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Through a concrete case, we discuss the main published protocols to initiate methadone and illustrate the advantages and disadvantages of rapid or gradual initiation and on-demand or fixed doses with rescue doses. Daily doses can vary widely depending on the protocol chosen. An on-demand administration could lead to an overdose as illustrated in our case. A better understanding of particularities and limitations of these protocols could lead to safer methadone initiation. Systematic comparison of different protocols and calculation of the daily dose should be a standard in clinical practice.

A recent review suggests minimal respiratory depression (RD) after perioperative methadone, while another identified RD in up to 37 percent of patients. A meta-analysis is equivocal. At our institution, five of 75 opioid naive patients (6.6 percent) given perioperative methadone received naloxone. We report three of these cases in detail. Two others were discovered during an electronic medical record search for opioid naïve patients who received methadone plus naloxone during their anesthesia care. Our five patients indicate that RD owing to methadone can occur with excessive perioperative adjuvant medications and/or in patients who are taking home central nervous system depressants. We define perioperative adjuvant medications as medications given by the anesthesiologist prior to induction and intraoperatively. The risks and benefits of perioperative methadone administration, specifically in patients who received post-operative naloxone, deserve further investigation.

Both short-acting (SA) opioids and long-acting (LA) opioids have been used for chronic pain (defined as pain lasting >3 months). SA opioids have a duration of action ranging between 2 and 4 hours, result in rapidly fluctuating drug levels and are suitable for acute, unstable, intermittent, breakthrough, and procedure-related pain.

Introduction: The 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep guidelines from the Society of Critical Care Medicine recommend opioids as a first-line treatment option for non-neuropathic pain among critically ill adults and prioritize pain management optimization before the administration of sedatives. Although analagosedation is recommended, the downstream effects, such as intensive care unit (ICU)-acquired opioid dependence, are not well described. The purpose of this study is to determine the impact of continuous infusions of opioids for mechanically ventilated patients prescribed opioids on discharge.Methods: This was a single-center, retrospective chart review of mechanically ventilated patients admitted to the medical ICU at a tertiary medical center from July 1, 2018 to June 30, 2019. The primary objective of this study was to compare the incidence of opioid prescriptions at discharge between those who received opioid infusions versus intermittent administrations. Secondary objectives included risk factors for receiving opioid prescriptions at discharge and readmission within 90 days with an active opioid prescription and/or a diagnosis of opioid use disorder.Results: A total of 100 patients were included. There was no statistically significant difference in the incidence of opioid prescriptions at discharge between the groups (p = 0.933). Only one patient was readmitted within 90 days with documented opioid use disorder and 11 patients with prescription opioids on their home medication list. A best-fit logistic regression model including the type of opioid administration (p = 0.275), length of stay (p = 0.018), and opioid dose (p = 0.137) showed that length of stay was the only significant predictor of discharge opioid prescribing.Conclusion: The incidence of opioid prescriptions at discharge for critically ill, mechanically ventilated patients did not differ based on opioid administration strategy. ICU length of stay appears to be a predictive factor of opioid discharge prescriptions.

Objective: Ketamine has been shown to decrease opioid utilization as an adjunct, but limited evidence is available on ketamine as a primary analgesic strategy.Design: A retrospective chart review.Patients and participants: Mechanically ventilated adult patients (≥18 years) in the surgery-trauma intensive care unit (STICU) with continuous infusion ketamine or fentanyl with concomitant propofol for at least 12 hours were screened for inclusion. The final analysis included 22 patients in the ketamine/propofol (KP) group and 24 patients in the fentanyl/propofol (FP) group.Interventions: Patients in the STICU received KP or FP continuous infusions.Main outcome measures: The primary outcome compared opioid requirements between both groups during mechanical ventilation.Results: The median opioid requirement during mechanical ventilation was significantly higher in the FP group compared to the KP group (median 1,392 milligrams of morphine equivalents (MMEs) [interquartile range (IQR) 709.5-2,292] versus 206.3 MME [IQR 87-510], p < 0.001). After extubation, there was no difference in opioid utilization. Patients in the KP group spent less time at goal Critical Care Pain Observation Tool compared to the FP group (median 77.6 percent, IQR [71.9-85.2] versus 88.9 percent, IQR [76.9-97.4], p = 0.003). The proportions of patients developing adverse effects were not significantly different between the two groups.Conclusions: Among critically ill mechanically ventilated patients in the STICU, continuous ketamine resulted in significantly less opioids during mechanical ventilation. Further studies with a larger sample size are needed to assess the appropriate dosing strategy for ketamine to produce adequate analgesia when used as a primary analgesic in mechanically ventilated patients.

Objective: Given the current opioid epidemic and the fact that children continue to be undertreated for pain following surgeries, it is important to understand caregivers’ attitudes toward post-operative opioid use.Design: A survey was distributed to caregivers of pediatric patients undergoing otolaryngologic procedures.Setting: An academic hospital in Boston, Massachusetts.Participants: Sixty-eight caregivers completed the survey.Main outcome measure: Caregiver attitudes toward post-operative opioid use.Results: The study results are as follows: 38.1 percent of parents stated they would feel comfortable giving their child opioids post-operatively, 30.2 percent would not feel comfortable, and 31.7 percent were unsure. For every increase in 1 year of age of the child, there was an increase in the odds of a parent being comfortable giving opioids. Caregivers who had taken opioids in the past were more likely to feel comfortable, while those who were employed were less likely to feel comfortable. The most common reason reported for not feeling comfortable was addiction potential. The comfort level did not differ based on the caregivers’ education level, income, race, or language.Conclusion: The majority of caregivers are unsure about or do not feel comfortable giving their child opioids post-operatively. Most are specifically concerned about the risk of addiction. Understanding caregivers’ views on opioids in a diverse patient population is essential, so surgeons can counsel caregivers and provide appropriate post-operative pain management in their patients.

Objective: This article overviews the current statistics and factors related to increased rates of opioid use disorder (OUD) in rural areas, uncovering factors that may contribute to increased vulnerability to opioid overdose. We qualitatively review opinions, feelings, and thoughts surrounding this issue in rural areas of Utah, analyzing participant stories in reference to three themes through qualitative interviews, including the solitude of addiction, the beguiling strength of addiction, and one way out of addiction.Design: In 2018, three focus groups were convened with 25 individuals from the rural area. Participants either currently or formerly (self-reported substance free for 6 months or more) experienced OUD with prescription opioids and heroin, or were family members of individuals who currently and formerly experienced OUD. These focus groups addressed current issues in OUDs in a rural Utah community related to person, place, and time. Following the focus groups, six individuals were invited to participate in semi-structured interviews. In-depth, semi-structured interviews queried individual experiences through a phenomenological approach, using a moderator guide with queries focused on identified themes related to the solitude, the intensity, and the difficulty escaping substance use disorder (SUD). Methodology included training community scholars with lived experience and member-checking to ensure phenomenological emphasis.Results: Our qualitative reviews of the experience of OUD and SUD in rural Utah discussed the relevance and the nuance of the three identified themes. The interviewee statements further underscore the solitude, intensity, and difficulty of an individual's journey through SUD, the all-consuming nature of OUD, and the trouble that these factors cause in rural recovery.Conclusions: We conclude that even during difficult situations in the rural experience with the opioid crisis, hope persists. OUD support in rurality may differ from the expected urban experience and include more coordination with criminal justice workers. Rural Americans have insights to share that could help turn the tide of this crisis.

Objective: Prescription opioids are an effective pain treatment strategy but can lead to long-term opioid misuse. Identifying at risk patients during hospitalization can inform the development of prevention interventions post-discharge. Using the Opioid Risk Tool (ORT) as a screening measure, this study predicted factors associated with pain and opioid use at 2 weeks post-discharge in trauma patients.Design: A quality improvement prospective study design was used.Setting: Participant recruitment took place at an inpatient Level 1 trauma center in Houston, Texas.Participants: Participants (n = 103) were patients admitted to the adult trauma service. Patients completed the ORT in the hospital and a survey at 2 weeks post-discharge.Main outcome measure: The survey assessed pain intensity and interference, injury-related stress, medication use, and need for additional pain treatment. Wilcoxon–Mann–Whitney U test, the Spearman rank-order correlation, and chi-square test of independence tested the ORT as a predictor of follow-up outcomes. Post hoc analyses relied on logistic and quantile regression.Results: The ORT identified 15.5 percent of patients at high risk for opioid-related aberrant behavior. Survey results indicated high percentages of patients reporting moderate to severe pain (79.6 percent), pain interference (77.9 percent), taking pain pills (59.6 percent), experiencing stress (76.9 percent), and needing pain treatment (52.4 percent). The ORT predicted injury-related stress with the high-risk category having higher stress levels than low risk (Z = 2.518, p = 0.012).Conclusion: Risk of opioid misuse assessed in hospitalized trauma patients was associated with injury-related stress reported post-discharge. This highlights the importance of including stress assessments in follow-up appointments.

Objectives: Literature supporting best practice of perioperative buprenorphine management for opioid use disorder is evolving with more recent studies trending toward maintenance of home dose. To guide treatment protocols at our institution, we evaluated patients taking medication for opioid use disorder (MOUD) undergoing similar surgeries. Patients were maintained on either their outpatient buprenorphine or methadone.Patients and participants: Data were collected on 46 patients maintained on buprenorphine MOUD who underwent surgery. A subset of these patients (n = 24) was compared with 24 patients maintained on methadone MOUD, matched on surgical procedure, admission date, age, and sex.Design: This is a retrospective matched control study.Setting: An academic, tertiary, Level 1 trauma center.Main outcome measures: Primary outcomes were post-operative opioid use and post-anesthesia care unit (PACU) length of stay.Results: No significant differences in demographic characteristics, physical status, comorbid psychiatric diagnoses, or illicit substance use history were observed between patient groups. A higher proportion of patients taking methadone was admitted due to infection (41.7 percent vs 16.7 percent, p = 0.031) and underwent nonelective surgery (75.0 percent vs 45.8 percent, p = 0.039). No significant differences were observed between patients taking buprenorphine versus methadone with respect to PACU length of stay, post-operative opioid consumption, time-to-transition to oral opioids, or discharge opioid prescriptions. Patients taking buprenorphine were more likely to receive intravenous lidocaine (25.0 percent vs 0.0 percent, p = 0.031) and ketamine (83.3 percent vs 54.2 percent, p = 0.039).Conclusion: Findings from this study support accumulating evidence that patients should be maintained on buprenorphine MOUD throughout the perioperative period.

Objective: More than one in five American adults experiences chronic pain, and numerous approaches can be used to treat chronic pain. Opioid analgesics are commonly used to treat pain though precise estimates of the prevalence of opioid analgesic use vary widely. This study sought to determine the prevalence of opioid use for pain among adults in the United States.Methods: We performed a retrospective analysis of the National Health Interview Survey, a national-level household-based annual survey of self-reported health status of US adults, using a chronic pain module introduced in the 2019 edition. We examined overall rates of opioid medication use for pain and correlates of opioid use using survey-weighted analyses.Results: We found 30.8 million adults (95 percent CI: 29.3-32.3 million), or 12.3 percent (11.8-12.8) of the population, had used opioids for pain in the preceding 12 months, while 9.3 million (8.6-10.0 million), or 3.7 percent (3.5-4.0), had used opioids for chronic pain in the preceding 3 months. Individuals reporting pain every day were more likely to have used opioids than those experiencing pain less frequently. Individuals who had tried other methods such as physical therapy and self-management programs were more likely to have used opioids. Individuals who used opioids for pain were more likely to report poorly controlled pain, with 38.0 percent (31.5-45.0) reporting their pain management was “not at all effective.” Conclusions: Opioid use for chronic pain is common and frequently part of a multimodal and multidisciplinary approach.

Objective: To examine (1) patient perceptions regarding their engagement and the engagement of their families in perioperative pain management, (2) demographic and clinical characteristics associated with perceived patient and family engagement, and (3) the association between perceived patient and family engagement and patient outcomes.Design: A prospective, observational study. Setting: The Personalized Pain Program (PPP) at the Johns Hopkins Hospital in Baltimore, Maryland.Participants: Patients having more than one visit to the PPP.Interventions: n/a.Main outcome measures: Since the inception of the PPP, patients were surveyed prior to each clinic visit to assess their pain severity and interference using the Brief Pain Inventory. Starting August 22, 2018, two additional questions were added to the survey to assess patient perceptions of their engagement and the engagement of their families in perioperative pain management. In addition, electronic medical records were reviewed to collect data on daily opioid consumption during the first and last PPP visits presurgery and post-surgery. Results: The final analysis included 511 survey responses from 155 patients. Perceived engagement of the patient in perioperative pain management improved over time (p < .001) and was significantly associated with reduction in prescription opioid consumption after surgery (coef = 12.7, SE = 5.8, p = .031).Conclusions: Surgical patients and their family members should be actively engaged in perioperative pain management to improve prescription opioid use and the quality and safety of perioperative care.

Objective: To assess sex disparities in opioid prescribing practices and patient outcomes.Design: A retrospective cross-sectional study.Setting: Thirty-three primary care clinics in an academic health system.Participants: 2,738 adults prescribed 10+ outpatient opioid prescriptions within 12 months.Main outcome measure(s): Patient and primary care provider (PCP) sex-based differences in clinical outcomes, opioid prescribing, and rates of adherence to guideline-concordant opioid prescribing practices.Results: Female PCPs were more likely (p < 0.001) to prescribe lower morphine-equivalent daily dose (MEDD) of opioids and complete risk assessment for opioid misuse than male PCPs. PCPs did not differ by sex in adherence rates to controlled substance agreements, urine drug, depression screening, or opioid-benzodiazepine coprescribing. Female patients were more likely (all p ≤ 0.01) to be screened for opioid misuse, treated with lower MEDD, receive opioid-benzodiazepine coprescriptions, have higher pain interference, anxiety and depression diagnoses, and have an overdose diagnosis; they were less likely (all p < 0.001) to report alcohol use or have an alcohol use disorder diagnosis and utilized health care at higher rates than male patients.Conclusions: Sex differences were found in clinician opioid-prescribing practices and adherence to opioid prescribing guidelines and patient characteristics associated with long-term opioid therapy. Strategies to identify sex-related disparities and enhance guideline-concordant opioid prescribing and monitoring could contribute to improved patient care, and clinical and safety outcomes.

Objective: This study aimed to ascertain the reasons why patients with opioid dependence leave treatment.Design: Prospective follow-up observational study.Setting: This study was carried out at a tertiary care substance use treatment facility in north India with both outpatient and inpatient services. The facility is a public-funded institution.Participants: One hundred and twenty opioid-dependent male patients with age 18 years or more who were willing to provide a valid telephone number for follow-up and willing to consent for the study were included.Main outcome measure(s): Enquiries were made using the Reasons to Leave Treatment Questionnaire (RLTQ) and an open-ended question about why the patient left treatment.Results: As per the RLTQ, the most common reasons for patients with opioid dependence leaving treatment were in the domains of external influence, motivational inconsistencies, and problem severity. Logistic problem was another issue that was highlighted by the patients. On open-ended question, the most common reason for leaving treatment pertained to feeling that one has improved and does not need treatment. Baseline characteristics that predicted patients leaving treatment were not being prescribed buprenorphine at discharge, not being formally educated, and living alone or in a nuclear family.Conclusion: Several factors may lead to patients with opioid dependence leaving treatment prematurely after receiving inpatient care. Addressing these reasons might help to better retain patients in treatment and improve their outcomes.

Objective: To develop and evaluate a relevant and readily accessible post-professional opioid use disorder (OUD) education program for a rural and frontier state.Design: Observational study. Setting/participants: Healthcare providers enrolled in Extension for Community Healthcare Outcomes (ECHO) Idaho Opioid, a tele-mentoring education program.Main outcome measure: Participant-level demographics of those that attended the ECHO Idaho Opioid program and post-session and program evaluation surveys.Results: A total of 273 individuals attended at least one ECHO Idaho Opioid session (per session average = 22.8); 183 post-session evaluations (per session average = 6.3) and 42 program evaluations were completed. The program was well received by providers in a rural and frontier state and may be a viable option to enhance patient care for OUD patients in these communities.Conclusion: The Project ECHO model is successful at reaching providers across diverse geographic regions, overcoming barriers associated with attending advanced trainings or developing peer networks to improve patient care. The model can be used to develop educational content and delivery that participants believe is satisfactory, valuable, and applicable to their profession and practice.

Aside from respiratory suppression in overdose, full opioid agonist agents are known to cause sleep-disordered breathing (SDB). The increasing rates of opioid overdose in the United States have led to increasing use of medication-assisted treatments for opioid use disorders. Dose-dependent increase in SDB has been documented with methadone. There is emerging literature in the form of case reports providing evidence of buprenorphine and buprenorphine–naloxone contributing to sleep apnea. We report an additional case of a female patient developing central sleep apnea during initiation of buprenorphine–naloxone treatment. The condition resolved with dose reduction.

Problem: Drug addiction and misuse is a medical and societal problem that has exacted a heavy toll on the United States, and, indeed, the world. In the United States, opioids are currently the main driver of drug overdose deaths. Despite the proven safety and efficacy of medically assisted therapy (MAT) using buprenorphine for the treatment of opioid use disorder (OUD), as well as the fact that its use is regulated by US Federal Law, many states have enacted separate and often burdensome regulations that restrict the prescribing of buprenorphine beyond those required by the US Drug Enforcement Agency (DEA) under the provisions of the DATA 2000 Act, and unnecessarily reduce the availability of effective treatment of OUD in those states. Purpose: The purpose of this article is to review the pharmacology of both buprenorphine (and naloxone as an additive) and the risks associated with the misuse of buprenorphine products and to consider if such additional state oversight and restrictions improves or is deleterious to public safety in the face of this national epidemic. Conclusion: We conclude that the placing of unnecessary and unscientific restraints on the treatment of patients with OUD is inconsistent with the principles of harm reduction, and such restraints should be removed unless/until they can be supported by real evidence.

Buprenorphine/naloxone (BPN/NX) is a first-line treatment for opioid use disorder. Conventional treatment guidelines recommend a period of opioid abstinence and the presence of moderate withdrawal before initiation to avoid precipitated withdrawal. A newer approach of “microdosing” removes this requirement and has potential benefits. We present two cases of successful induction of BPN/NX using a microdosing regimen in an inpatient withdrawal unit. Both cases did not result in precipitated withdrawal and did not necessitate prior cessation of other opioids. This case report highlights how the use of microdosing to induct BPN/NX treatment can reduce potential barriers and complications with treatment initiation.

Background: Availability and access to opioid agonist treatment (OAT) are limited despite its evidence of effectiveness in treating opioid use disorders (OUDs). COVID-19 pandemic has inadvertently exacerbated the problems of restricted access to OAT and, at the same time, has increased odds of harm due to opioid use. Objectives: We examined (a) adaptations conceived or implemented in the buprenorphine (BPN)-based OAT service delivery at the national, regional, or local level during the COVID-19 pandemic and (b) the impact of such transformations on the quantitative and qualitative aspects of service delivery. We focused exclusively on BPN-based OAT. Methods: We carried out a systematic electronic database search in PubMed and Google Scholar. We included all types of articles. Additionally, we looked up relevant websites of international and national government agencies working in the field of drug abuse. Results: We included 21 articles from 10 countries in the review and summarized the results in a narrative format. The majority of literature was from developed countries. We observed changes in the BPN initiation, dosing, and dispensing protocols, and particular emphasis on telemedicine. There was limited literature on service provisions for the vulnerable population. The changing modes of service delivery have possibly increased the number of new patients and reduced the risk of exposure owing to limited in-person contact. Conclusion: Newer adaptations to meet with the challenges of COVID-19 pandemic in the BPN-based OAT delivery tend to be innovative, flexible, and patient centered. Although it is too early to comment on these newer adaptations’ impact, the outcome's directions appear to be positive.

There is limited evidence and no clear consensus suggesting best practices for perioperative buprenorphine management in patients with opioid use disorder. As such, we aimed to develop a standardized perioperative management approach with the goals of (1) optimizing perioperative analgesia, (2) minimizing relapse risk, (3) setting expectations for patients and clinicians, (4) achieving prescribing consistency and mitigating risk among clinicians not familiar with perioperative buprenorphine management, and (5) maintaining continuity throughout care transitions. An interprofessional expert focus group convened to develop a consensus algorithm based upon buprenorphine's unique pharmacologic features and published perioperative management recommendations. The resulting consensus algorithm continues the patient's home buprenorphine dose in order to minimize relapse risk, but utilizes a divided dose approach starting the day of surgery if moderate to severe post-operative pain is expected. This strategy leverages the analgesic effects of buprenorphine while allowing for additional opioid binding to optimize analgesia. A patient-centered multimodal perioperative approach including local and/or regional anesthetics and nonopioid adjuncts is employed. Post-operative care is optimized by preoperative planning, including standardized patient assessment, perioperative communication with the buprenorphine prescriber, and education for patients and clinicians. Overall, integrating an understanding of pharmacology and clinical impact through the use of a readily adaptable algorithm such as the divided dose approach is key to optimizing patient care in this high-risk population.

Background: Currently, in the United States, there is an epidemic of opioid abuse. While this problem is well known to the public due to significant media and political attention, patients are poorly educated on the proper handling and disposal of unused opioids. Instead, the onus has fallen on the healthcare provider to minimize the number of opioids prescribed. Study objective: To improve proper opioid disposal rates after gynecologic surgery by providing educational materials along with a disposal bag. Study design: We performed a prospective study evaluating baseline understanding of medication disposal using a questionnaire given to the patients during their preoperative visit. Subsequently, patients were provided written information on proper disposal of their medications and an activated charcoal medication disposal bag. Study patients completed a survey about disposal of their unused opioids at their last post-operative visit. The success of education and proper disposal of opioid medications were evaluated. Results: Thirty-five patients, average age of 45 (range 20-77), were enrolled, and 31 patients successfully completed both surveys. The surgeries performed included hysterectomy 23 percent (n = 7), laparoscopic excision of endometriosis 32 percent (n = 10), laparoscopic ovarian cystectomy 23 percent (n = 7), prolapse repair 3 percent (n = 1), and midurethral sling procedures 19 percent (n = 6). Chronic pelvic pain was identified in 39 percent (n = 12) of our patient population. Prior to education, 52 percent (n = 16) of patients did not dispose of their opioids. Furthermore, 71 percent (n = 22) of patients stated they had never been educated by a medical provider regarding appropriate disposal. Nineteen percent (n = 6) confirmed they have used an opioid medication prescribed to someone else. Demographic data show 65 percent (n = 20) of these patients had completed a college degree or greater. After education and being given a reliable option for medication disposal with the Deterra ® bag, 94 percent (n = 29) of patients properly disposed of their opioids after surgery, demonstrating a 45 percent (p < 0.001) increase in proper disposal. In our study alone, 491 tablets of 5mg oxycodone were properly disposed. The majority of patients, 77 percent (n = 24) used the drug disposal bag, and when queried, stated they would be willing to pay on average $7.70 (range 0-20) per bag. Without education and a simple option for disposal, 422 tablets prescribed may have been subject to inappropriate diversion. Conclusion: This study clearly shows that patient education, coupled with a reliable option for opioid disposal, is effective. We strongly encourage other surgical institutions to implement similar practices not only for our surgical patients’ safety, but also for the tens of thousands of patients who died of opioid abuse in the last year.

Objective: Studies dating back to 1964 consistently support the effectiveness of methadone as a maintenance treatment for opioid use disorder (OUD), and since 2003, the effectiveness of buprenorphine. Short-term detoxification has not proven to be an effective treatment, as it results in high relapse rates when compared with maintenance treatment with an opioid agonist therapy (OAT). The question about the duration of maintenance treatment for OUD has been debated with recommendations ranging from a minimum of 1 year, 2 years, to indefinitely. Other factors such as misconceptions, regulations, and insurance barriers also have an impact on the duration dilemma of OAT. Design: There were no a priori criteria for article inclusion and this is not a structured literature review. It is a review of articles of convenience from 1964 to 2018. Main outcome measure: This paper aims to address the dilemma of the ideal duration of OAT and to discuss the factors that could affect this decision. Results: Sustained OAT has had significantly better long-term outcomes than short-term detoxification or time limited maintenance. Optimal outcomes are dependent on adequate treatment duration. Conclusions: Addiction is a chronic brain disease and its treatment should be similar to the treatment of other chronic medical and psychiatric diseases. Long-term, sometimes lifetime, continuation of OAT for the treatment of OUD results in optimal outcomes when measuring morbidity and mortality. The accumulated evidence does not support any arbitrary limitation to the duration of OAT.

Objective: Hospital resource utilization is reported to be higher among patients with opioid use disorder (OUD) compared with those without OUD at national and local levels. However, utilization of healthcare services associated with OUD in North Carolina (NC) has not been adequately characterized. We describe inpatient hospital resource utilization among adults with an OUD—diagnosed in NC and the United States (US). We hypothesize that hospitalized adults with OUD will have longer hospital stays, more frequent use of emergency services, a higher number of diagnoses, and comparable hospital charges compared with hospitalized adults without OUD. Design: A retrospective cross-sectional study analyzing hospital discharge abstracts included in the 2016 NC State Inpatient Databases (SIDs) and the 2016 National Inpatient Sample (NIS). OUD and non-OUD groups were compared using the Student's t-test for continuous variables and the χ 2 test for categorical variables. Participants: Adults 18 years and older from SID (n = 25,871) and NIS (n = 148,255) databases were included in the analysis. Main outcome measures: Length of stay (LOS), use of emergency services, discharge diagnosis, and hospital charge among hospitalized adults with OUD. Results: In NC, patients with OUD were younger (age 18-35), more likely to be white, and more likely to be hospitalized in areas with the lowest median income compared with patients without OUD. Compared to the US, twice as many NC OUD patients were self-payers. Hispanic patients, Medicare beneficiaries, and those in the highest income areas experienced the longest LOS and highest hospital charge. Patients with OUD were more likely to have five or more diagnoses and those with five or more diagnoses had higher LOS and hospital charges. OUD hospitalizations were also associated with more frequent use of emergency services. The most common co-occurring diagnoses were psychoses, substance abuse or dependence, and septicemia or severe sepsis. Conclusion: High percentages of self-payers and lower-income OUD patients indicate the need for Medicaid eligibility outreach programs in NC. High LOS and hospital charges among Hispanic, Medicare-covered, and high-income OUD patients call for a more detailed examination to identify underlying causes of disproportionate resource utilization in NC hospitals.

Objectives: To quantify the prevalence of opioid drug dependence and abuse in United States between 2017 and 2018 and identify which opioid molecules are associated with a higher level of dependence and abuse.Design: National Survey on Drug Use and Health (NSDUH) data for 2017 and 2018 have been extracted. The variables related to painkillers were studied, the most important ones were selected, and several variable crosses were made. After the data were extracted, they were analyzed using Microsoft Excel and PivotTables, calculating the relative prevalence and percentages of patients with abuse and dependence.Results: In total, 1.4 million people had dependence on pain relievers (PRs) in 2018. The last PR used was mostly hydrocodone (33 percent) and oxycodone (24 percent). The main reasons for using a PR without a doctor's prescription were relieving pain (48 percent), feel good (16 percent), and relax or relieve tension (15 percent). Among patients who used a PR with a medical prescription, 1.5 million used it more frequently than prescribed, 1.2 million used it longer than prescribed, and 1.9 million used it in higher amounts than prescribed.Conclusions: Abuse and dependence to PRs is lower than expected with over 1.4 million people in the United States having dependence in 2018 (0.6 percent point prevalence). Most cases of dependence are associated with misuse or abuse of prescriptions without medical supervision or the use of medications without a prescription of their own. Oxycodone and hydrocodone are the molecules most associated with dependence, misuse, abuse, and use without prescription. The age of onset of oxycodone misuse is very early (14 years old). Fentanyl does not seem relevant in any of the variables studied.

Objective: The present investigation aims to identify characteristics associated with heroin use among those reporting prescription opioid misuse from a nationally representative sample, and how these characteristics vary by urbanicity. Design: A cross-sectional analysis.Setting: Pooled 2015-2018 data from the National Survey on Drug Use and Health (NSDUH), the leading source for nationally representative substance use, mental health, and other health-related data and trends in the United States.Patients and participants: 23,719 participants (12,109 male and 11,610 female) reporting previous prescription opioid misuse in the 2015-2018 NSDUH data. Interventions: None.Main outcome measures: Univariable and multivariable logistic regressions were used to assess the association of characteristics with heroin use, stratified by urbanicity.Results: After multivariable adjustment, factors associated with heroin use among prescription opioid misusers were male sex, non-Hispanic White race, low educational attainment, recent nonopioid illicit drug use, and recent nonopioid prescription drug misuse. Commercial health insurance was associated with lower odds of heroin use among both rural and urban prescription opioid misusers, but an observed association between Medicaid and greater odds of heroin use was stronger among urban versus rural participants. In contrast, observed associations between illicit drug use other than marijuana in the past year and greater odds of heroin use were stronger among rural vs urban participants.Conclusion: Important differences exist between factors associated with heroin use among urban and rural prescription opioid misusers, and there is a need to consider broader polysubstance use trends and barriers to mental healthcare access to adequately address heroin use.

Objective: To identify the strongest predictors of opioid use among older United States’ (US) adults (≥50 years) with pain.Design: Cross-sectional retrospective database design.Setting: 2017 Medical Expenditure Panel Survey data.Participants: Civilian, noninstitutionalized sample of US adults aged ≥50 years alive for the calendar year with pain in the past 4 weeks.Interventions: Hierarchical logistic regression models assessed significant predictors of opioid use, which included: predisposing, enabling, need, personal health practices, and external environmental factors.Main outcome measures: Opioid use status (opioid user vs. nonopioid user). Results: Among 51,372,861 civilian, noninstitutionalized US adults alive aged ≥50 years with pain in 2017, the opioid use prevalence was 27.4 percent (95 percent confidence interval = 25.8-29.0). Predictors of opioid use included: white versus other race (adjusted odds ratio, AOR = 1.430), Hispanic versus non-Hispanic ethnicity (AOR = 0.648), up to high school versus higher than high school education (AOR = 1.259), functional limitation versus no limitation (AOR = 1.580), little/moderate versus quite a bit/extreme pain (AOR = 0.422), good versus fair/poor perceived mental health status (AOR = 1.429), smokers versus nonsmokers (AOR = 1.523), and residing in the northeast versus west US (AOR = 0.646).Conclusions: This study of 51 million older US adults with pain indicated that several factors including race, ethnicity, education, functional limitations, pain severity, mental health status, smoking status, and region of the country were predictors of opioid use. Future research is needed in additional clinical populations and to investigate where these findings diverge from previous studies.

Objective: To benchmark opioid abuse risk among student pharmacists attending three northeast pharmacy schools utilizing the opioid risk tool (ORT).Design: A cross-sectional, anonymous risk assessment questionnaire.Setting: Three pharmacy schools in the northeast United States.Participants: Professional year 1 (P1) through professional year 3 (P3) student pharmacists.Methods: ORT was collected and scored by investigators and inputted into an electronic format for analysis. Students voluntarily participated, and 812 surveys were completed during one course meeting time and day at each school.Results: The majority of students were in the low-risk category (n = 581, 71.6 percent). Additionally, 137 (16.9 percent) patients were categorized as moderate risk and 94 (11.6 percent) as high risk. No statistically significant differences existed when comparing risk groups across the first through third professional year student pharmacist cohorts. There were no statistically significant differences in the proportion of risk groups among the three pharmacy cohorts between low-risk versus the high-risk groups. When comparing risk groups by gender, males were found to have a statistically significant higher proportion of being classified as moderate or high risk.Conclusions: The results of this study demonstrate that there may be some student pharmacists with an increased risk for opioid abuse potential. There is potential need for education regarding opioid risk awareness and abuse prevention, which may serve as a call to action for professional school students and practitioners to understand baseline opioid abuse risk if they require chronic pain therapy.

Objective: To describe a group medical visit (GMV) model to facilitate medication assisted therapy.Design: Retrospective cohort analysis.Participants: Adult patients over 18 years of age desiring to receive medication assisted therapy (MAT).Methods: We describe the MAT GMV model including the clinical flow and group facilitation processes. The key elements for documentation and the medical portion of the visit are discussed. Using descriptive methods, we report the characteristics of our patient population entailing demographics, co-occurring mental health diagnosis, and medication use.Results: A total of 32 patients have participated in our MAT GMV over the past 2 years with nine active patients. Age range of participants is 20-65, with about half of them between 31 and 54; race and ethnicity have been primarily White (87 percent) with equal distribution of male and female patients. Most patients had one or more co-occurring mental health disorder. The majority of patients had a prescription of buprenorphinenaloxone 8-2 mg twice a day (62 percent). Many of our patients had repeated co-occurring illegal substance use on urine testing resulting in program dismissal.Conclusions: MAT GMV is a straightforward and innovative way to deliver care to patients affected by opioid use disorder who are in a maintenance state. One of the biggest obstacles to successful participation in this program is repeated co-occurring illegal substance use. When remission is achieved via MAT GMV, provider efficiency is also increased and patients accomplish a sense of wellbeing via therapy, self-management, and medication assistance.

Objective: Primary care physicians (PCPs) are positioned to mitigate opioid morbidity and mortality, but their engagement in primary, secondary, and tertiary opioid-related prevention behaviors is unclear. The objective of this study was to evaluate Tennessee PCPs’ engagement in and intention to engage in multiple opioid-related prevention behaviors.Methods: A survey instrument was developed, pretested, and pilot tested with practicing PCPs. Thereafter, a census of eligible Tennessee PCPs was conducted using a modified, four-wave tailored design method approach. Three patient scenarios were employed to assess physician intention to engage in 10 primary, secondary, and tertiary prevention behaviors. Respondents were asked to report, given 10 similar scenarios, the number of times (0-10) they would engage in prevention behaviors. Descriptive statistics were calculated using SPSS version 25.Results: A total of 296 usable responses were received. Physician intention to engage in prevention behaviors varied across the 10 behaviors studied. Physicians reported frequently communicating risks associated with prescription opioids to patients (8.9 ± 2.8 out of 10 patients), infrequently utilizing brief questionnaires to assess for risk of opioid misuse (1.7 ± 3.3 out of 10 patients), and screening for current opioid misuse (3.1 ± 4.3 out of 10 patients). Physicians reported seldomly co-prescribing naloxone for overdose reversal and frequently discharging from practice patients presenting with an opioid use disorder.Conclusions: This study noted strengths and opportunities to increase engagement in prevention behaviors. Understanding PCPs’ engagement in opioid-related prevention behaviors is important to effectively target and implement morbidity and mortality reducing interventions.

Introduction: The opioid epidemic and current opioid use guidelines for chronic noncancer pain have resulted in an overwhelmingly large number of patients undergoing opioid tapers. Even though the literature for tapering guidelines is growing, there is little guidance for tapering patients on ultra high-dose opioids.Case description: This case report describes in detail the opioid tapering approach used to taper a 53-year-old male with chronic low back pain on a regimen of a morphine equivalent daily dose (MEDD) of 1,990 mg. Patient reported many side effects such as chronic nausea, irritability, psychomotor depression, and functional impairment. He was admitted for a medically supervised opioid taper for 12 days.Results: The patient was discharged with an MEDD of 392 mg with additional taper as an outpatient to an MEDD of 200 mg. Adequate pain relief and resolution of side effects were achieved without the patient reporting significant withdrawal symptomatology in the outpatient setting.

Objective: Chronic pain is common in the military, and over a quarter of active-duty military members have received a prescription for opioids. This study reviewed the initial opioid prescription among those who became future long-term users at an Air Force base in the United States and reports the characteristics of the provider and patient.Methods: Our single-center retrospective study evaluated initial opioid prescriptions leading to long-term use within the military’s electronic medical record at a large military medical treatment facility including active-duty patients and veterans. Of the 3,701 charts reviewed, 348 patients met the inclusion criteria for the long-term opioid use.Results: Older patient groups received a higher initial amount of opioids than younger groups (p = 0.007). Primary care outpatient clinics started 43 percent of initial long-term opioid users, while surgical specialties contributed to 34 percent of the sample. In our study, 35.9 percent of the long-term opioid users were given their first opioid prescription within 30 days of an operation. Veterans or those separated from the military were less likely to have a behavioral disorder than active duty or family members.Conclusions: Our sample mirrored the civilian population in terms of age, gender, and most common pain diagnosis. We found that older patients initially received a higher dispensed amount compared to our younger patients. There was a concerning trend for surgical patients to develop into chronic opioid users.

Background: Patient beliefs about pain and opioids have been reported from qualitative data. To overcome limitations of unstructured assessments and small sample sizes, we determined if pain and pain medication beliefs varied by chronic pain status and opioid analgesic use (OAU) duration in primary care patients . Methods: Cross-sectional survey data obtained in 2017 and 2018 from 735 patients ≥ 18 years of age. The eight-item Barriers Questionnaire (BQ) measured beliefs about pain and pain medication. Patients reported OAU and use of other pain treatments. Multiple linear regression models estimated the association between never OAU, 1-90 day OAU and >90 day OAU and each BQ item . Results: Overall, respondents were 49.1 (±15.4) years old, 38.7 percent white, 28.4 percent African-American, 23.5 percent Hispanic, and 68.6 percent female. About one-third never used opioids, 41.8 percent had 1-90 day OAU, and 21.6 percent had > 90 day OAU. Multiple linear regression analyses showed that compared to never OAU, > 90 day OAU had lower average agreement that analgesics are addictive ( β = − 0.50; 95 percent CI: − 0.96, − 0.03), and 1-90 day OAU ( β = − 0.53; 95 percent CI: − 0.96, − 0.10) and > 90 OAU ( β = − 0.55; 95 percent CI: − 1.04, − 0.06) had lower average agreement that analgesics make people do or say embarrassing things . Conclusions: Patients with chronic OAU reported less concern about addiction and opioid-related behavior change. Never users were most likely to agree that opioids are addictive. There continues to be a need to educate patients about opioid risks. Assessing patients' beliefs may identify patients at risk for chronic OAU .

Based on evidence of the immunosuppressive effects of chronic opioids, long-term users of prescription and illicit opioids comprise an unrecognized but growing population of Americans with compromised immune function and respiratory depression who may be at high risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 19 (COVID-19)-related hospitalization, prolonged ICU stay, adverse events, and death. This perspective is of broad clinical and public health importance because the US has the highest population of long-term users of prescription opioids, a sequel of a decade-long practice of opioid overprescribing in the US. For long-term opioid users who are hospitalized for COVID-19, clinicians face clinical challenges arising from the suppressive effects of opioids on the respiratory and immune functions, as well as the potential for adverse drug-drug interaction when opioids have to be continued in long-term users. More research is needed to further understand the association of long-term opioid use and susceptibility to COVID-19 and other emerging infections.

Objective: Immediate-release (IR) oxycodone formulations may be manipulated for nonoral routes of administration. Oxycodone abuse-resistant immediate-release (ARIR) is a novel abuse-deterrent formulation (ADF) of IR oxycodone. This study aimed to assess the intravenous (IV) abuse potential of Oxycodone ARIR relative to commercially available IR oxycodone tablets using in vitro laboratory studies. Design: Intact or manipulated tablets were incubated in 5 or 10 mL of room temperature water for increasing amounts of time. For each timepoint, syringeability, defined as the ability to draw up water-immersed intact or manipulated tablets into a syringe, was assessed on a scale of 1 (very easy) to 10 (impossible). If the prepared sample could be drawn into a syringe, the proportion of syringeable oxycodone was measured analytically. Results: In all conditions, it was nearly impossible to draw any liquid into a syringe from samples containing manipulated Oxycodone ARIR tablets (N = 5/ group), and most samples released very low concentrations (

Objective: Opioid use is a continuing problem for the United States. Individuals who use opioids have a high risk of misuse, especially with prescription opioids. Substances that are often used in combination with opioids include methamphetamines, sedatives, and benzodiazepines, as well as tobacco, alcohol, and marijuana, but not in a medical setting. We sought to determine (a) the relationship between various drugs (eg, methamphetamine, benzodiazepines) and opioid use, as well as (b) the relationship between polysubstance use and opioid use . Design: We created a screening instrument that requested the patients seeking medical care at Federally Qualified Health Centers (FQHC) and Veterans Affairs (VA) hospitals in West Alabama self-report their substance usage . Setting: This study took place in outpatient primary care settings (FQHCs and VA hospitals) in west Alabama . Participants: De-identified electronic health records for 346 adults were obtained from consenting medical facilities. Missing data were found in 33 of the records obtained. The final usable sample for this study was 311 . Main Outcome Measure: The screening tool was comprised of five sections: demographics, tobacco use, alcohol abuse, drug use, and mental health. The primary outcome measure of this study was the number of days of opioid use in the past 30 days . Results: Thirteen individuals (4.18 percent) reported opioid use in the last 30 days. While polysubstance or dual substance use was not in the majority of the participant responses, the significant substances that were used in conjunction with opioids were methamphetamine, hallucinogens, and benzodiazepines . Conclusions: Individuals who are polysubstance users have a higher likelihood of opioid use. Interventions that target opioid use would serve the population stronger by including screenings and potential treatments for polysubstance use additionally .

The prevalence of opioid abuse has reached an epidemic level. National guidelines recommend safer opioid prescribing practices, including potentially monitoring patients with urine drug testing (UDT). There is limited research evidence surrounding the use of UDT in the context of chronic noncancer pain (CNCP). We evaluated the efficacy of systematic, randomized UDT to detect and manage opioid misuse among patients with CNCP in primary care. The Marathon Family Health Team (MFHT) designed and implemented a clinic-wide, randomized UDT program called the HARMS (High-yield Approach to Risk Mitigation and Safety) Program. This retrospective chart review includes 77 CNCP patients being prescribed opioids, who were initially stratified by their prescriber as “low-risk.” Each month, 10 percent of patients were selected for a random UDT with double testing (immunoassay and liquid chromatography-mass spectrometry). The primary outcome measure was UDT leading to a change in management plan. Of the 77 patients in the study, 55 (71 percent) completed at least one UDT during the 12-month study period. Overall, 22 patients had aberrant results. UDT led directly to changes in management in 15 of those patients. Four of those 15 patients were escalated to an addictions program, two were tapered from opioids with informed discussion, and nine were escalated to the high-risk monitoring stream. The results of this study show that in low-risk CNCP patients prescribed opioids, applying systematic UDT in a primary care setting is effective for detecting high risk behaviors and addiction, and altering management. Further research is needed with larger numbers using a prospective study design.

Objective: Pilot study to assess psychometric indices of the screener and opioid assessment for patients with pain-revised (SOAPP-R ©) with item response theory. Design: Correlational . Setting: Patients . Outcome measures: The SOAPP-R©, the pain self-efficacy questionnaire (PSE-Q), and the patient health questionnaire-9 (PHQ-9) and a demographic questionnaire. Results: A three-dimensional model provided the best fit for the SOAPP-R© item responses, with scales entitled drug-alcohol concerns, pain medication, and emotional stress; reliabilities were 0.77, 0.71, and 0.80 for those three scales. Significant correlations were found with the PSE-Q, the PHQ-9, and the SPQ for the drug-alcohol scale but not for the two remaining scales. Conclusions: The SOAPP-R© showed invariance and support for validity, but with a three-dimensional scale structure.

Introduction and aims: Mental health disorders and substance abuse are risk factors that both precede and follow chronic opioid use. We predicted that incident opioid users would have lower rates of mental health comorbidities than chronic opioid users, but that incident chronic opioid users would have lower rates of mental health comorbidities than prevalent chronic users.Design and methods: We used administrative health claims data to evaluate differences in lifetime mental health and substance abuse comorbidity profiles of people who were prevalent and incident chronic opioid users, as well as those who used opioids acutely. Results were stratified by age.Results: Over 5,188 people were prevalent chronic opioid users at study entry. Of the 10,079 people who initiated opioids, 10.2 percent had a subsequent chronic episode (incident chronic) and the remainder stopped within 90 days (incident acute). In prevalent chronic users compared to incident chronic users, rates of depression and anxiety were higher across all age groups (odds ratio (OR) across age groups range from = 1.60, 95 percent confidence interval (CI) = 1.35,1.89, to OR = 6.66, 95 percent CI = 3.02, 14.69) and prevalence of alcohol abuse was higher in those aged 55 to 74 years (OR = 5.11, 95 percent CI = 1.83, 14.24, p = 0.002). Acute users were less likely than incident chronic users to have depression and anxiety in those aged over 74 years (depression OR = 0.82, 95 percent CI = 0.70, 0.95; anxiety OR = 0.82, 95% CI 0.70, 0.98).Conclusions: Mental health morbidities commonly associated with chronic opioid use increase in prevalence as chronic use continues. Refereed/Peer-reviewed

The use of opioid analgesics for pain management has increased dramatically over the past decade, with corresponding increases in negative sequelae including overdose and death. Physicians, policymakers, and researchers are focused on finding ways to decrease opioid use and overdose. This crisis calls for a coordinated response that includes the entire healthcare sector. In this work, the authors lay out a blueprint for such a response at the level of the academic medical center. The proposed model is a comprehensive opioid overdose prevention, response, and education program to evaluate, monitor, and address prescription opioid-related adverse events and addiction among all patients within a healthcare system. The approach includes three inter-related elements: (1) creation of an organizational structure that is subdivided into subcommittees to facilitate cross-functional collaboration and implementation. These subcommittees will focus on Research and Design, Implementation, Advisory, and Compliance with the recommendation. (2) Development of an effective communication plan throughout the institution to enable the organization to function seamlessly and efficiently as a single unit, (3) development of a data tracking and reporting system that intended to have a 360° view of all aspects of opioid prescription and downstream patient outcomes. The most effective response system will require an organizational structure that facilitates the ad hoc constitution of cross-functional teams with members drawn from all levels of the organizational hierarchy (executive leadership to frontline staff). Such a structure provides the teams with immediate solutions as developed by the frontline staff and authority to remove institutional barriers that may delay or limit the successful implementation. The model described was developed in our institution by a cross-functional team that included members from the Johns Hopkins School of Medicine and Johns Hopkins University Carey Business School, Department of Operations Management. The multidisciplinary nature of collaboration allowed us to develop a model for an immediate institution-wide response to the opioid crisis, and one that other healthcare organizations could adopt with local modification as a template for execution. The model also meant to serve as a template for an institutional rapid-response that can be seamlessly implemented during any future drug-related crisis or epidemic.

Background and objective: There is evidence that opioid initiation post-surgery is contributing to the problem of chronic misuse and/or abuse of over the counter medications in the community, and that orthopedic patients may be particularly at risk. The aim of the systematic review with meta-analysis was to identify research that examined opioid use at 3, 6, and 12 months post-operatively by previously opioid naïve orthopedic surgery patients.Design, databases, and data treatment: A searched review with meta-analysis was undertaken. Eight databases were search. Meta-analyses conducted at all three time points (3 months, 6 months, and 12 months).Results: The search yielded 779 records, and after screening, 13 papers were included in meta-analysis. Results provide strong evidence that post-operative opioid use amongst the opioid naïve is a real effect (7 percent at 3 months, 4 percent at 6 months, and 2 percent at 12 months). A Z-test for overall effect revealed strong evidence that this proportion was nonzero for opioid use at 3, 6, and 12 months (p < 0.001 for all time points). A small but significant proportion of opioid naïve patients who are prescribed opioids remain on these medications up to 12 months post-operatively.Conclusions: The nature of the studies included in the meta-analysis were varied, hence subanalyses regarding surgery type, characteristics of the patient group or other potential factors that might influence the progression to longer term opioid use after these surgeries could not be explored. Given this, further research in this area should explore such specific orthopedic subgroups.

Objectives: (1) To estimate the prevalence, geographic distribution, and demographic characteristics of patients diagnosed with mental and behavioral disorders due to the use of opioids in Colombia, between 2009 and 2018. (2) To describe the opioid sales trends in Colombia over the last few years. Methods: We conducted an observational study analyzing information from Individual National Registry of Health Services and the Colombian official database for pharmaceuticals prices and quantities sold. The included ICD-10 codes were mental and behavioral disorders due to the use of opioids (F11) codes subdivisions. Results: 12,557 cases of mental and behavioral disorders due to opioid use were reported, with a rate of 3.0 per 100,000 inhabitants for the studied period. Men represented 74.2 percent, with a male:female ratio of 2.9:1. The highest prevalence was found between 20 and 24 years, in the northwest Colombian area. A progressive increase in the total number of opioid units sold during the study period was found, and the most frequently sold opioids were tramadol (55 percent) and codeine (20 percent). Conclusions: Recognition of opioid use disorders has increased in the last 10 years; it affects more males than females, mostly young adults, and is higher in certain affluent regions of Colombia. We found a progressive annual increase in the sales of opioids in the country, which could be related to the increase in the rate of registries. Studies that have analyzed opioid abuse in Latin America are limited, and further studies are needed to evaluate this situation in middle-income countries from the region.

Opioids are an indispensable part of perioperative pain management of cancer surgeries. Opioids do have some side effects and abuse potential, and some laboratory data suggest a possible association of cancer recurrence with perioperative opioid use. Opioid-free anesthesia and opioid-sparing anesthesia are emerging new concepts worldwide to safeguard patients from adverse effects of opioids and potential abuse. Opioid-free anesthesia could lead to ineffective pain management, leaving the perioperative physician with limited options, while opioid-sparing anesthesia may be a rational approach. This consensus guideline includes general considerations of the safe use of perioperative opioids along with concomitant use of central neuraxial or regional blockade and systematic nonopioid analgesics. Region-specific onco-surgeries with their specific recommendations and consensus statements for judicious use of opioids are suggested. Use of epidural analgesia or regional catheter during thoracic, abdominal, pelvic, and lower limb surgeries and use of regional nerve blocks/catheter in head neck, neuro, and upper limb onco-surgeries, wherever possible along with nonopioids analgesics, are suggested. Short-acting opioids in small aliquots may be allowed to control breakthrough pain for expedient control of pain. The purpose of this consensus practice guideline is to provide the practicing anesthesiologists with best practice evidence and consensus recommendations by the expert committee of the Society of Onco-Anesthesia and Perioperative Care for safe opioid use in onco-surgeries.

Introduction: Urine drug screens (UDS) assist in clinical planning and assessment of adherence in opioid agonist treatment (OAT). Urine drug screens may also be used in criminal justice and child protection settings. Buprenorphine (BPN) UDS testing is complex. Immunoassay often does not detect BPN and gas chromatography-mass spectrometry (GC-MS) is needed. A limited understanding of testing can negatively influence UDS interpretation and clinical decision making. Objectives: The primary aim was to determine detection rates of BPN in UDS in participants on BPN or buprenorphine/naloxone (BNX) treatment. The secondary aim was to identify if comorbidities, sex, co-prescribed medications, or dosing site and observation were associated with BPN detection. Setting: Public outpatient clinic in a specialist addiction treatment service. Design/participants: In this retrospective observational study, records of clients on supervised BPN/BNX treatment between September 2017 and 2018 were reviewed. Measures: Data extracted included UDS results, age, sex, indication for BPN, frequency of observed doses, dose of BPN, dosing site, co-morbid medical conditions, and medications. Results: One hundred and sixty-one medical records were reviewed. Ninety-seven (60 percent) underwent screening urine immunoassay. Of these 97, 51 (53 percent) had further GC-MS testing for BPN of which 22 (43 percent) did not detect BPN despite directly observed OAT. Co-prescription of medications known to interact with cytochrome P450 3A4 was associated with nondetection of BPN (p < 0.05). No significant association between median dose, dosing site, and observed dosing and BPN detection was identified. Conclusion: Urine drug testing for BPN is complex. Failure to detect BPN does not betoken nonadherence to treatment and is associated with co-prescription of drugs interacting with cytochrome P450 3A4.

Opioid abuse represents a public health crisis that has significant associated morbidity and mortality. Since beginning in the early 1990’s, the opioid abuse epidemic has been difficult to control due to regulatory, economic, and psychosocial factors that have perpetuated its existence. This era of opioid abuse has been punctuated by three distinct rises in mortality, precipitated by unique public health problems that needed to be addressed. Patients affected by opioid abuse have been historically treated with either methadone or naltrexone. While these agents have clinical utility supported by robust literature, we the authors posit that buprenorphine is a superior therapy for both opioid use disorder (OUD) as well as pain. This primacy is due to the pharmacological properties of buprenorphine which render it unique among other opioid medications. One such property is buprenorphine’s ceiling effect of respiratory depression, a common side effect and complicating factor in the administration of many classical opioid medications. This profile renders buprenorphine safer, while simultaneously retaining therapeutic utility in the medical practitioner’s pharmacopeia for the treatment of opioid use disorder and pain.

Objective: To examine syringe services program (SSP) participants’ interest in long-acting injectable buprenorphine. Design: SSP participants completed a 136-item questionnaire by phone. Items assessed quantitative ratings of interest in sublingual and injectable buprenorphine, preference for sublingual versus injectable buprenorphine, and reasons for preferences. Setting: Two large urban SSPs. Participants: SSP participants ≥ 18 years of age with current or lifetime opioid use disorder (OUD). Main outcome measure(s): (1) Interest in sublingual and injectable buprenorphine, respectively, on a scale from 0 to 10 (0 = no interest and 10 = high interest); and (2) preference for sublingual buprenorphine versus injectable buprenorphine. Participants were also asked whether they agreed with statements that presented potential reasons for preferring each formulation. Results: A total of 104 unique participants were interviewed, of which 72 (69 percent) were currently receiving or considering buprenorphine treatment. Among these 72 participants, the median level of interest in starting or continuing sublingual buprenorphine was 8 out of 10 (interquartile range [IQR]: 6-10) and in starting injectable buprenorphine was 5 out of 10 (IQR: 1-9). Thirty-six (50 percent) preferred sublingual, 27 (38 percent) preferred injectable, and 9 (13 percent) preferred neither or declined to answer. Participants who preferred injectable buprenorphine most commonly agreed that the convenience of the monthly injection was the reason for their preference. Conclusions: Among SSP participants with OUD, we found moderate interest in injectable buprenorphine. Introducing this new form of buprenorphine treatment at SSPs could help meet the needs of individuals who are not well-served by standard OUD treatment models.

Objective: To demonstrate the prevalence of opioid use disorder (OUD) in the military health system (MHS), geographically map OUD patients and providers, and offer policy recommendations to help increase buprenorphine waiver prescribing. Design: This study was a retrospective review of data from the MHS records. Deidentified records of MHS OUD patients receiving buprenorphine were utilized. Secondary data with nonpersonally identifiable information (PII) were used for pulling records of buprenorphine prescribing providers within the direct care system (MHS providers) and providers from the purchased care system (civilian facilities accepting TRICARE beneficiaries). Setting: This study reviewed records of individuals within the MHS, in the United States, and its territories. Patients and participants: Patients within the MHS system with a diagnosis of OUD. Providers, within the MHS or purchased care, who had prescribed buprenorphine were selected. Main outcome measured: The number of OUD patients in the MHS and providers caring for these OUD patients. In addition, geographical maps illustrating the dispersion of OUD patients, and prescribers were created. Results: The vast majority of MHS OUD patients receive their care from purchase care. Between 2015 and 2018, there has been a shift in the number OUD diagnosed patients by region, and the number of OUD prescribers. Conclusion: The MHS population, particularly active duty, is a transient population. As such, it is not a surprise that the population of OUD patients or prescribers varied by region during that time period. Furthermore, results demonstrate that there is a need to increase the number of buprenorphine-waivered prescribers within the MHS. Changes in policy may encourage more providers to obtain the waiver or increase patient load.

Opioid use disorder is a major public health problem, and opioid replacement therapy with buprenorphine (BPN) is a clinically effective and evidence-based treatment for it. To deter misuse of the tablet through the injecting route, BPN coformulated with naloxone (BNX) in 4:1 ratio is available in many countries. Despite this, significant diversion and injecting use of the BNX combination has been reported from across the world. In this article, the pharmacological properties of BPN and BNX and the evidence for their diversion are reviewed. Also, a critical examination is made of the evidence supporting the role of naloxone in reducing the agonist effects of BPN when used through the injecting route. Based on this evidence, a hypothesis explaining the continued diversion of BNX has been proposed.