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Opioid Abuse [keywords]
- Rates of fetal polydrug exposures in methadone-maintained pregnancies from a high-risk population. [Journal Article]
- PLoS One 2013; 8(12):e82647.
Methadone maintenance treatment (MMT) is the standard of care during pregnancy for opioid-dependency, showing efficacy in improving prenatal care and reducing risk of relapse. By design, however, MMT is only intended to prevent withdrawal thus facilitating cognitive behavioural interventions. In order to maximize the benefits of MMT, it is essential that methadone is both properly prescribed and that additional addiction treatment is concurrently administered. This study aims to determine the effectiveness of MMT engagement in high-risk pregnant women in reducing polydrug use by objective laboratory examination of neonatal meconium.Over a 29-month period, the Motherisk Laboratory at the Hospital for Sick Children in Toronto analyzed meconium samples as per request by social services and hospitals for drugs of abuse.Of the 904 meconium samples received, 273 were tested for methadone with 164 positive and 109 negative for methadone. Almost half of the methadone positive samples (46.34%) were also positive for at least one other opioid compound, which did not differ statistically from the methadone-negative control samples (46.79%; Chi square test, p=0.94). No differences were found between the methadone positive and negative groups in rates of concurrent amphetamines, cocaine, cannabis, and alcohol use indicating a similar risk of polydrug use between pregnant women taking or not taking methadone in this population.The high rates of additional opioid and other drug use in the MMT group, suggest that MMT is failing this population of patients. It is possible that methadone doses during pregnancy are not appropriately adjusted for changes in pharmacokinetic parameters (e.g. blood volume, renal function) during the second and third trimesters. This may result in sub-therapeutic dosing creating withdrawal symptoms leading to additional substance use. Alternatively, these results may be demonstrating a substantial lack in delivery of addiction support services in this vulnerable population.
- Increases in the Use of Prescription Opioid Analgesics and the Lack of Improvement in Disability Metrics Among Users. [JOURNAL ARTICLE]
- Reg Anesth Pain Med 2013 Dec 4.
In the United States, use of oral opioid analgesics has been associated with increasing rates of addiction, abuse, and diversion. However, little is known about the recent national use of non-illicit prescription opioid analgesics (those prescribed in a physician-patient relationship), the primary source of these drugs for the general US population. Our primary objective was to examine trends in the use of prescription opioid analgesics in the United States and to identify defining characteristics of patient users of prescribed opioids from 2000 to 2010.We used the nationally representative Medical Expenditure Panel Survey to examine trends in prescription oral opioid analgesic use from 2000 to 2010. We used survey design methods to make national estimates of adults (18 years and older) who reported receiving an opioid analgesic prescription (referred to as opioid users) and used logistic regression to examine predictors of opioid analgesic use. Our primary outcome measures were national estimates of total users of prescription opioid analgesics and total number of prescriptions. Our secondary outcome was that of observing changes in the disability and health of the users.The estimated total number of opioid analgesic prescriptions in the United States increased by 104%, from 43.8 million in 2000 to 89.2 million in 2010. In 2000, an estimated 7.4% (95% confidence interval, 6.9-7.9) of adult Americans were prescription opioid users compared with 11.8% (95% confidence interval, 11.2-12.4) in 2010. On the basis of estimates adjusted for changes in the general population, each year was associated with a 6% increase in the likelihood of receiving an opioid prescription from 2000 to 2010. Despite the apparent increase in use, there were no demonstrable improvements in the age- or sex-adjusted disability and health status measures of opioid users.The use of prescription opioid analgesics among adult Americans has increased in recent years, and this increase does not seem to be associated with improvements in disability and health status among users. On a public health level, these data suggest that there may be an opportunity to reduce the prescribing of opioid analgesics without worsening of population health metrics.
- Long-Term Antagonism of κ Opioid Receptors Prevents Escalation of and Increased Motivation for Heroin Intake. [Journal Article]
- J Neurosci 2013 Dec 4; 33(49):19384-92.
The abuse of opioid drugs, both illicit and prescription, is a persistent problem in the United States, accounting for >1.2 million users who require treatment each year. Current treatments rely on suppressing immediate withdrawal symptoms and replacing illicit drug use with long-acting opiate drugs. However, the mechanisms that lead to preventing opiate dependence are still poorly understood. We hypothesized that κ opioid receptor (KOR) activation during chronic opioid intake contributes to negative affective states associated with withdrawal and the motivation to take increasing amounts of heroin. Using a 12 h long-access model of heroin self-administration, rats showed escalation of heroin intake over several weeks. This was prevented by a single high dose (30 mg/kg) of the long-acting KOR antagonist norbinaltorphimine (nor-BNI), paralleled by reduced motivation to respond for heroin on a progressive-ratio schedule of reinforcement, a measure of compulsive-like responding. Systemic nor-BNI also significantly decreased heroin withdrawal-associated anxiety-like behavior. Immunohistochemical analysis showed prodynorphin content increased in the nucleus accumbens core in all heroin-exposed rats, but selectively increased in the nucleus accumbens shell in long-access rats. Local infusion of nor-BNI (4 μg/side) into accumbens core altered the initial intake of heroin but not the rate of escalation, while local injection into accumbens shell selectively suppressed increases in heroin intake over time without altering initial intake. These data suggest that dynorphin activity in the nucleus accumbens mediates the increasing motivation for heroin taking and compulsive-like responding for heroin, suggesting that KOR antagonists may be promising targets for the treatment of opioid addiction.
- Potential misuse and inappropriate prescription practices involving opioid analgesics. [Journal Article, Research Support, U.S. Gov't, P.H.S.]
- Am J Manag Care 2013 Aug; 19(8):648-65.
Opioid misuse and abuse are growing concerns among the medical and public health communities.To examine the prevalence of indicators for potential opioid misuse in a large, commercially insured adult population.We adapted existing indicators developed by expert panels to include having overlapping opioid prescriptions, overlapping opioid and benzodiazepine prescriptions, long-acting/ extended release (LA/ER) opioids for acute pain,and high daily doses of opioids (>100 morphine milligram equivalents). These indicators were assessed among continuously enrolled individuals aged 18-64 years from the 2009 Truven Health MarketScan databases. Analyses were stratified by sex.We identified 3,391,599 eligible enrollees who received at least 1 opioid prescription. On average, enrollees obtained 3.3 opioid prescriptions, and the average annual days of supply was 47 days. Twice as many enrollees received opioid prescriptions for acute pain as for chronic pain. About a quarter of the enrollees had at least 1 indicator of either potential misuse by patients or inappropriate prescription practices by providers. About 15% of enrollees had high daily doses;7.8% had opioid overlap; and 7.9% had opioid and benzodiazepine overlap. Among those prescribed LA/ER opioids, 24.3% were treated for acute pain. Overlap indicators were more common among women.Our findings underscore the critical need to develop programs aimed at promoting appropriate use of opioids. Retrospective opioid utilization reviews similar to our analyses can potentially help managed care organizations and healthcare providers improve patient care and reduce the risk of adverse outcomes related to these medications.
- Trimebutine: abuse, addiction and overdose. [Journal Article]
- Prescrire Int 2013 Oct; 22(142):241-2.
Trimebutine, an antispasmodic drug, is used to relieve pain associated with irritable bowel syndrome, despite a lack of proven efficacy. Trimebutine has been shown to act on peripheral opioid receptors. Cases of trimebutine abuse and addiction have been reported in young adults, especially with the injectable form. Cases of serious accidental or intentional trimebutine overdose have been reported in infants and young adults, leading to neurological disorders (loss of consciousness, coma, drowsiness and convulsions) and cardiac disorders (bradycardia, ventricular tachycardia, arterial hypertension). Time to symptom onset was less than 3 hours after trimebutine intake. In practice, trimebutine is by no means a harmless drug, contrary to the impression given by the limited safety data available. Patients with pain due to irritable bowel syndrome should be informed of the adverse effects of trimebutine, and the harm-benefit balance should be reassessed in patients already taking this drug.
- Hydromorphone: Evolving to Meet the Challenges of Today's Health Care Environment. [JOURNAL ARTICLE]
- Clin Ther 2013 Nov 27.
Hydromorphone, a potent analogue of morphine, has long had an important role in pain management and is included in several international guidelines for managing pain. Advances in hydromorphone formulations and the ways in which hydromorphone is being used clinically today warrant a review of the drug's pharmacotherapeutic utility.The history and recent advances in hydromorphone pharmacotherapy are reviewed. Areas covered include the pharmacologic and metabolic profile of hydromorphone, the role of hydromorphone in pain management, formulations and routes of administration, and issues related to relative opioid potencies, equianalgesic ratios, and opioid rotation. Because hydromorphone, like all opioids, carries a risk of misuse, abuse, and illicit diversion, the related issues of tamper-resistant formulations and "dose-dumping" of extended-release formulations are discussed.Due to the epidemic of prescription opioid overdoses associated with prescription opioid abuse in the United States, development of tamper-resistant opioid formulations that avoid dose-dumping issues has become a significant goal of pharmaceutical manufacturers. The current formulation of hydromorphone extended-release potentially provides the benefits of long-acting hydromorphone (ie, continuous pain control, increased quality of life, freedom to perform daily activities) to appropriate patients, while reducing the risks of abuse and without compromising safety.
- The Prevalence of Diagnosed Opioid Abuse in Commercial and Medicare Managed Care Populations. [JOURNAL ARTICLE]
- Pain Pract 2013 Dec 1.
To measure the prevalence of diagnosed opioid abuse and prescription opioid use in a multistate managed care organization.This retrospective claims data analysis reviewed the prevalence of diagnosed opioid abuse and the parallel prevalence of prescription opioid use in half-year intervals for commercial and Medicare members enrolled with Humana Inc., from January 1, 2008 to June 30, 2010. Diagnosis of opioid abuse was defined by ≥ 1 medical claim with any of the following ICD-9-CM codes: 304.0 ×, 304.7 ×, 305.5 ×, 965.0 ×, excluding 965.01, and opioid use was defined by ≥ 1 filled prescription for an opioid. The prevalence of opioid abuse was defined by the number of members with an opioid abuse diagnosis, divided by the number of members enrolled in each 6-month interval.The 6-month prevalence of diagnosed opioid abuse increased from 0.84 to 1.15 among commercial and from 3.17 to 6.35 among Medicare members, per 1,000. In contrast, there was no marked increase in prescription opioid use during the same time period (118.0 to 114.8 for commercial members, 240.6 to 256.9 for Medicare members, per 1,000). The prevalence of diagnosed opioid abuse was highest among members younger than 65 years for both genders in commercial (18- to 34-year-olds) and Medicare (35- to 54-year-olds) populations.Despite a stable rate of prescription opioid use among the observed population, the prevalence of diagnosed opioid abuse is increasing, particularly in the Medicare population.
- "Nonmedical" prescription opioid use in North America: a call for priority action. [EDITORIAL]
- Subst Abuse Treat Prev Policy 2013 Dec 1; 8(1):39.
Nearly four years after the United States Congress heralded a "decade of pain control and research," chronic pain remains a mounting public health concern worldwide. The escalating prevalence of chronic pain in recent years has been paralleled by a rise in prescription opioid availability, misuse, and associated human and social costs. However, national monitoring surveys in the U.S. and Canada currently fail to differentiate between prescription opioid misuse for the purposes of euphoria versus pain or withdrawal management. Furthermore, there is a lack of evidence-based guidelines for pain management among high-risk individuals, and a glaring lack of education for practitioners in the areas of pain and addiction medicine. Herein we propose multiple avenues for intervention and research in order to mitigate the individual, social and structural problems related to undertreated pain and prescription opioid misuse.
- Factors influencing the selection of hydrocodone and oxycodone as primary opioids in substance abusers seeking treatment in the United States. [Journal Article]
- Pain 2013 Dec; 154(12):2639-48.
The purpose of the present study was to identify the factors that influence the selection of hydrocodone and oxycodone as primary drugs of abuse in opioid-dependent subjects (n=3520) entering one of 160 drug treatment programs around the country. Anonymous, self-administered surveys and direct qualitative interviews were used to examine the influence of demographic characteristics, drug use patterns, and decision-related factors on primary opioid selection. Our results showed that oxycodone and hydrocodone were the drugs of choice in 75% of all patients. Oxycodone was the choice of significantly more users (44.7%) than hydrocodone (29.4%) because the quality of the high was viewed to be much better by 54% of the sample, compared to just 20% in hydrocodone users, who cited acetaminophen as a deterrent to dose escalation to get high and hence, its low euphoric rating. Hydrocodone users were generally risk-averse women, elderly people, noninjectors, and those who prefer safer modes of acquisition than dealers (ie, doctors, friends, or family members). In contrast, oxycodone was a much more attractive euphorigenic agent to risk-tolerant young, male users who prefer to inject or snort their drugs to get high and are willing to use more aggressive forms of diversion. Prevention and treatment approaches, and pain physicians, should benefit from these results because it is clear that not all drug abusers share the same characteristics, and the decision to use one drug over another is a complex one, which is largely attributable to individual differences (eg, personality, gender, age, and other factors).
- Agreement between DSM-IV and ICD-10 criteria for opioid use disorders in two Iranian samples. [JOURNAL ARTICLE]
- Addict Behav 2013 Nov 4.
The aim of this study was to determine the agreement between the two systems in opioid users in the general population and a clinical sample. Two series of data were used in this study. The first was the data of 236 home-residing opioid abusers aged 15-64, who had previously participated in the Iran Mental Health Survey (IranMHS) in 2011, and the second was the data of 104 general psychiatry patients from inpatient or outpatient wards of two psychiatry hospitals in Tehran. Opioid use disorders were evaluated with CIDI-version 2.1. The disorders were assessed in all participants who used opioid substances for at least 5 times during the past 12months. In the sample from the general population, the agreement between the two systems on the diagnosis of dependence was excellent (0.81). The agreement between the two systems on the diagnosis of abuse and harmful use was 0.41. In the clinical sample, the agreement between the two systems on the diagnosis of dependence or any opioid use disorder was 0.96 and 0.93, respectively. The agreement between abuse and harmful use was 0.9 and -0.02 with and without regarding hierarchy, respectively. The inter-rater reliability of both DSM-IV and ICD-10 systems for all diagnosis was more than 0.95. The results of the diagnosis of dependence in the two systems had a weak concordance with treatment. The diagnostic criteria of DSM-IV and ICD-10 regarding dependence are very similar and the diagnosis produced by each system is concordant with the other system. However, the two systems have noticeable discrepancies in the diagnosis of abuse and harmful use. The discrepancies result from their conceptual differences and necessitate further revision in the definition of these disorders in the two systems.