNeil J.

Res Social Adm Pharm. 2018 Mar 19. pii: S1551-7411(17)30669-1. doi: 10.1016/j.sapharm.2018.03.060. [Epub ahead of print]

Comments: How pharmacists can help.

36) Establishment of a pharmacist-led service for patients at high risk for opioid overdose.

Tewell R, Edgerton L, Kyle E.

Am J Health Syst Pharm. 2018 Mar 15;75(6):376-383. doi: 10.2146/ajhp170294.

Comments: Pharmacists are good at getting naloxone to people who may need it.

37) Naloxone for Opioid Overdose and the Role of the Pharmacist.

Toderika Y, Williams S.

Consult Pharm. 2018 Feb 1;33(2):98-104. doi: 10.4140/TCP.n.2018.98.

Comments: As above!

38) Predicting pharmacy syringe sales to people who inject drugs: Policy, practice and perceptions.

Meyerson BE, Davis A, Agley JD, Shannon DJ, Lawrence CA, Ryder PT, Ritchie K, Gassman R.

Int J Drug Policy. 2018 Mar 17;56:46-53. doi: 10.1016/j.drugpo.2018.02.024. [Epub ahead of print]

Comments: Communities with high rates of opioid overdose death were less likely to have pharmacies that dispensed syringes to PWID.

9 papers on fentanyl:

39) Abuse of fentanyl: An emerging problem to face.

Kuczyńska K, Grzonkowski P, Kacprzak Ł, Zawilska JB.

Forensic Sci Int. 2018 Aug;289:207-214. doi: 10.1016/j.forsciint.2018.05.042. Epub 2018 Jun 2. Review.

Comments: Reviewing emerging presence of fentanyl in Poland.

40) Fentanyl-contaminated drugs and non-fatal overdose among people who inject drugs in Baltimore, MD.

Park JN, Weir BW, Allen ST, Chaulk P, Sherman SG.

Harm Reduct J. 2018 Jul 5;15(1):34. doi: 10.1186/s12954-018-0240-z.

Comments: While this is an interesting effort, I’m not convinced that “perceived fentanyl presence” as a risk factor for overdose is particularly useful.

41) Fentanyl self-testing outside supervised injection settings to prevent opioid overdose: Do we know enough to promote it?

McGowan CR, Harris M, Platt L, Hope V, Rhodes T.

Int J Drug Policy. 2018 May 11;58:31-36. doi: 10.1016/j.drugpo.2018.04.017. [Epub ahead of print]

Comments: Not really, but we are desparate.

42)Community-Based Response to Fentanyl Overdose Outbreak, San Francisco, 2015.

Rowe C, Wheeler E, Stephen Jones T, Yeh C, Coffin PO.

J Urban Health. 2018 May 3. doi: 10.1007/s11524-018-0250-x. [Epub ahead of print]

Comments: Another role for naloxone distribution programs is as an early warning system of changes in the opioid market. In this case, a locality was alerted to fentanyl entering the supply by an increase in naloxone reversals, with no associated deaths. Of note, this clearly overlaps with the “naloxone” section above.

43) Characteristics of opioid-maintained clients smoking fentanyl patches: The importance of confirmatory drug analysis illustrated by a case series and mini-review.

Kimergård A, Dunne J, Bøgen A, Hindersson P, Breindahl T.

Drug Test Anal. 2018 Apr 19. doi: 10.1002/dta.2397. [Epub ahead of print]

Comments: Testing for fentanyl can be tricky in clinical practice.

44) Efficacious Vaccine against Heroin Contaminated with Fentanyl.

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

ACS Chem Neurosci. 2018 Mar 23. doi: 10.1021/acschemneuro.8b00079. [Epub ahead of print]

Comments: Interesting idea.

45) Fentanyl related overdose in Indianapolis: Estimating trends using multilevel Bayesian models.

Phalen P, Ray B, Watson DP, Huynh P, Greene MS.

Addict Behav. 2018 Mar 20. pii: S0306-4603(18)30121-7. doi: 10.1016/j.addbeh.2018.03.010. [Epub ahead of print]

Comments: Fentanyl deaths became predominant.

46) How Did We Get Here? Heroin and Fentanyl Trafficking Trends: A Law Enforcement Perspective.

Dismukes LC.

N C Med J. 2018 May-Jun;79(3):181-184. doi: 10.18043/ncm.79.3.181.

Comments: Describes a focus on the dark net.

47) Amount of naloxone used to reverse opioid overdoses outside of medical practice in a city with increasing illicitly manufactured fentanyl in illicit drug supply.

Bell A, Bennett AS, Jones TS, Doe-Simkins M, Williams LD.

Subst Abus. 2018 Mar 20:1-12. doi: 10.1080/08897077.2018.1449053. [Epub ahead of print]

Comments: There was no change in the dose or amount of lay-administered naloxone required to reverse overdoses in the community, regardless of a rapid increase in fentanyl-related overdoses.

13 papers on medications for opioid use disorder:

48) Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis.

Ma J, Bao YP, Wang RJ, Su MF, Liu MX, Li JQ, Degenhardt L, Farrell M, Blow FC, Ilgen M, Shi J, Lu L.

Mol Psychiatry. 2018 Jun 22. doi: 10.1038/s41380-018-0094-5. [Epub ahead of print]

Comments: Our medications for opioid use disorder – methadone, buprenorphine, and extended-release naltrexone – reduce mortality, particularly if used for over a year.

49) Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study.

Larochelle MR, Bernson D, Land T, Stopka TJ, Wang N, Xuan Z, Bagley SM, Liebschutz JM, Walley AY.

Ann Intern Med. 2018 Jun 19. doi: 10.7326/M17-3107. [Epub ahead of print]

Comments: Another fascinating analysis out of a powerful dataset. After overdose, 11% enrolled in methadone for a median of 5 months, 17% buprenorphine for 4 months, and naltrexone for 1 month. Methadone and buprenorphine were associated with similar reductions in mortality (adjusted hazard ratio 0.47 and 0.41, respectively). Naltrexone was not associated with a mortality benefit, although the AHR was 1.44, suggesting a possible increase in mortality.

50) Developing an opioid use disorder treatment cascade: A review of quality measures.

Williams AR, Nunes EV, Bisaga A, Pincus HA, Johnson KA, Campbell AN, Remien RH, Crystal S, Friedmann PD, Levin FR, Olfson M.

J Subst Abuse Treat. 2018 Aug;91:57-68. doi: 10.1016/j.jsat.2018.06.001. Epub 2018 Jun 2. Erratum in: J Subst Abuse Treat. 2018 Sep;92:99.

Comments: There’s a lot of work going on now to determine the markers of successful care for patients with opioid use disorder. It’s an exciting time in which we are hopefully seeing a transformation in which substance use disorders are treated as chronic diseases, rather than somebody else’s problem.

51) Trends in engagement in the cascade of care for opioid use disorder, Vancouver, Canada, 2006-2016.

Socías ME, Wood E, Kerr T, Nolan S, Hayashi K, Nosova E, Montaner J, Milloy MJ.

Drug Alcohol Depend. 2018 Aug 1;189:90-95. doi: 10.1016/j.drugalcdep.2018.04.026. Epub 2018 May 29.

Comments: Generated 4 stages of OUD care: linkage to care, linkage to methadone/buprenorphine, retention on medications, and stability – and evaluated changes from 2006 to 2016. They found that all parameters improved, but retention on medications was lower than goal (about a third of patients).

52) Opioid Use Disorders: Perioperative Management of a Special Population.

Ward EN, Quaye AN, Wilens TE.

Anesth Analg. 2018 May 25. doi: 10.1213/ANE.0000000000003477. [Epub ahead of print]

Comments: Great topic. So much mismanagement, particularly of patients on buprenorphine as it is too often stopped leading to chaos in the hospital. The general rule is to continue buprenorphine!!! Use ancillary pain medications. Dose the bup 3-4 times a day. Use hydromorphone or fentanyl if necessary.

53) National Institute on Drug Abuse International Program: improving opioid use disorder treatment through international research training.

Gust SW, McCormally J.

Curr Opin Psychiatry. 2018 Jul;31(4):287-293. doi: 10.1097/YCO.0000000000000426.

Comments: International research on OUD treatment and overdose prevention.

54) Stigma associated with medication treatment for young adults with opioid use disorder: a case series.

Hadland SE, Park TW, Bagley SM.

Addict Sci Clin Pract. 2018 May 7;13(1):15. doi: 10.1186/s13722-018-0116-2.

Comments: Case reports of patients being denied proper medical care. Grrr. If you had type 2 diabetes and were kicked off your insulin due to the ignorance of supposed “providers”, you’d make millions in court. Honestly, I can’t wait to see those cases emerge for people with opioid use disorder. Sadly, that is often the best way to change practice in the overly litigious United States.

55) Buprenorphine Therapy for Opioid Use Disorder.

Zoorob R, Kowalchuk A, Mejia de Grubb M.

Am Fam Physician. 2018 Mar 1;97(5):313-320.

Comments: A review of above.

56) Methadone maintenance treatment: A 15-year retrospective study in Split-Dalmatia County, Croatia.

Sutlovic D, Kljucevic Z, Sliskovic L, Susnjar H, Viskovic I, Definis-Gojanovic M.

Ther Drug Monit. 2018 Apr 11. doi: 10.1097/FTD.0000000000000519. [Epub ahead of print]

Comments: Programmatic data review.

57) Pharmacogenetics of Opioid Use Disorder Treatment.

Crist RC, Clarke TK, Berrettini WH.

CNS Drugs. 2018 Apr;32(4):305-320. doi: 10.1007/s40263-018-0513-9.

Comments: Metabolism, clearance, treatment outcomes for OUD meds.

58) Effectiveness of Tapering from Methadone or Buprenorphine Maintenance Treatment Compared to Traditional Maintenance Treatment for People with Opiate Addiction: Systematic Review [Internet].

Dalsbø TK, Steiro A, Strømme H, Reinar LM.

Oslo, Norway: Knowledge Centre for the Health Services at The Norwegian Institute of Public Health (NIPH); 2017 Mar 2.

Comments: Insufficient data, although it’s clear from clinical practice that treatment should be provided as long as the patient will accept it, ideally at least a year.

59) The effect of Housing First on adherence to methadone maintenance treatment.

Parpouchi M, Moniruzzaman A, Rezansoff SN, Russolillo A, Somers JM.

Int J Drug Policy. 2018 Mar 30;56:73-80. doi: 10.1016/j.drugpo.2018.03.012. [Epub ahead of print]

Comments: No effect on adherence to OUD treatment with methadone.

60) Implementing Treatment of Opioid-Use Disorder in Rural Settings: a Focus on HIV and Hepatitis C Prevention and Treatment.

Havens JR, Walsh SL, Korthuis PT, Fiellin DA.

Curr HIV/AIDS Rep. 2018 Aug;15(4):315-323. doi: 10.1007/s11904-018-0402-3. Review.

Comments: 3% of primary care providers can provide buprenorphine. Can we please throw out the waiver requirement?

7 more emergency medical care papers (there’s overlap here, obviously):

61) Catch and release: evaluating the safety of non-fatal heroin overdose management in the out-of-hospital environment.

Stam NC, Pilgrim JL, Drummer OH, Smith K, Gerostamoulos D.

Clin Toxicol (Phila). 2018 Jun 6:1-7. doi: 10.1080/15563650.2018.1478093. [Epub ahead of print]

Comments: Not withstanding the remarkably offensive title, in effect describing people who use drugs as fish, the study shows no risk to releasing patients after initial paramedic treatment for opioid overdose.

62) Substance use and homelessness among emergency department patients.

Doran KM, Rahai N, McCormack RP, Milian J, Shelley D, Rotrosen J, Gelberg L.

Drug Alcohol Depend. 2018 May 22;188:328-333. doi: 10.1016/j.drugalcdep.2018.04.021. [Epub ahead of print]

Comments: Patients in emergency departments who are homeless have higher rates of problematic substance use.

63) Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care.

Sanello A, Gausche-Hill M, Mulkerin W, Sporer KA, Brown JF, Koenig KL, Rudnick EM, Salvucci AA, Gilbert GH.

West J Emerg Med. 2018 May;19(3):527-541. doi: 10.5811/westjem.2018.1.36559. Epub 2018 Mar 8. Review.

Comments: Criteria for naloxone were – respiratory rate under 12, pinpoint pupils, presence of drug paraphernalia, and altered mental status. Interesting and may account for why we didn’t see as much naloxone given for prescription opioid overdose events during that era.

64) Safety of a Brief Emergency Department Observation Protocol for Patients With Presumed Fentanyl Overdose.

Scheuermeyer FX, DeWitt C, Christenson J, Grunau B, Kestler A, Grafstein E, Buxton J, Barbic D, Milanovic S, Torkjari R, Sahota I, Innes G.

Ann Emerg Med. 2018 Mar 9. pii: S0196-0644(18)30082-9. doi: 10.1016/j.annemergmed.2018.01.054. [Epub ahead of print]

Comments: Brief observation is fine. Similar to the above “catch and release” paper.

65) Rate of patients at elevated risk of opioid overdose visiting the emergency department.

Pedigo JR, Seifert CF.

Am J Emerg Med. 2018 Mar 22. pii: S0735-6757(18)30247-X. doi: 10.1016/j.ajem.2018.03.055. [Epub ahead of print]

Comments: More opioid overdose ED visits.

66) A Descriptive Analysis of Care Provided by Law Enforcement Prior to EMS Arrival in the United States.

Klassen AB, Core SB, Lohse CM, Sztajnkrycer MD.

Prehosp Disaster Med. 2018 Apr;33(2):165-170. doi: 10.1017/S1049023X18000213. Epub 2018 Mar 13.

Comments: Overall police provide the initial care in 2% of cases and 13% of drug overdoses – in Norway (rates probably much higher in other countries like the U.S.).

67) Ambulance-attended opioid overdoses: an examination into overdose locations and the role of a safe injection facility.

Madah-Amiri D, Skulberg AK, Braarud AC, Dale O, Heyerdahl F, Lobmaier P, Clausen T.

Subst Abus. 2018 Jun 27:1-17. doi: 10.1080/08897077.2018.1485130. [Epub ahead of print]

Comments: Fascinating look at overdose ambulance calls – where they happen, if they are transported, overdose severity. Useful for a deeper understanding of the epidemiology of serious overdose.

7 surveillance-esque papers:

68) Standard Death Certificates Versus Enhanced Surveillance to Identify Heroin Overdose-Related Deaths.

Horon IL, Singal P, Fowler DR, Sharfstein JM.

Am J Public Health. 2018 Apr 19:e1-e5. doi: 10.2105/AJPH.2018.304385. [Epub ahead of print]

Comments: I love these type of projects. Basically re-litigating the cause of death from the medical examiner’s conclusion. This may sound bad, but the decision the medical examiner makes should be extremely conservative – based only upon what they are quite sure is true. By re-evaluating the data, we can identify a great many more probable heroin overdose events.

69) Accurate identification of opioid overdose deaths using coronial data.

Roxburgh A, Pilgrim JL, Hall WD, Burns L, Degenhardt L.

Forensic Sci Int. 2018 Mar 26;287:40-46. doi: 10.1016/j.forsciint.2018.03.032. [Epub ahead of print]

Comments: One quarter of “morphine” deaths were re-attributed to heroin on review of the clinical record. This passes my sniff test.

70) Mapping Drug Overdose Demographic and Socioeconomic Characteristics in the Community.

Rooney BL, Voter MT, Eberlein CM, Schossow AJ, Fischer CL.

WMJ. 2018 Mar;117(1):18-23.

Comments: Interesting chart review project of overdoses showing up in an emergency department in Wisconsin.

71) Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses – United States, July 2016-September 2017.

Vivolo-Kantor AM, Seth P, Gladden RM, Mattson CL, Baldwin GT, Kite-Powell A, Coletta MA.

MMWR Morb Mortal Wkly Rep. 2018 Mar 9;67(9):279-285. doi: 10.15585/mmwr.mm6709e1.

Comments: Up and up.

72) Prevalence of gabapentin in drug overdose postmortem toxicology testing results.

Slavova S, Miller A, Bunn TL, White JR, Kirschke D, Light T, Christy D, Thompson G, Winecker R.

Drug Alcohol Depend. 2018 May 1;186:80-85. doi: 10.1016/j.drugalcdep.2018.01.018. Epub 2018 Mar 10.

Comments: I remain doubtful that this represents a problem with gabapentin.

73) Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants – United States, 2015-2016.

Seth P, Scholl L, Rudd RA, Bacon S.

MMWR Morb Mortal Wkly Rep. 2018 Mar 30;67(12):349-358. doi: 10.15585/mmwr.mm6712a1.

Comments: We really need a major effort on surveillance.

74) Trends in Injector Deaths in Ireland, as Recorded by the National Drug-Related Deaths Index, 1998-2014.

Lynn TM, Lynn E, Keenan E, Lyons S.

J Stud Alcohol Drugs. 2018 Mar;79(2):286-292.

Comments: 90% of deaths were overdose (poisoning) deaths.

And lots (35) more!

75) Opioid tolerance and clinically recognized opioid poisoning among patients prescribed extended-release long-acting opioids.

Young JC, Lund JL, Dasgupta N, Jonsson Funk M.

Pharmacoepidemiol Drug Saf. 2018 Jun 11. doi: 10.1002/pds.4572. [Epub ahead of print]

Comments: Wow. Honestly surprising results. One-third of patients started on >=90 morphine equivalent milligrams (MEMs) had no been receiving >=60 MEMs for 7 of the prior 14 days.

76) Prescription opioid use among individuals with serious mental illness.

Spivak S, Cullen B, Eaton W, Nugent K, Spivak A, Fenton A, Rodriguez K, Mojtabai R.

Psychiatry Res. 2018 May 31;267:85-87. doi: 10.1016/j.psychres.2018.05.075. [Epub ahead of print]

Comments: The intersection of mental illness, opioid use, and benzodiazepine use is fascinating and potentially quite complex. This study found that 12.9% of patients at two urban psychiatry clinics were prescribed opioids, and that being prescribed opioids was associated with having used heroin and using benzos; using benzos was associated with suicidal ideation. This doesn’t account for chicken or egg, but is interesting nonetheless.

77) Medical, psychosocial, and treatment predictors of opioid overdose among high risk opioid users.

Schiavon S, Hodgin K, Sellers A, Word M, Galbraith JW, Dantzler J, Cropsey KL.

Addict Behav. 2018 May 30. pii: S0306-4603(18)30575-6. doi: 10.1016/j.addbeh.2018.05.029. [Epub ahead of print]

Comments: Some unusual associations with overdose: HCV infection, witnessing an overdose, or more buprenorphine treatment episodes.

78) Polydrug use patterns, risk behavior and unmet healthcare need in a community-based sample of women who use cocaine, heroin or methamphetamine.

Lorvick J, Browne EN, Lambdin BH, Comfort M.

Addict Behav. 2018 Oct;85:94-99. doi: 10.1016/j.addbeh.2018.05.013. Epub 2018 May 24.

Comments: Polydrug use is associated with lots of health problems and risk behaviors.

79) Not just heroin: Extensive polysubstance use among US high school seniors who currently use heroin.

Palamar JJ, Le A, Mateu-Gelabert P.

Drug Alcohol Depend. 2018 Jul 1;188:377-384. doi: 10.1016/j.drugalcdep.2018.05.001. Epub 2018 Jun 4.

Comments: Interesting analysis. Alcohol use is less likely as heroin use increases, but benzodiazepine use is.

80) Methodologic limitations of prescription opioid safety research and recommendations for improving the evidence base.

Ranapurwala SI, Naumann RB, Austin AE, Dasgupta N, Marshall SW.

Pharmacoepidemiol Drug Saf. 2018 Jun 3. doi: 10.1002/pds.4564. [Epub ahead of print] Review.

Comments: Concerns with studies used to justify the CDC opioid prescribing guidelines.

81) Quantity fluctuations of illicitly used opioids and overdose risk.

Rowe C, Wheeler E, Vittinghoff E, Santos GM, Behar E, Coffin PO.

Int J Drug Policy. 2018 May 25;58:64-70. doi: 10.1016/j.drugpo.2018.05.004. [Epub ahead of print]

Comments: An interesting analysis of data from a randomized trial of overdose prevention, finding that variations in the amount of opioids used over time was associated with subsequent overdose.

82) Association Between Prescription Drug Monitoring Programs and Nonfatal and Fatal Drug Overdoses: A Systematic Review.

Fink DS, Schleimer JP, Sarvet A, Grover KK, Delcher C, Castillo-Carniglia A, Kim JH, Rivera-Aguirre AE, Henry SG, Martins SS, Cerdá M.

Ann Intern Med. 2018 May 8. doi: 10.7326/M17-3074. [Epub ahead of print]

Comments: First, can we please call these what they are: Controlled Substance Monitoring Programs (CSMPs)? Please? Second, as the review concludes data are insufficient.

83) Risk factors for opioid overdose among hospitalized patients.

Vu Q, Beselman A, Monolakis J, Wang A, Rastegar D.

J Clin Pharm Ther. 2018 May 23. doi: 10.1111/jcpt.12701. [Epub ahead of print]

Comments: For patients in the hospital, risk of overdose was associated with older age, being in the ICU, getting other depressants, and impaired kidneys.

84) Trends in non-medical prescription opioids and heroin co-use among adults, 2003-2014.

Mital S, Windle M, Cooper HLF, Crawford ND.

Addict Behav. 2018 May 16. pii: S0306-4603(18)30468-4. doi: 10.1016/j.addbeh.2018.05.005. [Epub ahead of print]

Comments: Pulling trends from the National Survey on Drug Use and Health is tough work. Authors found increasing co-use of these opioids.

85) Toots, tastes and tester shots: user accounts of drug sampling methods for gauging heroin potency.

Mars SG, Ondocsin J, Ciccarone D.

Harm Reduct J. 2018 May 16;15(1):26. doi: 10.1186/s12954-018-0232-z.

Comments: Such important work! Not just tester shots. Also “slow shots”, trying the drug through other routes of administration first, watching someone else use first, etc.

86) Post-stroke Intranasal (+)-Naloxone Delivery Reduces Microglial Activation and Improves Behavioral Recovery from Ischemic Injury.

Anttila JE, Albert K, Wires ES, Mätlik K, Loram LC, Watkins LR, Rice KC, Wang Y, Harvey BK, Airavaara M.

eNeuro. 2018 Apr 18;5(2). pii: ENEURO.0395-17.2018. doi: 10.1523/ENEURO.0395-17.2018. eCollection 2018 Mar-Apr.

Comments: I’m so intrigued by this. Clinically, I have sometimes seen a slight reaction to naloxone when given for a non-opioid arrest event – have always wondered what was going on.

87) Young adults’ opioid use trajectories: From nonmedical prescription opioid use to heroin, druginjection, drug treatment and overdose.

Guarino H, Mateu-Gelabert P, Teubl J, Goodbody E.

Addict Behav. 2018 May 1. pii: S0306-4603(18)30362-9. doi: 10.1016/j.addbeh.2018.04.017. [Epub ahead of print]

Comments: Use started with Rx opioids, 83% transitioned to heroin and 64% to heroin injection, generally within 4 years of initial nonmedical use. First overdose occurred on average <1 year after starting heroin.

88) Harm Reduction Strategies for the Opiod [sic] Crisis.

Castillo T.

N C Med J. 2018 May-Jun;79(3):192-194. doi: 10.18043/ncm.79.3.192.

Comments: What’s happening in North Carolina.

89) Perceptions of Health-Related Community Reentry Challenges among Incarcerated Drug Users in Azerbaijan, Kyrgyzstan, and Ukraine.

Rozanova J, Morozova O, Azbel L, Bachireddy C, Izenberg JM, Kiriazova T, Dvoryak S, Altice FL.

J Urban Health. 2018 May 4. doi: 10.1007/s11524-018-0256-4. [Epub ahead of print]

Comments: Prisoners did not prioritize getting on methadone for opioid use disorder prior to release. Presumably this is related to both access and competing priorities.

90) Physician Prescribing of Opioids to Patients at Increased Risk of Overdose From Benzodiazepine Use in the United States.

Ladapo JA, Larochelle MR, Chen A, Villalon MM, Vassar S, Huang DYC, Mafi JN.

JAMA Psychiatry. 2018 Apr 12. doi: 10.1001/jamapsychiatry.2018.0544. [Epub ahead of print]

Comments: Although new opioid prescriptions have been declining, including among patients taking benzodiazepines, getting started on opioids is still more likely for patients already using benzodiazepines compared to those not using benzos. Authors conclude that other factors appear to be contributing to overdose, rather than prescribing practices.

91)Addressing the growing opioid and heroin abuse epidemic: a call for medical school curricula.

Ratycz MC, Papadimos TJ, Vanderbilt AA.

Med Educ Online. 2018 Dec;23(1):1466574. doi: 10.1080/10872981.2018.1466574.

Comments: Yes, please! All medical students should get buprenorphine waivered in order to complete pre-clinical training.

92)The long-term impact of post traumatic stress disorder on recovery from heroin dependence.

Mills KL, Marel C, Darke S, Ross J, Slade T, Teesson M.

J Subst Abuse Treat. 2018 Jun;89:60-66. doi: 10.1016/j.jsat.2018.04.001. Epub 2018 Apr 4.

Comments: Patients with PTSD and opioid use disorder did just as well as those without PTSD with regard to recovery, but had higher rates of major depression, attempted suicide, trauma, and poor occupational function.

93)Re-racialization of Addiction and the Redistribution of Blame in the White Opioid Epidemic.

Mendoza S, Rivera AS, Hansen HB.

Med Anthropol Q. 2018 Apr 27. doi: 10.1111/maq.12449. [Epub ahead of print]

Comments: Such complicated issues. Overall, the narrative of white opioid users opened an opportunity for us to treat ALL people with substance use disorders with respect.

94)The U.S. opioid epidemic: One disease, diverging tales.

McBain R, Rose AJ, LaRochelle MR.

Prev Med. 2018 Apr 20. pii: S0091-7435(18)30134-8. doi: 10.1016/j.ypmed.2018.04.023. [Epub ahead of print] No abstract available.

Comments: Interesting discussion of opioid health outcomes in older versus younger adults.

95) Survey Assessing Medical Student and Physician Knowledge and Attitudes Regarding the Opioid Crisis.

Chouinard S, Prasad A, Brown R.

WMJ. 2018 Mar;117(1):34-37.

Comments: A lot of education is needed.

96) Delayed Cerebral Edema Leading to Cerebral Hernia in a Patient With Heroin Overdose.

Amjad W, Qureshi WT, Farooq AU.

Am J Ther. 2018 Apr 11. doi: 10.1097/MJT.0000000000000761. [Epub ahead of print] No abstract available.

Comments: I have no way to access.

97) Safe and unsafe spaces: Non-fatal overdose, arrest, and receptive syringe sharing among people who inject drugs in public and semi-public spaces in Baltimore City.

Hunter K, Park JN, Allen ST, Chaulk P, Frost T, Weir BW, Sherman SG.

Int J Drug Policy. 2018 Apr 13;57:25-31. doi: 10.1016/j.drugpo.2018.03.026. [Epub ahead of print]

Comments: Injecting in public spaces was associated with overdose, arrest, and receptive syringe sharing.

98) Implementation of Online Opioid Prevention, Recognition and Response Trainings for Laypeople: Year 1 Survey Results.

Simmons J, Rajan S, Goldsamt LA, Elliott L.

Subst Use Misuse. 2018 Apr 11:1-6. doi: 10.1080/10826084.2018.1451891. [Epub ahead of print]

Comments: Online training in naloxone is certainly sufficient.

99) America’s Opioid Epidemic: a Comprehensive Review and Look into the Rising Crisis.

Ostling PS, Davidson KS, Anyama BO, Helander EM, Wyche MQ, Kaye AD.

Curr Pain Headache Rep. 2018 Apr 4;22(5):32. doi: 10.1007/s11916-018-0685-5. Review.

Comments: Review of issues related to opioid crisis.

100) Blocking interleukin-4 enhances efficacy of vaccines for treatment of opioid abuse and prevention of opioid overdose.

Laudenbach M, Baruffaldi F, Robinson C, Carter P, Seelig D, Baehr C, Pravetoni M.

Sci Rep. 2018 Apr 3;8(1):5508. doi: 10.1038/s41598-018-23777-6.

Comments: Given the diversity of opioids, I remain skeptical that a vaccine specific to an individual opioid would be particularly beneficial.

101) Fatal and non-fatal overdose among opiate users in South Wales: A qualitative study of peer responses.

Holloway K, Hills R, May T.

Int J Drug Policy. 2018 Mar 29;56:56-63. doi: 10.1016/j.drugpo.2018.03.007. [Epub ahead of print]

Comments: Hm. These results seem a bit odd and may be specific to South Wales. Overdose isn’t that hard to identify…

102) An electronic intervention to improve safety for pain patients co-prescribed chronic opioids and benzodiazepines.

Zaman T, Rife TL, Batki SL, Pennington DL.

Subst Abus. 2018 Mar 29:1-8. doi: 10.1080/08897077.2018.1455163. [Epub ahead of print]

Comments: The VA has done some remarkable work, always with attention to the needs of its patients.

103) Preventing Opioid Overdose in the Clinic and Hospital: Analgesia and Opioid Antagonists.

Peglow SL, Binswanger IA.

Med Clin North Am. 2018 Jul;102(4):621-634. doi: 10.1016/j.mcna.2018.02.005. Review.

Comments: Review of overdose prevention plans.

104) Opioid use and harms associated with a sustained-release tapentadol formulation: a postmarketing study protocol.

Peacock A, Larance B, Farrell M, Cairns R, Buckley N, Degenhardt L.

BMJ Open. 2018 Mar 23;8(3):e020006. doi: 10.1136/bmjopen-2017-020006.

Comments: Methods for a postmarketing study that has not yet been conducted.

105) The President’s Commission on Combating Drug Addiction and the Opioid Crisis: Origins and Recommendations.

Madras BK.

Clin Pharmacol Ther. 2018 Mar 23. doi: 10.1002/cpt.1050. [Epub ahead of print]

Comments: As title says.

106) Reemergence of Intravenous Drug Use as Risk Factor for Candidemia, Massachusetts, USA.

Poowanawittayakom N, Dutta A, Stock S, Touray S, Ellison RT 3rd, Levitz SM.

Emerg Infect Dis. 2018 Apr;24(4). doi: 10.3201/eid2404.171807.

Comments: As title says. Hopefully an inspiration for infectious disease providers to engage in addiction medicine.

107) Beyond the walls: Risk factors for overdose mortality following release from the Philadelphia Department of Prisons.

Pizzicato LN, Drake R, Domer-Shank R, Johnson CC, Viner KM.

Drug Alcohol Depend. 2018 Aug 1;189:108-115. doi: 10.1016/j.drugalcdep.2018.04.034. Epub 2018 Jun 5.

Comments: In Pennsylvania, former inmates released from state prison. 3% died and one-third were due to overdose. Whites were at higher risk than Blacks and Latinos and serious mental illness predicted overdose death.

108) Criminal justice continuum for opioid users at risk of overdose.

Brinkley-Rubinstein L, Zaller N, Martino S, Cloud DH, McCauley E, Heise A, Seal D.

Addict Behav. 2018 Feb 24. pii: S0306-4603(18)30089-3. doi: 10.1016/j.addbeh.2018.02.024. [Epub ahead of print]

Comments: Criminal justice settings need to take substance use disorders seriously, providing services that can greatly improve health and post-release survival.

109) “Taking away the chaos”: a health needs assessment for people who inject drugs in public places in Glasgow, Scotland.

Tweed EJ, Rodgers M, Priyadarshi S, Crighton E.

BMC Public Health. 2018 Jul 4;18(1):829. doi: 10.1186/s12889-018-5718-9.

Comments: Support for safer consumptions spaces in Scotland.