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

Nolan ML, Allen B, Paone D.

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

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

2) Opioid Use Disorder.

Dydyk AM, Jain NK, Gupta M.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Fagiola M, Hahn T, Avella J.

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

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

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

Guy GP Jr, Zhang K.

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

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

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

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

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

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

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

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

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

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

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

Cataife G, Dong J, Davis CS.

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

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

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

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

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

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

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

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

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

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

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

Carter G, Caudill P.

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

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

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

Rosenblum D, Unick J, Ciccarone D.

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

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

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

Quast TC.

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

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

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

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

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

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

17) Opioid use disorder.

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

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

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

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

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

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

Comment: Wastewater analyses are increasingly fascinating.

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

Lowder EM, Amlung J, Ray BR.

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

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

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

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

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

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

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

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

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

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

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

Eldridge LA, Agley J, Meyerson BE.

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

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

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

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

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

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

24) An Inpatient Psychiatric Program Targeting Opioid Overdoses.

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

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

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

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

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

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

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

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

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

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

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

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

Hoots B, Vivolo-Kantor A, Seth P.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Abiragi M, Bauler LD, Brown T.

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

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

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

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

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

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

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

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

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

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

Bohringer C, Astorga C, Liu H.

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

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

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

Winstanley EL, Stover AN, Feinberg J.

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

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

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

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

Brar R, Sutherland C, Nolan S.

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

Comments: Desperate for such options.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Schuler MS, Dick AW, Stein BD.

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

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

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

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

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

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

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

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

Thakur T, Frey M, Chewning B.

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

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

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

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

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

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

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

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

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

Comments: Yes.

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

Geiger C, Smart R, Stein BD.

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

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

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

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

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

Comments: Review.

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

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

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

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

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

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

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

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

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

Davis CS, Carr DH.

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

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

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

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

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

Comments: Syringe access programs.

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

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

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

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

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

McLean K, Kavanaugh PR.

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

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

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

Rajesh K, Crijns TJ, Ring D.

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

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

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

Oliver JE, Carlson C.

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

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

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

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

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

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

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

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

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

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

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

Walsh SL, Long KQX.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Caulkins JP, Pardo B, Kilmer B.

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

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

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

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

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

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

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

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

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

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

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

Smith JO, Malinowski SS, Ballou JM.

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

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

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

Patel B, Kosten TR.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

29) Monoclonal Antibodies for Combating Synthetic Opioid Intoxication.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

36) Editorial: Prescription for Addiction.

Riggs P.

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

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

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

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

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

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

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

Donaghy J.

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

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

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

Frank JW, Wakeman SE, Gordon AJ.

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

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

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

Rosenthal RN.

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

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

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

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

Bhardwaj SB, Cochran G, Kmiec J.

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

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

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

Dean A, Kimmel S.

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

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

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

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

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

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

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

Kim YM.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mitchell MT.

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

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

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

Crabtree A, Masuda JR.

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

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

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

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

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

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

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

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

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

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

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

Plunkett AR, Peden RM.

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

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

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

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

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

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

1) Fighting fire with fire: development of intranasal nalmefene to treat synthetic opioid overdose.

Krieter P, Gyaw S, Crystal R, Skolnick P.

J Pharmacol Exp Ther. 2019 Apr 2. pii: jpet.118.256115. doi: 10.1124/jpet.118.256115. [Epub ahead of print]

Comments: Nalmefene has high affinity and >7h duration of effect. But not at all clear that we need a more potent opioid antagonist, as the high mortality with fentanyl is likely due to rapid progression to cardiac arrest.

2) The Affordable Care Act In The Heart Of The Opioid Crisis: Evidence From West Virginia.

Saloner B, Landis R, Stein BD, Barry CL.

Health Aff (Millwood). 2019 Apr;38(4):633-642. doi: 10.1377/hlthaff.2018.05049.

Comments: The ACA is really one of the best tools we have for the health system to approach this crisis appropriately.

3) News Media Reporting On Medication Treatment For Opioid Use Disorder Amid The Opioid Epidemic.

Kennedy-Hendricks A, Levin J, Stone E, McGinty EE, Gollust SE, Barry CL.

Health Aff (Millwood). 2019 Apr;38(4):643-651. doi: 10.1377/hlthaff.2018.05075.

Comments: Addiction experts aren’t so great at pitching their story.

4) Trends in and correlates of tranquilizer misuse among adults who misuse opioids in the United States, 2002-2014.

Boggis JS, Feder K.

Drug Alcohol Depend. 2019 Feb 16;198:158-161. doi: 10.1016/j.drugalcdep.2019.01.014. [Epub ahead of print]

Comments: 28% of those reporting opioid misuse also report tranquilizer misuse.

5) How prepared are pharmacists to provide over-the-counter naloxone? The role of previous education and new training opportunities.

Lai Joyce Chun K, Olsen A, Taing MW, Clavarino A, Hollingworth S, Dwyer R, Middleton M, Nielsen S.

Res Social Adm Pharm. 2019 Mar 22. pii: S1551-7411(18)30328-0. doi: 10.1016/j.sapharm.2019.03.003. [Epub ahead of print]

Comments: 81% of pharmacists in Australia were willing to be trained in opioid overdose prevention.

6) Evidence-Based Guidelines for EMS Administration of Naloxone.

Williams K, Lang ES, Panchal A, Gasper JJ, Taillac P, Gouda J, Hedges M.

Prehosp Emerg Care. 2019 Mar 29:1-41. doi: 10.1080/10903127.2019.1597955. [Epub ahead of print]

Comments: It makes sense that intranasal is preferred over intramuscular, but why would intravenous be preferred over other routes of administration when it’s challenging and risky to place an IV in emergency settings? This really doesn’t make sense.

7) Opioid agonist treatment and the process of injection drug use initiation.

Mittal ML, Jain S, Sun S, DeBeck K, Milloy MJ, Hayashi K, Hadland SE, Werb D.

Drug Alcohol Depend. 2019 Apr 1;197:354-360. doi: 10.1016/j.drugalcdep.2018.12.018. Epub 2019 Jan 22.

Comments: People who inject drugs but are in opioid agonist treatment were half as likely (0.52) to report recently helping someone else start injecting, compared to those not in treatment. This is a very compelling reason to expand treatment access. 

8) Microfluidic analysis of fentanyl-laced heroin samples by surface-enhanced Raman spectroscopy in a hydrophobic medium.

Salemmilani R, Moskovits M, Meinhart CD.

Analyst. 2019 Mar 28. doi: 10.1039/c9an00168a. [Epub ahead of print]

Comments: This looks like a qualitative way to identify fentanyl in heroin samples. While that is interesting, what is more needed is quantitative assessment / relative concentration.

9) Unintentional drug overdose deaths involving cocaine among middle-aged and older adults in New York City.

Han BH, Tuazon E, Kunins HV, Mantha S, Paone D.

Drug Alcohol Depend. 2019 Mar 14;198:121-125. doi: 10.1016/j.drugalcdep.2019.01.042. [Epub ahead of print]

Comments: “Characteristics of decedents of cocaine-involved overdose overlap with populations with high [cardiovascular disease] burden…”

10)Trends in fentanyl and fentanyl analogue-related overdose deaths – Montgomery County, Ohio, 2015-2017.

Daniulaityte R, Juhascik MP, Strayer KE, Sizemore IE, Zatreh M, Nahhas RW, Harshbarger KE, Antonides HM, Martins SS, Carlson RG.

Drug Alcohol Depend. 2019 Mar 18;198:116-120. doi: 10.1016/j.drugalcdep.2019.01.045. [Epub ahead of print]

Comments: Solid data on the emergency of fentanyl and analogues in Ohio.

11)The association between county-level safety net treatment access and opioid hospitalizations and mortality in New York.

Haley SJ, Maroko AR, Wyka K, Baker MR.

J Subst Abuse Treat. 2019 May;100:52-58. doi: 10.1016/j.jsat.2019.02.004. Epub 2019 Feb 22.

Comments: Geographic proximity to opioid treatment programs/buprenorphine providers is associated with less of an increase in opioid overdose mortality.

12)Medications for Opioid Use Disorder Save Lives.

Leshner AI, Mancher M; Committee on Medication-Assisted Treatment for Opioid Use Disorder, Board on Health Sciences Policy, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine.

Washington (DC): National Academies Press (US); 2019 Mar 20.

Comments: Review of medications.

13)US Emergency Department Visits for Acute Harms From Prescription Opioid Use, 2016-2017.

Lovegrove MC, Dowell D, Geller AI, Goring SK, Rose KO, Weidle NJ, Budnitz DS.

Am J Public Health. 2019 May;109(5):784-791. doi: 10.2105/AJPH.2019.305007. Epub 2019 Mar 21.

Comments: Fascinating data on opioids in 267,020 ED visits. 38.9% were therapeutic use, 30.4% of which were due to gastrointestinal effects (e.g. constipation). 47.6% were due to nonmedical use, 30.0% of which were due to unresponsiveness or cardiorespiratory failure and 35.7% of which were due to altered mental status. 13.5% were due to self-harm. These are very useful data.

14)Opioid Use Disorders in Adolescents-Updates in Assessment and Management.

Yule AM, Lyons RM, Wilens TE.

Curr Pediatr Rep. 2018 Jun;6(2):99-106. doi: 10.1007/s40124-018-0161-z. Epub 2018 Apr 25.

Comments: Buprenorphine use is supported.

15)Comparative Human Factors Evaluation of Two Nasal Naloxone Administration Devices: NARCAN_®Nasal Spray and Naloxone Prefilled Syringe with Nasal Atomizer.

Tippey KG, Yovanoff M, McGrath LS, Sneeringer P.

Pain Ther. 2019 Mar 15. doi: 10.1007/s40122-019-0118-0. [Epub ahead of print]

Comments: No surprise here – the manufactured device is easier to use, particularly for untrained bystanders.

16)Development and evaluation of a standardized research definition for opioid overdose outcomes.

Binswanger IA, Narwaney KJ, Gardner EM, Gabella BA, Calcaterra SL, Glanz JM.

Subst Abus. 2019 Mar 15:1-9. doi: 10.1080/08897077.2018.1546263. [Epub ahead of print]

Comments: An important first step, but there’s a lot left to figure out.

17)At-a-glance – Supervised Injection Services: a community-based response to the opioid crisis in the City of Ottawa, Canada.

DelVillano S, de Groh M, Morrison H, Do MT.

Health Promot Chronic Dis Prev Can. 2019 Mar;39(3):112-115. doi: 10.24095/hpcdp.39.3.03. English, French. 

Comments: As title describes.

18)Intranasal naloxone rapidly occupies brain mu-opioid receptors in human subjects.

Johansson J, Hirvonen J, Lovró Z, Ekblad L, Kaasinen V, Rajasilta O, Helin S, Tuisku J, Sirén S, Pennanen M, Agrawal A, Crystal R, Vainio PJ, Alho H, Scheinin M.

Neuropsychopharmacology. 2019 Mar 13. doi: 10.1038/s41386-019-0368-x. [Epub ahead of print]

Comments: It’s long been thought that there would be other potential benefits to intranasal naloxone. Authors suggest gambling and alcohol use disorder. Others have suggested eating disorders.

19)Managing Opioid Use in Orthopaedic Patients Through Harm Reduction Strategies.

Worley J.

Orthop Nurs. 2019 Mar/Apr;38(2):129-135. doi: 10.1097/NOR.0000000000000524.

Comments: Targeting orthopedic providers.

20)Comparison of the Pharmacokinetic Properties of Naloxone Following the Use of FDA-Approved Intranasal and Intramuscular Devices Versus a Common Improvised Nasal Naloxone Device.

Krieter PA, Chiang CN, Gyaw S, McCann DJ.

J Clin Pharmacol. 2019 Mar 12. doi: 10.1002/jcph.1401. [Epub ahead of print]

Comments: We’ve known this for awhile and nobody has used the improvised device in years, so … 

21)Provider perceptions of system-level opioid prescribing and addiction treatment policies.

Haffajee RL, French CA.

Curr Opin Psychol. 2019 Feb 4;30:65-73. doi: 10.1016/j.copsyc.2019.01.018. [Epub ahead of print] Review.

Comments: Awareness is increasing.

22)Life after opioid-involved overdose: survivor narratives and their implications for ER/ED interventions.

Elliott L, Bennett AS, Wolfson-Stofko B.

Addiction. 2019 Mar 9. doi: 10.1111/add.14608. [Epub ahead of print]

Comments: A really important element of medicine is not to blame patients for their disease. This gets difficult in emergency settings – and not just for substance use disorders. Recurrent visits for unmanaged diabetes, noncompliance with congestive heart failure regimens, etc., can lead to judgmental care and lack of empathy. Nonetheless, the stigma for substance use disorders comes far more readily.

23)Prescription Drug and Alcohol Use Disorders: Safe Prescribing of Opioids.

Shin T.

FP Essent. 2019 Mar;478:11-18.

Comments: The important element to the CDC guidelines described here is that they were not designed for people already on opioids. The guidelines don’t say you should automatically taper people to the levels identified in the CDC guidelines, and increasing data shows that can be hazardous (including a recent FDA statement on the issue)

24)Evaluation and optimization of take-home naloxone in an academic medical center.

Cooler J, Ross CA, Robert S, Linder L, Ruhe AM, Philip A.

Ment Health Clin. 2019 Mar 1;9(2):105-109. doi: 10.9740/mhc.2019.03.105. eCollection 2019 Mar.

Comments: Use of educational videos.

25)From Substance Use Disorders in Life to Autopsy Findings: A Combined Case-Record and Medico-Legal Study.

Brådvik L, Löwenhielm P, Frank A, Berglund M.

Int J Environ Res Public Health. 2019 Mar 5;16(5). pii: E801. doi: 10.3390/ijerph16050801.

Comments: Great idea, but this study lumped suicide with undetermined with accidental overdose. Not sure what to do with such results.

26)Potential uses of naltrexone in emergency department patients with opioid use disorder.

Bradley ES, Liss D, Carriero SP, Brush DE, Babu K.

Clin Toxicol (Phila). 2019 Mar 4:1-7. doi: 10.1080/15563650.2019.1583342. [Epub ahead of print]

Comments: In the context of an overdose after prolonged abstinence, this might be reasonable. Again, while important to have as an option, the applications of naltrexone for opioid use disorder are limited.

27)Successful treatment with slow-release oral morphine following afentanyl-related overdose: A case report.

Prinsloo G, Ahamad K, Socías ME MD, MSc.

Subst Abus. 2019 Mar 4:1-3. doi: 10.1080/08897077.2019.1576086. [Epub ahead of print]

Comments: There are many options for treating opioid use disorder, beyond the three options available in the U.S.

28)An evaluation of Take Home Naloxone program implementation in British Columbian correctional facilities.

Pearce LA, Mathany L, Rothon D, Kuo M, Buxton JA.

Int J Prison Health. 2019 Mar 11;15(1):46-57. doi: 10.1108/IJPH-12-2017-0058. Epub 2019 Feb 20.

Comments: Focus groups.

29)Scotland’s National Naloxone Programme.

Bird SM, McAuley A.

Lancet. 2019 Jan 26;393(10169):316-318. doi: 10.1016/S0140-6736(18)33065-4. No abstract available. 

Comments: Review of some of the estimates produced in Scotland.

30)Trends and correlates of perceived access to heroin among young adults in the United States, 2002-2016.

Salas-Wright CP, Oh S, Vaughn MG, Muroff J, Amodeo M, Delva J.

Drug Alcohol Depend. 2018 Dec 1;193:169-176. doi: 10.1016/j.drugalcdep.2018.09.009. Epub 2018 Oct 18.

Comments: “probably impossible” to obtain heroin.

31)Characterizing fentanyl-related overdoses and implications for overdose response: Findings from a rapid ethnographic study in Vancouver, Canada.

Mayer S, Boyd J, Collins A, Kennedy MC, Fairbairn N, McNeil R.

Drug Alcohol Depend. 2018 Dec 1;193:69-74. doi: 10.1016/j.drugalcdep.2018.09.006. Epub 2018 Oct 12.

Comments: Rapid onset, chest rigidity, etc.

32)Utilization of opioid agonist therapy among incarcerated persons with opioid use disorder in Vancouver, Canada.

Bozinoff N, DeBeck K, Milloy MJ, Nosova E, Fairbairn N, Wood E, Hayashi K.

Drug Alcohol Depend. 2018 Dec 1;193:42-47. doi: 10.1016/j.drugalcdep.2018.09.003. Epub 2018 Oct 6.

Comments: It reduces illicit use and overdose.

33)The Impact of Patient Characteristics and Postoperative Opioid Exposure on Prolonged Postoperative Opioid Use: An Integrative Review.

Lanzillotta JA, Clark A, Starbuck E, Kean EB, Kalarchian M.

Pain Manag Nurs. 2018 Oct;19(5):535-548. doi: 10.1016/j.pmn.2018.07.003. Epub 2018 Aug 29. Review.

Comments: Unclear how much the actual act of prescribing for prolonged periods has on post-operative opioid use, as there are many other predictors of prolonged post-operative use that may be outside of the surgeon’s control.

34)Addressing the Fentanyl Analogue Epidemic by Multiplex UHPLC-MS/MS Analysis of Whole Blood.

Bergh MS, Bogen IL, Wilson SR, Øiestad ÅML.

Ther Drug Monit. 2018 Dec;40(6):738-748. doi: 10.1097/FTD.0000000000000564.

Comments: Identifying fentanyl analogues in blood.

35)Young Man After Overdose.

Lebin JA, Wu EH, McCoy AM, Gross JA.

J Emerg Med. 2018 Oct;55(4):e109-e110. doi: 10.1016/j.jemermed.2018.07.002. Epub 2018 Aug 16. No abstract available. 

Comments: Undigested pasta mistaken for drug packing materials.

36)Reducing the opioid overdose death toll in North America.

Hall WD, Farrell M.

PLoS Med. 2018 Jul 31;15(7):e1002626. doi: 10.1371/journal.pmed.1002626. eCollection 2018 Jul.

Comments: Review of strategies including medications, naloxone, and supervised injection sites.

37)Reframing the Prevention Strategies of the Opioid Crisis: Focusing on Prescription Opioids, Fentanyl, and Heroin Epidemic.

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

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

Comments: A review of the crisis and education, increased access to non-opioid pain management options, and use of medications for opioid use disorder.

38)Unit-Dose Packaging and Unintentional Buprenorphine-Naloxone Exposures.

Wang GS, Severtson SG, Bau GE, Dart RC, Green JL.

Pediatrics. 2018 Jun;141(6). pii: e20174232. doi: 10.1542/peds.2017-4232. Epub 2018 May 3.

Comments: Appears to have reduced pediatric exposures.

39)Scene Safety and Force Protection in the Era of Ultra-Potent Opioids.

Lynch MJ, Suyama J, Guyette FX.

Prehosp Emerg Care. 2018 Mar-Apr;22(2):157-162. doi: 10.1080/10903127.2017.1367446. Epub 2017 Sep 28.

Comments: As the article describes, this is media craziness. The “overdose” events from touching fentanyl are consistent with panic attacks, not opioid toxicity. If transdermal exposure to fentanyl was a concern, there would be no way to distribute it to people who use drugs. Some serious education is needed.

40)Death From Opioid Overdose After Deep Brain Stimulation: A Case Report.

Zhang C, Huang Y, Zheng F, Zeljic K, Pan J, Sun B.

Biol Psychiatry. 2018 Jan 1;83(1):e9-e10. doi: 10.1016/j.biopsych.2017.07.018. Epub 2017 Aug 1. No abstract available. 

Comments: This is a death during a clinical trial of deep brain stimulation for treatment of opioid use disorder. A patient relapsed and died from heroin overdose.

41)Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts.

Rose ME.

Pain Med. 2018 Apr 1;19(4):793-807. doi: 10.1093/pm/pnx048. Review.

Comments: This is a more complex issue than this article makes it out to be.

42)Pharmacist-led health-system approaches to reduce opioid overdose and death.

Saldaña SN, Weaver N, Stanford B.

J Am Pharm Assoc (2003). 2017 Mar – Apr;57(2S):S8-S9. doi: 10.1016/j.japh.2016.09.005. Epub 2016 Nov 16. No abstract available. 

Comments: Encouraging.

43)Bringing naloxone to ground zero: Huntington, West Virginia.

Babcock C, Rockich-Winston N, Booth C.

J Am Pharm Assoc (2003). 2017 Mar – Apr;57(2S):S9-S10. doi: 10.1016/j.japh.2016.09.006. Epub 2016 Nov 9. No abstract available. 

Comments: West Virginia. Oh West Virginia. If there were a place more in need…

1) Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2011-2016.

Hedegaard H, Bastian BA, Trinidad JP, Spencer M, Warner M.

Natl Vital Stat Rep. 2018 Dec;67(9):1-14.

Comment: Nice summary of the data demonstrating the shift from prescribed opioids to heroin to fentanyl, with rising methamphetamine and persistent cocaine presence.

2) Enhanced Intranasal Absorption of Naltrexone by Dodecyl Maltopyranoside: Implications for the Treatment of Opioid Overdose.

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

J Clin Pharmacol. 2019 Jan 30. doi: 10.1002/jcph.1384. [Epub ahead of print]

Comment: Fascinating that the half-life of naltrexone is only 2.2 hours when administered intranasally … would be great to see that for managing alcohol use.

3) Emergency department physicians’ and pharmacists’ perspectives on take-home naloxone.

Holland TJ, Penm J, Dinh M, Aran S, Chaar B.

Drug Alcohol Rev. 2019 Jan 29. doi: 10.1111/dar.12894. [Epub ahead of print]

Comment: Qualitative assessment of opinions.

4) Take-home naloxone: a life saver in opioid overdose.

The Lancet.

Lancet. 2019 Jan 26;393(10169):296. doi: 10.1016/S0140-6736(19)30153-9. No abstract available. 

Comment: Editorial supporting take-home naloxone.

5) Feasibility and Acceptability of a Checklist and Learning Collaborative to Promote Quality and Safety in the Perinatal Care of Women with Opioid Use Disorders.

Goodman D, Zagaria AB, Flanagan V, Deselle FS, Hitchings AR, Maloney R, Small TA, Vergo AV, Bruce ML.

J Midwifery Womens Health. 2019 Jan;64(1):104-111. doi: 10.1111/jmwh.12943.

Comment: Some good changes – more naloxone provided, more counseling regarding breastfeeding, and more nicotine-replacement therapy initiated.

6) Correlates of seeking emergency medical help in the event of an overdose in British Columbia, Canada: Findings from the Take Home Naloxone program.

Karamouzian M, Kuo M, Crabtree A, Buxton JA.

Int J Drug Policy. 2019 Jan 25. pii: S0955-3959(19)30014-3. doi: 10.1016/j.drugpo.2019.01.006. [Epub ahead of print]

Comment: Great analysis of naloxone programmatic data. 55.7% of lay naloxone administrations were followed by a call for emergency medical services, again demonstrating that we do not have data showing a reduction in calling 911 when naloxone is administered. 

7) Seizures in tramadol overdoses reported in the ToxIC registry: predisposing factors and the role of naloxone.

Murray BP, Carpenter JE, Dunkley CA, Moran TP, Alfaifi M, Alsukaiti WS, Kazzi Z.

Clin Toxicol (Phila). 2019 Jan 24:1-5. doi: 10.1080/15563650.2018.1547826. [Epub ahead of print]

Comment: Tramadol is a weird drug. This analysis found that when it caused an opioid-like overdose, seizures were less likely, and that naloxone use was not associate with tramadol seizures.

8) “You Never Know What You’re Getting”: Opioid Users’ Perceptions of Fentanyl in Southwest Pennsylvania.

McLean K, Monnat SM, Rigg K, Sterner GE 3rd, Verdery A.

Subst Use Misuse. 2019 Jan 24:1-12. doi: 10.1080/10826084.2018.1552303. [Epub ahead of print]

Comment: Fentanyl use patterns are evolving – it seems to be here to stay this time.

9) Development of a Cascade of Care for responding to the opioid epidemic.

Williams AR, Nunes EV, Bisaga A, Levin FR, Olfson M.

Am J Drug Alcohol Abuse. 2019 Jan 24:1-10. doi: 10.1080/00952990.2018.1546862. [Epub ahead of print]

Comment: Nice to see this development.

10) Blockade of the human ether a-go-go related gene (hERG) potassium channel by fentanyl.

Tschirhart JN, Li W, Guo J, Zhang S.

Mol Pharmacol. 2019 Jan 21. pii: mol.118.114751. doi: 10.1124/mol.118.114751. [Epub ahead of print]

Comment: First, you gotta love the naming culture for these genes. Now the human ether a-go-go gene potassium channel effects could prolong the QT interval, which could result in ventricular arrhythmias and, ultimately, cardiac arrest. Is this playing a role in fentanyl-related deaths? Not sure. 

11) Changing risk and presentation of overdose associated with consumption of street drugs at a supervised injection site in Vancouver, Canada.

Notta D, Black B, Chu T, Joe R, Lysyshyn M.

Drug Alcohol Depend. 2019 Jan 15;196:46-50. doi: 10.1016/j.drugalcdep.2018.12.016. [Epub ahead of print]

Comment: Great use of these data. As fentanyl entered the heroin supply in Vancouver, the rate of “heroin” overdoses rose 4.8 fold. This is interesting, as fentanyl knowingly used at the Sydney injection facility was 4 times more likely than heroin to result in overdose – honestly I would have expected an even more substantial increase in “heroin” overdose events in the context of heroin contaminated with fentanyl. Notably, there was a several fold increase in overdose events for all drugs being injected in Vancouver over the period studied. They also saw an increase in rigidity (a potential complication of fentanyl) from 10.4% of “heroin” overdoses in 2010/11 to 18.9% in 2017.

12) High Prevalence of Self-Reported Exposure to Adulterated Drugs Among People Who Experienced an Opioid Overdose in Canada: A Cohort Study.

Prangnell A, Fairgrieve C, Nosova E, DeBeck K, Milloy MJ, Hayashi K.

Subst Use Misuse. 2019 Jan 20:1-6. doi: 10.1080/10826084.2018.1555257. [Epub ahead of print]

Comment: Two-thirds of people who overdosed believed their drugs had been adulterated. While the current drug supply is very dynamic, I suspect this finding would hold for overdoses in areas not heavily affected by fentanyl; that is, this is a common perception among people who have overdosed, explained by the actor-observer bias.

13) Associations between implementation of Project Lazarus and opioid analgesic dispensing and buprenorphine utilization in North Carolina, 2009-2014.

Alexandridis AA, Dasgupta N, McCort AD, Ringwalt CL, Rosamond WD, Chelminski PR, Marshall SW.

Inj Epidemiol. 2019 Jan 21;6(1):2. doi: 10.1186/s40621-018-0179-2.

Comment: Limited effects.

14) What should clinicians do as fentanyl replaces heroin?

Bisaga A.

Addiction. 2019 Jan 20. doi: 10.1111/add.14522. [Epub ahead of print] No abstract available. 

Comment: Be creative, be innovative, don’t be shy.

15) Twenty years of the methadone treatment protocol in Ireland: reflections on the role of general practice.

Delargy I, Crowley D, Van Hout MC.

Harm Reduct J. 2019 Jan 17;16(1):5. doi: 10.1186/s12954-018-0272-4. Review.

Comment: 20 years and 10,000 patients later.

16) Overdose Deaths Involving Fentanyl and Fentanyl Analogs – New York City, 2000-2017.

Colon-Berezin C, Nolan ML, Blachman-Forshay J, Paone D.

MMWR Morb Mortal Wkly Rep. 2019 Jan 18;68(2):37-40. doi: 10.15585/mmwr.mm6802a3.

Comment: It’s always tricky to use toxicology results in overdose mortality surveillance because there are many substances found on toxicology which may not have contributed to the death (e.g. something the patient takes medically that was at a low or appropriately therapeutic level and doesn’t interact with likely causal drugs, or something that is a by-product of decomposition). In this circumstance, however, it made sense.

17) Changes in Buprenorphine-Naloxone and Opioid Pain Reliever Prescriptions After the Affordable Care Act Medicaid Expansion.

Saloner B, Levin J, Chang HY, Jones C, Alexander GC.

JAMA Netw Open. 2018 Aug 3;1(4):e181588. doi: 10.1001/jamanetworkopen.2018.1588.

Comment: Buprenorphine treatment increased and opioid pain reliever prescriptions did not. That makes solid sense.

18) Pharmacokinetics of a novel, approved, 1.4 mg intranasal naloxone formulation for reversal of opioid overdose- a randomised controlled trial.

Skulberg AK, Åsberg A, Khiabani HZ, Røstad H, Tylleskar I, Dale O.

Addiction. 2019 Jan 14. doi: 10.1111/add.14552. [Epub ahead of print]

Comment: Intranasal 1.4mg was ~50% bioavailable, which is half as good as intramuscular, and the pharmacokinetics were similar to 0.8mg intramuscular, although the time to peak effect was about 5 minutes slower.

19) Overdose mortality rates in Croatia and factors associated with self-reported drug overdose among persons who inject drugs in three Croatian cities.

Handanagic S, Bozicevic I, Sekerija M, Rutherford GW, Begovac J.

Int J Drug Policy. 2019 Jan 11;64:95-102. doi: 10.1016/j.drugpo.2018.11.017. [Epub ahead of print]

Comment: Polydrug injection.

20) Increased Presence of Fentanyl in Cocaine-Involved Fatal Overdoses: Implications for Prevention.

Nolan ML, Shamasunder S, Colon-Berezin C, Kunins HV, Paone D.

J Urban Health. 2019 Jan 11. doi: 10.1007/s11524-018-00343-z. [Epub ahead of print]

Comment: These data suggest that fentanyl is responsible for a good amount of the increase in cocaine deaths in NYC. Was that intentionally consumed or contaminating cocaine? Given that the demographics of cocaine related deaths have historically been fairly distinct from opioid deaths in NYC, I wonder if comparing demographics would help to elucidate which is the case.

21) Non-Medical Use of Novel Synthetic Opioids: A New Challenge to Public Health.

Lovrecic B, Lovrecic M, Gabrovec B, Carli M, Pacini M, Maremmani AGI, Maremmani I.

Int J Environ Res Public Health. 2019 Jan 9;16(2). pii: E177. doi: 10.3390/ijerph16020177. Review.

Comment: Yup, we’re in a mess.

22) Primary Care for Persons Who Inject Drugs.

Visconti AJ, Sell J, Greenblatt AD.

Am Fam Physician. 2019 Jan 15;99(2):109-116.

Comment: Love this topic, which drove me into medicine in the first place. Excellent to see physicians, scientists, and academic publications take on this need.

23) Reversal of Pediatric Opioid Toxicity with Take-Home Naloxone: a Case Report.

Lebin JA, Chen BC, Valento MJ.

J Med Toxicol. 2019 Jan 10. doi: 10.1007/s13181-018-0695-z. [Epub ahead of print]

Comment: This may be the first journal report of pediatric reversal with take-home naloxone, but it’s not the first story … it’s been happening in the community for decades.

24) Drug Overdose Deaths Among Women Aged 30-64 Years – United States, 1999-2017.

VanHouten JP, Rudd RA, Ballesteros MF, Mack KA.

MMWR Morb Mortal Wkly Rep. 2019 Jan 11;68(1):1-5. doi: 10.15585/mmwr.mm6801a1.

Comment: Increased overdose mortality across the board among women.

25) Increasing Naloxone Access and Use to Prevent Opioid Overdose Death and Disability.

White ND.

Am J Lifestyle Med. 2018 Oct 20;13(1):33-35. doi: 10.1177/1559827618803874. eCollection 2019 Jan-Feb. Review.

Comment: Legislation and pronouncements have only done so much.

26) Opioid overdose detection using smartphones.

Nandakumar R, Gollakota S, Sunshine JE.

Sci Transl Med. 2019 Jan 9;11(474). pii: eaau8914. doi: 10.1126/scitranslmed.aau8914.

Comment: This is a fascinating topic. We can saturate the world with naloxone, but it still won’t prevent overdose events from becoming fatal among people who are isolated from others (e.g. marginally housed, living in hotel rooms). In San Francisco, about one-third of deaths occurred in single-room occupancy hotel units – a number that is unlikely to be significantly affected by responder interventions. To have non-invasive tools that can detect concerning vital signs could be hugely beneficial if implemented well.

27) Intravenous Misuse of Methadone, Buprenorphine and Buprenorphine-Naloxone in Patients Under Opioid Maintenance Treatment: A Cross-Sectional Multicentre Study.

Lugoboni F, Zamboni L, Cibin M, Tamburin S; Gruppo InterSERT di Collaborazione Scientifica (GICS).

Eur Addict Res. 2019;25(1):10-19. doi: 10.1159/000496112. Epub 2019 Jan 9.

Comment: People who inject drugs frequently try to inject other drugs.

28) Predictive Factors of Treatment Outcomes for Hospital Care in Children with Acute Methadone Poisoning.

Atighi Y, Eizadi-Mood N, Mansourian M, Zamani A, Saffaei A, Sabzghabaee AM.

J Res Pharm Pract. 2018 Oct-Dec;7(4):200-204. doi: 10.4103/jrpp.JRPP_16_141.

Comment: Accidental opioid poisoning amoung children at home is always tragic. While our first effort has to be avoiding such events, an earlier manuscript today showed that having naloxone at home can help mitigate when they do occur.

29) Perspectives on rapid fentanyl test strips as a harm reduction practice among young adults who use drugs: a qualitative study.

Goldman JE, Waye KM, Periera KA, Krieger MS, Yedinak JL, Marshall BDL.

Harm Reduct J. 2019 Jan 8;16(1):3. doi: 10.1186/s12954-018-0276-0.

Comment: People use them and often implement some overdose prevention or management strategies when results are positive.

30) Legally Lethal Kratom: A Herbal Supplement with Overdose Potential.

Palasamudram Shekar S, Rojas EE, D’Angelo CC, Gillenwater SR, Martinez Galvis NP.

J Psychoactive Drugs. 2019 Jan 8:1-3. doi: 10.1080/02791072.2018.1562591. [Epub ahead of print]

Comment: Kratom’s another “weird” drug with some opioid properties. Took 10 days to recover – wow!

31) The importance of buprenorphine research in the opioid crisis.

Pendergrass SA, Crist RC, Jones LK, Hoch JR, Berrettini WH.

Mol Psychiatry. 2019 Jan 7. doi: 10.1038/s41380-018-0329-5. [Epub ahead of print]

Comment: Yep. Although I’d say implementation is more important.

32) Implementation of a collaborative model for opioid overdose prevention on campus.

Hill LG, Holleran Steiker LK, Mazin L, Kinzly ML.

J Am Coll Health. 2019 Jan 7:1-4. doi: 10.1080/07448481.2018.1549049. [Epub ahead of print]

Comment: Further expansion of naloxone.

33) Divergence In Recent Trends In Deaths From Intentional And Unintentional Poisoning.

Hempstead K, Phillips J.

Health Aff (Millwood). 2019 Jan;38(1):29-35. doi: 10.1377/hlthaff.2018.05186.

Comment: Notwithstanding a huge increase in unintentional opioid deaths and a shift in the causal opioids, poisoning suicide deaths have not changed during this period, again suggesting that suicide and unintentional overdose are distinct processes.

34) Medication Treatment For Opioid Use Disorders In Substance Use Treatment Facilities.

Mojtabai R, Mauro C, Wall MM, Barry CL, Olfson M.

Health Aff (Millwood). 2019 Jan;38(1):14-23. doi: 10.1377/hlthaff.2018.05162.

Comment: Uh … yeah. Please.

35) Changes in Pharmacists’ Perceptions After a Training in Opioid Misuse and Accidental Overdose Prevention.

Eukel HN, Skoy E, Werremeyer A, Burck S, Strand M.

J Contin Educ Health Prof. 2019 Jan 3. doi: 10.1097/CEH.0000000000000233. [Epub ahead of print]

Comment: More training pharmacists.

36) Commentary on Stam et al. (2019): Drugs, death and statistics.

Darke S.

Addiction. 2019 Jan 6. doi: 10.1111/add.14520. [Epub ahead of print] No abstract available. 

Comment: As usual, the author has insightful comments on overdose research and surveillance. Heroin deaths are often miscoded as morphine (or codeine?) deaths and stimulant deaths are often missed because the immediate medical cause of a cerebral hemorrhage or cardiac arrest is sufficient for the cause of death field.

37) On-site identification of psychoactive drugs by portable Raman spectroscopy during drug-checking service in electronic music events.

Gerace E, Seganti F, Luciano C, Lombardo T, Di Corcia D, Teifel H, Vincenti M, Salomone A.

Drug Alcohol Rev. 2019 Jan;38(1):50-56. doi: 10.1111/dar.12887. Epub 2019 Jan 6.

Comment: Portable drug detection is very exciting.

38) An age-based analysis of nonmedical prescription opioid use among people who use illegal drugs in Vancouver, Canada.

Cheng T, Small W, Dong H, Nosova E, Hayashi K, DeBeck K.

Subst Abuse Treat Prev Policy. 2018 Nov 27;13(1):41. doi: 10.1186/s13011-018-0180-3.

Comment: No age differences.

39) Utilizing Buprenorphine in the Emergency Department after Overdose.

Johns SE, Bowman M, Moeller FG.

Trends Pharmacol Sci. 2018 Dec;39(12):998-1000. doi: 10.1016/j.tips.2018.10.002. Review.

Comment: Good idea, when patients want it.

40) Pharmacological Research as a Key Component in Mitigating the Opioid Overdose Crisis.

Baumann MH, Kopajtic TA, Madras BK.

Trends Pharmacol Sci. 2018 Dec;39(12):995-998. doi: 10.1016/j.tips.2018.09.006. Review.

Comment: Review with focus on what new medications could provide.

41) At-a-glance – What can paramedic data tell us about the opioid crisis in Canada?

Do MT, Furlong G, Rietschlin M, Leyenaar M, Nolan M, Poirier P, Field B, Thompson W.

Health Promot Chronic Dis Prev Can. 2018 Sep;38(9):339-342. doi: 10.24095/hpcdp.38.9.06. English, French. 

Comment: It’s tricky to track opioid overdose with paramedic calls for several reasons (e.g. diagnosis codes are preliminary in this triage service, using naloxone administration as a marker misses a lot of events that aren’t “typical” heroin overdoses, the impact of naloxone programming is unclear, etc). Nonetheless, if you can access the data in a useful way, exploring this data source is irresistible.

42) Review of Case Narratives from Fatal Overdoses Associated with Injectable Naltrexone for Opioid Dependence.

Saucier R, Wolfe D, Dasgupta N.

Drug Saf. 2018 Oct;41(10):981-988. doi: 10.1007/s40264-018-0653-3. Erratum in: Drug Saf. 2018 May 24. 

Comment: It is concerning that in overdose deaths the manufacturer placed the blame on opioid use disorder and did not consider elevated risk for overdose after treatment discontinuation. I would agree that a registry is in order.