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Objectives Opioid prescription rates worldwide suggest miscalibrated risk perceptions among those who prescribe, dispense, and take opioids. Findings from cognitive science show that risk perceptions can differ systematically depending on whether people learn about risks by description or experience. We investigated the effects of descriptive and simulated experience risk formats on patients’ risk perceptions and behavior regarding long-term strong opioid use. Methods 300 German patients with chronic noncancer pain were randomly assigned in an exploratory randomized controlled trial to either a descriptive format (fact box) or a simulated experience format (interactive simulation). Primary endpoints were subjective and objective risk perceptions and intended intake behavior. Results Both formats significantly improved patients’ objective risk perception; patients who saw the fact box estimated some outcomes more accurately (p = .031). Formats were equally effective in improving patients’ subjective risk perception in terms of opioids’ harms; however, patients receiving the simulation showed a greater reduction and termination of their opioid intake (p = .030) and a higher uptake of alternative therapies. Conclusions Descriptive and simulated experience risk formats improve risk perceptions and behavior regarding potent but highly risky drugs. Practice implications To eliminate risky behavior, simulated experience formats may be superior to descriptive formats.

Background Given the national opioid crisis, postoperative analgesia at discharge must be thoughtfully prescribed. Data specifically related to thoracic procedures remain scarce. This study assessed adequacy of pain control with standardized and limited opioids after thoracic procedures. Methods A standardized prescription comprised 15 hydromorphone tabs, 7 days of acetaminophen, and 3 days of ibuprofen was provided on discharge to elective thoracic surgery patients. On the first postoperative visit, patients completed a questionnaire regarding the number of hydromorphones used, use of additional opioids, pain-related limitation to function, and adequacy of pain control. Results A total of 122 patients undergoing thoracic surgery procedures were surveyed. Twelve underwent open procedures and were excluded. An additional 6 patients who used opioids chronically preoperatively were also excluded. The remaining 104 patients were included in the study. Median age was 66 years (age range, 17-90 years) and median length of stay was 2 days (range, 1-15 days). Seventeen (16%) patients used all prescribed hydromorphone and 56 (54%) used none, 18 (17%) asked for additional or other opioid, and 14 (13%) felt that their pain significantly limited their function. Nine (9%) felt that that their pain was inadequately controlled. Conclusions Pain after thoracic procedures, especially video-assisted thoracoscopic surgery, is adequately controlled with minimal opioid doses (combined with adjuncts), with less than 1 in 5 patients requiring additional prescriptions and very few patients complaining of pain that significantly limited their function. This study shows that a standardized limited opioid prescription is safe, is adequate, and can easily be implemented for the majority of thoracic surgery patients.

Background Opioid misuse continues to be a major concern in the United States, affecting both adults and adolescents. Unfortunately, even legitimate prescription opioid misuse in adolescence increases the risk for misuse later in life. Although adolescence is a critical period for learning, little is known about adolescents’ preferences for opioid safety education. One potential avenue for prescription opioid education is the use of serious games. Serious games can result in better health outcomes and understanding for adolescents and allow them to safely experience real-life scenarios. However, few studies have examined the use of serious games for adolescent opioid education. Objective This study explored adolescents’ preferences for prescription opioid education and design of a serious game focused on opioid safety education. Methods A focus group guide was adapted from 2 statewide surveys about participants’ perspectives on opioids. Recruitment packets with consent documents and an introduction to the study were sent home to eligible students. Ten focus groups were conducted with 68 middle and high school students in Wisconsin. Adolescents were asked to discuss their preferences for prescription opioid safety education and to design a serious game to educate teens about opioid safety. Focus groups were audio-recorded, professionally transcribed, and underwent content and thematic analyses using NVivo 12 software. Results Three preferred approaches for opioid safety education were identified, including the use of presentations, videos and websites, and serious games. Adolescents desired short presentations delivering personal stories to smaller audiences. They preferred websites and brief, engaging videos from reliable sources because of ease of access. Adolescents also preferred serious games for opioid education that were realistic and relatable. Conclusion When educating adolescents on prescription opioids, the use of presentations, particularly personal stories, brief and engaging websites and videos, or serious games with realistic and relatable scenarios should be incorporated.

Little is known about the mechanisms by which pain catastrophizing may be associated with opioid use outcomes. This study aimed to investigate the potential mediating role of beliefs about the appropriateness of pain medicines for pain treatment on the association between pain catastrophizing and prescription opioid use in a community chronic non-cancer pain (CNCP) sample. Individuals (N = 420) diagnosed with CNCP participated in a cross-sectional online self-report study with validated measures of pain medication beliefs, pain catastrophizing, and current prescription opioid use. Two parallel multiple mediator analyses with percentile-based bootstrapping examined pathways to both prescription opioid use and high-dose use (≥ 100mg oral morphine equivalents/day), while controlling for pain intensity and other relevant covariates. Pain medication beliefs significantly mediated the association between pain catastrophizing and prescription opioid use (CI = 0.011, 0.033). A similar pattern of findings was found for high-dose opioid use, with pain medication beliefs significantly mediating the pain catastrophizing-high-dose use association (CI = 0.006, 0.050). Pain medication beliefs are a potentially modifiable psychological mechanism by which pain catastrophizing is associated with opioid use, including high-dose use. These findings have important implications for personalizing prevention and treatment programs.

Background The opioid epidemic is a health crisis in the United States. Within orthopedic surgery, opioid misuse and incautious prescription remains a concern. In the last several years, there has been a growing interest and public effort toward reducing opioid use in total joint arthroplasty (TJA) in response to the opioid epidemic in the United States. We aim to review opioid-limiting practices, policies, and legislations that are implemented at the state level and nationally that are relevant to TJA, as well as evaluate studies that measure the efficacy of these policies in the management of patients undergoing TJA. Methods Two independent reviewers conducted a systematic review of national and state level opioid-limiting policies implemented in the United States and their effects on opioid prescription, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). Results We identified 3 national bills and 9 policies set forth by national organizations that imposed limits on opioid prescription. Opioid-reducing legislation was also identified in 24 states, with the majority specifying a 7-day limit on initial opioid prescription for acute pain management. Six research studies evaluating the impact of opioid-restricting policies on postoperative opioid prescription for TJA patients were found. Three studies assessed legislation at the state level while the others were institution-based guidelines. Overall, these studies demonstrated a significant decrease in mean morphine milligram equivalents of initial opioid prescription after implementing the policies. Conclusion Recent opioid-restricting legislation is effective in decreasing postoperative opioid prescriptions following TJA.

Introduction Improving access to naloxone is an important public health strategy in the U.S. This study examines the state-level trends in naloxone dispensing from 2012 to 2019 for all 50 states and the District of Columbia. Methods Data from IQVIA Xponent were used to examine the trends and geographic inequality in annual naloxone dispensing rates and the number of naloxone prescriptions dispensed per high-dose opioid prescription from 2012 to 2019 and from 2016 to 2019 to correspond with the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain release. Annual percentage change was estimated using linear regression. Analyses were conducted in 2020. Results Naloxone dispensing rates and the number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 2012 to 2019 across all states and the District of Columbia. Average state-level naloxone dispensing rates increased from 0.55 per 100,000 population in 2012 to 45.60 in 2016 and 292.31 in 2019. Similarly, the average number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 0.002 in 2012 to 0.24 in 2016 and 3.04 in 2019. Across both measures of naloxone dispensing, the geographic inequality gap increased during the study period. In 2019, the number of naloxone prescriptions dispensed per 100 high-dose opioid prescriptions ranged from 1.04 to 16.64 across states. Conclusions Despite increases in naloxone dispensing across all states, dispensing rates remain low, with substantial variation and increasing disparities over time at the state level. This information may be helpful in efforts to improve naloxone access and in designing state-specific intervention programs.

Background Residents report that faculty preference is a significant driver of opioid prescribing practices. This study compared opioid prescribing preferences of surgical residents and faculty against published guidelines and actual practice and assessed perceptions in communication and transparency around these practices. Methods Surgical residents and faculty were surveyed to evaluate the number of oxycodone tablets prescribed for common procedures. Quantities were compared between residents, faculty, Opioid Prescribing Engagement Network guidelines, and actual opioids prescribed. Frequency with which faculty communicate prescribing preferences and the desire for feedback and transparency in prescription practices were assessed. Results Fifty-six (72%) residents and 57 (59%) faculty completed the survey. Overall, faculty preferred a median number of tablets greater than recommended by Opioid Prescribing Engagement Network in 5 procedures, while residents did so in 9 of 14 procedures. On average, across all operations, faculty reported prescribing practices compliant with Opioid Prescribing Engagement Network 56.1% of the time, whereas residents did so 47.6% of the time (P = .40). Interestingly, opioids actually prescribed were significantly less than recommended in 7 procedures. Among faculty, 62% reported often or always specifying prescription preferences to residents, while only 9% of residents noted that faculty often did so. Residents (80%) and faculty (75%) were amenable to seeing regular reports of personal opioid prescription practices, and 74% and 65% were amenable to seeing practices compared with peers. Only 34% of residents and 44% of faculty wanted prescription practices made public. Conclusion There is a disconnect between opioid prescribing preferences and practice among surgical residents and faculty. Increased transparency through individualized reports and education regarding Opioid Prescribing Engagement Network guidelines with incorporation into the electronic medical record as practice advisories may reduce prescription variability.

Background In response to the opioid epidemic, Florida recently passed the opioid prescription limiting law, effective since July 1st, 2018. However, its impact on opioid prescription after total joint arthroplasty (TJA) has not been elucidated. Thus, our objective was to assess if this new law led to reduced opioid prescription after TJA and to determine its impact on perioperative clinical outcomes. Methods A retrospective chart review was conducted on a consecutive series of 658 primary TJAs (618 patients), performed by four surgeons in a single institution [1/2/2018-10/23/2018]. Based on effective date of the law, cases were divided into: prelaw (327 cases; 168 hips/159 knees) and postlaw (331 cases; 191 hips/140 knees) phases. Baseline demographics and surgical characteristics were compared. The effect of the law on perioperative outcomes: length of stay, complications, emergency department/office visits, patient phone calls, reoperation or readmission (90 days), and total morphine equivalents prescribed was investigated. Independent sample t-tests and chi-square analyses were performed. Results Prelaw and postlaw phases had no significant difference in baseline demographics and characteristics. No difference was found in length of stay. Opioid law implementation led to significantly lower total oral morphine equivalents after TJAs [Prelaw: 1059.9 ± 825.4 vs postlaw: 942.8 ± 691.7; P = .04], but did not result in a significant increase in 90-day complications, patient visits (office or emergency) or phone calls, and reoperation or readmission. Conclusion Our data suggest that Florida state opioid prescription limiting law has resulted in a marked decline in opioid prescription without any increase in rates of patient visits, phone calls, or readmission after TJA.

Background Prescription opioid misuse and suicide among adolescents are significant health challenges. Purpose This study investigated whether effects of prescription opioid misuse on depressive symptoms and suicidality are greater among female than male students. Methods Using the 2017 Youth Risk Behavior Survey (N = 14,765), this research estimated additive interactions using risk differences as well as multiplicative interactions using odds ratios. Discussion Results showed prescription opioid misuse was associated with significantly greater risks among females than males for depressive symptoms (31.1% vs. 20.8%), suicidal ideation (27.3% vs. 19.1%), suicide attempts (18.1% vs. 11.9%) and suicide attempts requiring treatment (8.5% vs. 4.4%). In contrast, multiplicative interactions using odds ratios were all nonsignificant. Conclusions Among students who misused prescription opioids, females compared to males had much higher average predicted margins of depressive symptoms, suicidal ideation, suicide attempts, and suicide attempts requiring treatment. Screening for depression and suicidality among adolescents who misuse prescription opioids, and vice versa, is paramount.

Objective To describe opioid prescribing patterns for patients undergoing kidney cancer surgery and evaluate associations with medical resource utilization in the postoperative setting. Methods Linked Surveillance, Epidemiology, and End Results - Medicare data were used to identify patients with kidney cancer who underwent partial or radical nephrectomy (open vs. minimally invasive) from 2007 to 2015. Total dose of discharge opioid prescriptions was quantified into 3 exposure groups based on observed tertiles: 1-199 (low), 200-300 (moderate), and >300 (high) oral morphine milligram equivalents. Associations between exposure groups and patient demographics, clinical factors, and hospital volumes were measured using multivariate logistic regression. Additionally, we identified associations with prior opioid exposure and postoperative medical resource utilization. Results Of 4538 patients meeting inclusion criteria, exposure group distributions were 35% (low), 43.5% (moderate) and 21.6% (high). Over one-third of patients (39.5%) received an opioid prescription within 6 months preceding surgery. High opioid prescriptions were associated with prior exposure, younger age, rural residence and open surgery (P Conclusion Prescribing patterns after kidney cancer surgery vary widely. Higher prescribed dose of post-surgical opioids is associated with 90-day hospital readmissions and long-term exposure. Prior opioid exposure conveys a higher risk of medical resource utilization. More judicious opioid prescribing may limit medical resource utilization and help combat the opioid epidemic.

Objectives To evaluate patient, provider, and facility factors associated with variation in opioid prescribing after endoscopic procedures for benign prostatic hyperplasia across a large academic health system to drive improvement efforts. Methods Opioids prescribed at discharge for patients who underwent an endoscopic prostate procedure March 2018-November 2019 were analyzed. Multivariable logistic and linear regression were used to evaluate the relationship between patient, provider, and facility factors and the receipt of any opioid prescription and the quantity prescribed. Results We included 724 patients who had surgery with one of 26 urologists across five facilities. 222 (30.7%) received an opioid prescription, and the average morphine milligram equivalents (MMEs) prescribed was 97.9±33.5. We found wide variation in the proportion of patients who received an opioid prescription across surgeons (range 0%-88.9%) and facilities (range 19.9%-66.7%) and the average MMEs prescribed (range 25-188.5). Outpatient surgery (OR 2.32; 95% confidence interval [CI] 1.22-4.40, P = .010) and preoperative opioid use (OR 15.04; CI 9.65-23.45, P Conclusions Opioid prescribing following endoscopic prostate procedures varied widely. Targeted interventions tailored to younger patients, those taking opioids preoperatively, recipients of outpatient surgery and those undergoing surgery at satellite facilities may be particularly high yield given the association between these factors and increased postoperative prescribing.

There has been a dramatic rise in opioid-related deaths over the past decade. Most of the reduction strategies have focused on outpatient use; however, recent studies have demonstrated an association between inpatient opioid use and consumption following discharge across a variety of surgical procedures. The objective of this study is to evaluate the association of inpatient use of opioids as well as the consumption of opioids after discharge following endovascular aortic aneurysm repair (EVAR).A prospectively maintained database was reviewed for cases between 2015 and 2018. Patients were included in the study if they underwent an elective EVAR, had an intensive care unit stay less than 1 day and total length of stay less than 3 days. Patients were contacted to participate in a survey of opioid use if they received a prescription at discharge. The primary outcome was percent of prescribed opioids consumed following discharge. Multivariate analyses were performed to determine predictors of receiving an opioid prescription.One hundred seventy-one patients were included in the analysis; 95% patients were white and 85% male. 59% of patients responded to the survey. Seventy-one (42%) received an opioid prescription at discharge. Patients that received a discharge prescription tended to be younger (71 vs. 75 years, P = 0.005) and more likely to have received opioids while in the hospital (79% vs. 45%, P0.001). Additionally, patients who received opioids at discharge received a significantly greater amount of milligram oral morphine equivalents (OME) while in the hospital (27.76 ± 38.91 vs. 10.05 ±29.43, P0.001). Multivariate analysis demonstrated age, estimated blood loss (EBL), and OME per day to be significant inpatient predictors of requiring an outpatient opioid prescription. Open femoral access (27%) was not a predictor of opioid prescription at discharge. A total of 1185 pills were prescribed (29.6 ± 2.06 per patient), but only 208 pills consumed (5.2 ± 1.27 per patient). Around 82% of total pills prescribed were not consumed.This study evaluates inpatient opioid use and postdischarge consumption following EVAR. These data identify key factors associated with receiving an opioid prescription at discharge and demonstrate that patients consume far fewer opioids than prescribed. These findings provide insight as to which patients may not require an outpatient prescription following EVAR, leading to potential practice-changing opioid reduction strategies.

Objective The purpose of this study was to describe changes in opioid-therapy prescription rates after a family medicine practice included on-site chiropractic services. Methods The study design was a retrospective analysis of opioid prescription data. The database included opioid prescriptions written for patients seeking care at the family medicine practice from April 2015 to September 2018. In June 2016, the practice reviewed and changed its opioid medication practices. In April 2017, the practice included on-site chiropractic services. Opiod-therapy use was defined as the average rate of opioid prescriptions over all medical providers at the practice. Results There was a significant decrease of 22% in the average monthly rate of opioid prescriptions after the inclusion of chiropractic services (F1,40 = 10.69; P Conclusion This study demonstrates that there were decreases in opioid-therapy prescribing rates after a family medicine practice included on-site chiropractic services. This suggests that inclusion of chiropractic services may have had a positive effect on prescribing behaviors of medical physicians, as they may have been able to offer their patients additional nonpharmaceutical options for pain management.

Introduction Prescription opioid misuse is a national crisis. Injured children often receive opioid medication at hospital discharge, but the role these prescriptions play in the opioid crisis has not been fully elucidated. Whether these opioids are administered, the duration of severe pain requiring opioids, and what the final disposition of unused opioids is in this population remain unknown. Methods A survey of parent/guardian perceptions of their child's pain after injury, duration of opioid administration, opioid storage and disposal, and perceptions of opioid education was designed. During a 12-month period, parents of injured children admitted to an ACS Level 1 Pediatric Trauma Center were prospectively enrolled by convenience sample. Surveys were in two steps with an enrollment survey prior to discharge and a follow-up survey 7–10 days after discharge. Results Seventy of 114 (61.4%) enrolled parents/guardians completed follow-up survey. Of the 79.1% that reported an opioid prescription for their child, 92.5% filled it. Of those reporting on opioid usage, 10.4% never used the opioid, 75% used opioids 7 days. Of those who filled the opioid prescription, 83.7% reported having leftover doses. Reasons for discontinuing opioids included the child no longer had pain (87.2%), the child ran out of medication (5.1%), other (7.7%). Regarding storage, 53.3% reported utilizing an unlocked bathroom cabinet, and 81.3% unlocked kitchen space. Of those reporting unused opioids, 83.3% reported not disposing them, and 38.2% reported no plan for disposal. Conclusion The majority of parents/guardians of injured children report resolution of severe pain requiring opioids within 72 h of hospital discharge, and virtually all by 7 days. The majority of injured children were prescribed a greater number of doses than they needed to treat their pain. Many parents/guardians store opioids in unsecure locations and a significant proportion report no plan to dispose of unused opioid doses. Further investigation is warranted to quantify and address the gap between pain control needs and opioid prescribing practices. The rate of unsecure storage and plan to retain unused opioids are potential targets for discharge opioid education. Type of study Cross-sectional survey. Level of Evidence Level IV.

BACKGROUND: Adolescents are affected by the opioid epidemic, but little is known about their attitudes toward opioids and preferences for opioid safety education. OBJECTIVES: This study explored adolescents’ awareness prescription opioid misuse, sources of medication information, and educational preferences. METHODS: An online survey explored adolescents’ understanding and perceptions of prescription opioids and opioid misuse and safety, medication information sources, and educational preferences. Eligible participants included students from three Wisconsin high schools who could speak and understand English. Participants were recruited through “backpack mail” and completed surveys online at school. Survey responses were compared across demographic information of study participants. Binary response items were compared across demographic strata by Fisher’s exact tests, and Likert responses were analyzed by Kruskal-Wallis tests. RESULTS: A total of 190 students (53% female, 53% White, 32% Hispanic) were surveyed. Most (83.5%) considered using someone else’s opioid medication to be misuse, 85.2% identified using opioids at a higher dose or frequency than prescribed as misuse, and 67.6% considered using an opioid prescription after its expiration date to be misuse. About 90% of students perceived that opioid misuse causes some, quite a bit, or a great deal of harm to a person’s physical and mental health and school ability. Many students were able to correctly identify examples and consequences of misuse, however 24.7% believed that flushing opioids down the drain was dangerous. The most common source for finding information about opioids was Google or other search engines (67.6%), followed by talking with parents (56.7%), talking with a doctor or nurse (54.9%), and online videos (42.3%). CONCLUSION: Adolescents have some opioid safety knowledge, but there is a clear opportunity to increase knowledge and understanding of risks. Adolescents could benefit from opioid safety education, particularly on safe storage and disposal, harms of misuse, and strategies for discouraging peer opioid misuse.

OBJECTIVE Standardization of prescriptions after specific procedures (laparoscopic appendectomy, cholecystectomy, inguinal/umbilical hernia repair) significantly reduces opioid prescriptions for these targeted procedures. We sought to determine the impact of increased attention to responsible opioid prescribing in the absence of protocolization. DESIGN Prescription practices of Laparoscopic Sleeve Gastrectomies and Roux-en-y Gastric Bypasses at a tertiary medical center (October 1, 2016-September 30, 2018) were retrospectively reviewed. Patients were grouped into whether surgical intervention took place before or after institution of an unrelated opioid protocol in November 2017. Patients with chronic opioid use or extended hospital stay (>4 days) were excluded. Discharge prescriptions, oral morphine equivalents (OME), and need for repeat prescriptions were compared. SETTING This study was set at Madigan Army Medical Center in Tacoma, Washington. PARTICIPANTS All general surgery residents engaged in clinical duties at our institution during the dates of the study were included. RESULTS Study population included 187 patients, with 91 patients undergoing surgery prior to the protocol and 88 post-protocol. Preprotocol patients were provided an average of 413 OME (SD 103) and 5.5% required repeat opioid prescriptions within 3 months of surgery. The most common opioid prescription was 300 mL of oxycodone elixir (450 OME, 88%). Postprotocol, opioid prescriptions fell 61% to an average of 161 OME (SD 71, p < 0.001). Repeat opioid requirements remained statistically unchanged (8.0%, p = 0.562). The most common opioid prescription postprotocol included 20 oxycodone tablets (150 OME, 76%). CONCLUSIONS Opioid reduction efforts reap benefits beyond those procedures specifically targeted. Focus on responsible opioid prescribing through standardization, even when limited to certain procedures, may result in a hospital culture change with global opioid prescription reduction.

Background The objectives of this study were to describe opioid prescribing after hospitalization for elective cardiac operation, to identify factors associated with increased opioid prescriptions, and to develop procedure-specific opioid prescribing guidelines. Methods We analyzed data from all adults (≥18 years) undergoing elective cardiac operation for acquired heart disease from July 2014 to March 2017 at 3 affiliated hospitals. Opioid prescription data were abstracted and converted to morphine milligram equivalents (MME). Multivariable logistic regression was performed with the outcome of top-quartile prescriptions. Results There were 4145 study patients after exclusion of preoperative opioid users (10.5%). Mean ± SD patient age was 63.9 ± 13.2 years, and 68.4% (n = 2835) were male. The operation was the first in 87.3% (3617); the most common operative approach was sternotomy in 91.0% (n = 3773), followed by robot-assisted operation in 4.6% (n = 192). The majority of patients, 72.7%, received an opioid prescription at hospital dismissal, with a median opioid prescription of 200 MME (interquartile range 0 to 375 MME; range 0 to 6400 MME). This varied by hospital, with medians of 150, 450, and 600 MME (P Conclusions Significant variation in opioid prescribing practices after cardiac operation was observed. The primary driver was hospital-centric as opposed to patient specific. Opioid prescribing guidelines were established to standardize posthospital pain management.

Many individuals believe that physicians can be difficult when they become patients, as having "just enough" knowledge or attempting to direct one's personal medical care presents problems particularly when dealing with a dynamic issue such as analgesia. Physicians are used to being advocates for their patients, and when they are the patients themselves, there is a certain degree of transition that changes one's perspective and affects how complex medical issues are addressed. There has been an evolution in management of pain concerns in recent decades with growing recognition of the toll of the opioid epidemic on our society.

Opioid use disorder is complex and not easily quantified among US populations because there are no dedicated reporting systems in place. We review indicators of opioid use disorder available at the state and county (human immunodeficiency virus [HIV] diagnoses among people who inject drugs, hepatitis C diagnosis in people

Objective To determine the impact of a drug deactivation system to post-surgical patients on the rate of opioid prescription disposal. Patients and Methods Two hundred post-operative patients discharged after inpatient surgery at a large academic medical center. This study was conducted August 20, 2018, through November 30, 2018. Patients were provided with a drug deactivation system (DDS) and instruction sheet along with their opioid prescription. Three to 4 weeks after dismissal, patients were surveyed about quantity of opioids remaining, use of DDS or other disposal methods, and satisfaction with DDS if used. Results One hundred forty-nine of 200 (74.5%) patients were surveyed. One hundred six reported leftover opioids and 29 (27.3%) had disposed of these medications. By the time of survey, 23 (21.2%) participants with leftover opioids had used the DDS to destroy their remaining supply and an additional 33 (31.1%) participants reported plans to use the disposal bag on a future date. Of the 23 participants who used the DDS, 22 (96.0%) reported that they were very satisfied with the disposal process. Conclusion Participants are willing to use a DDS and are satisfied with the process; however, additional education is needed to ensure timely disposal.

Although prescription opioid abuse is a serious concern, patients are commonly prescribed opioids for postoperative pain management. This study sought to evaluate the efficacy of low-dose steroids to reduce postoperative pain and opioid use after lumbar laminectomy and/or discectomy. In the 10-day period postdischarge, patients prescribed a low-dose steroid reported decreased pain scores compared with those who were not prescribed a low-dose steroid; however, there was no associated significant difference in opioid consumption. Outcomes data suggest that postoperative oral steroid may reduce postoperative pain but does not necessarily decrease short-term opioid use after lumbar laminectomy and/or discectomy.

The purpose of the study was to explore clinical management for new cases of musculoskeletal pain that are likely chronic. We used data from the National Ambulatory Medical Care Survey, 2007-2015, identifying visits with a new chronic musculoskeletal pain condition using predetermined ICD-9 codes. We documented prescribing of nonopioid pain medication, opioids, physical therapy (PT), counseling, and other nonpharmacologic treatments and explored associations between patient and provider factors for each of these treatments. There were 11,994 visits over the 9-year period for a new case of chronic musculoskeletal pain, representing an average of 36.8 million weighted visits per year or approximately 11.8% of the population. Proportions that were prescribed nonopioid medication, opioids, PT, counseling and other nonpharmacologic treatments were: 40.2, 21.5, 10.0, 15.2 and 14.3 respectively. Patient age was associated with type of treatment with a young to old gradient for other nonpharmacologic treatments, PT, opioids, counseling and other medications. Orthopedists were less likely to prescribe pharmacological treatments than family practice physicians and more likely to prescribe PT. Physicians who used the electronic medical record were more likely to prescribe opioids. Contrary to practice guidelines for managing musculoskeletal pain, many patients are prescribed opioids for a new chronic musculoskeletal problem. PERSPECTIVE: We outlined in a representative sample of Americans what treatments are being prescribed for new cases of likely chronic musculoskeletal pain. Opioid prescription was double that of physical therapy. Using the electronic medical record was associated with more opioid prescription- a novel finding that should be corroborated by future research.

Total knee arthroplasty (TKA) creates a relatively large degree of nociception, making it a good setting to study variation in pain intensity and pain alleviation. The purpose of this study is to investigate factors associated with a second prescription of opioid medications within 30 days of primary TKA.Using an insurance database, we studied 1372 people over a 6-year period with no mental health comorbidities including substance misuse and no comorbid pain illness at the time of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA were sought among patient demographics and the overall prescription morphine milligram equivalents. Patient and prescription-related risk factors were evaluated utilizing logistic relative risk regression. We reserved a year of data, 222 people, to evaluate the performance of the derived model.More than half the patients filled a second prescription for opioids within 30 days of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA included age (P.01), current smoker (P = .01), and the total morphine milligram equivalents of the initial prescription (P.01). Applied to the 222 people we reserved for validation, the model was 81% sensitive and 14% specific for a second prescription within 30 days, with a positive predictive value of 74%, and a negative predictive value of 20%.People that are given more opioids tend to request more opioids, but our model had limited diagnostic performance characteristics indicating that we are not accounting for the key factors associated with a second opioid prescription. Future studies might address undiagnosed patient social and mental health opportunities, factors known to associate with pain intensity and satisfaction with pain alleviation.Diagnostic Level III.

Painful conditions affect a significant population in the United States. As the scientific understanding of the benefits and harms of opioid therapy has evolved, so too has the application of prescription opioid therapy for the treatment of pain. The rapid increase in the use of prescription and illicit opioids over the past decade has contributed to a public health crisis commonly referred to as the "opioid crisis." In this article, the ethical approaches to treating patients with opioid pharmaceuticals as well as the development of regulation of opioid therapy in Washington State are reviewed.

Objective To evaluate the impact of a targeted intervention focused on increasing awareness of opioid overprescribing within an academic orthopaedic practice. Design Retrospective prescribing data was collected through an electronic chart review. A single time point, a departmental grand rounds titled “Opioid Use, Misuse, & Abuse in Orthopaedics,” was conducted on February 8, 2017. Opioid prescribing data was analyzed for the year preceding and year immediately following this targeted intervention. Narcotics were standardized using milligram morphine equivalents (MME) for comparison, and patients were categorized as opioid naive or non-naive based on whether an opioid prescription was written within 90 days prior to surgery. A segmented time series regression model was utilized to determine statistical significance of the educational intervention. Setting Academic Medical Center. Participants All patients undergoing orthopaedic procedures at our institution between January 2016 and March 2018. Results A total of 5882 patients underwent orthopaedic procedures at our institution during the study period. Of these, 2887 were in the year preceding and 2995 were in the year immediately following the targeted intervention to increase awareness of opioid overprescribing. The interve.ntion was associated with an acute decrease of 167 mean MME from 780 to 613 in opioid naive (p = 0.028) and 154 mean MME from 1,015 to 861 in opioid non-naive patients (p = 0.010). The intervention was also associated with a favorable change in the overall mean MME prescribing trend over time in both naive (p = 0.011) and non-naive (p = 0.064) patients. Conclusions This study demonstrates decreased opioid prescribing within an academic orthopaedic department after a targeted intervention focused on raising the awareness of opioid overprescribing. Ongoing provider education and awareness are critical parts of any plan to continue curtail opioid overprescribing among surgeons.

Purpose The purpose of this study is to determine the types of content and to what extent that individual State Boards of Nursing (SBON) in the U.S. are providing information and education for nurses to mitigate prescription opioid misuse and diversion by patients and the public. Design A descriptive, cross-sectional, survey research design was selected. Methods A survey of the SBON by two investigators, who independently reviewed each SBON website, was completed over a four-week time-period. The websites were explored for resources related to opioids. Links and descriptions were reviewed, then compared for accuracy. Results All but two SBON had at least some information on the mitigation of prescription opioid misuse and diversion. Minimal information was available regarding the mitigation of opioid misuse and diversion in 18 of the 50 states and DC (35%). Conclusions SBON have a responsibility to educate licensees to enable them to assist in the mitigation of opioid misuse and diversion. States have resources like PDMPs, opioid tool-kits, newsletters, announcements, and prescriber guidelines that need to be more numerous, of higher quality, and easier to access. SBON should be commended for the resources that they currently provide, but more can be done for nurses to aid in this endeavor. SBON are positioned to provide education and information for nurses to reduce opioid misuse, and diversion. The SBON websites need to have a link to their PDMP, opioid toolkit, OD treatment, and opioid prescribing guidelines readily accessible by nurses and especially APRNs.

Multiple studies have demonstrated that adults do not store prescription opioids safely. Increased prescription opioid rates have led to an increased incidence of opioid poisonings in children and adolescents.We investigated whether parents practiced safe storage, use, and disposal techniques of opioids that were prescribed to their child with cancer-related pain.We conducted a prospective cross-sectional survey of parents whose children were prescribed opioids and asked them about their patterns of storage, use, and disposal of prescription opioids.Virtually, all parents (106 of 109; 97%) completed the survey. Most parents (95 of 106; 90%) did not store opioids safely. Six of 106 parents (6%) gave their child's opioid pain medication to someone else with pain, and three of 106 parents (3%) personally took some of their child's opioid. Parents who personally took their child's opioid (P = 0.01) or gave it to another person (P 0.001) were more likely to use opioids unsafely with their child. A minority of parents (22 of 106; 21%) did not use opioids safely in their child. A small number of parents (3 of 22; 14%) did not dispose of opioids safely.Universal education about the safe use and disposal of opioids should be adopted when prescribing opioids. Pediatricians need to maintain vigilance about the nonmedical use of prescription opioid use by parents of children.

Background Postoperative overprescribing is common, and many patients will have excess medications. An effective method to encourage disposal is lacking. We hypothesized that a convenient home disposal kit will result in more appropriate disposal of excess opioids. Materials and methods We conducted a single-center prospective observational pilot study to evaluate the effectiveness of a postoperative opioid disposal kit. Patients in the intervention group received an opioid disposal kit and educational handout before discharge from the hospital. At the first follow-up visit, patients completed a survey in which they reported the remaining amount of pain medications from their original prescription and their plan for the excess medication. Patients were asked about risk factors for chronic opioid use. We used multivariable Poisson regression to identify independent factors associated with an increased likelihood of appropriate opioid disposal. Results The survey was offered to 904 patients with a response rate of 91.7%. After excluding those with missing data, 571 patients were included in the study. Overall, 83 (14.5%) patients never filled an opioid prescription, and 286 (60.0%) patients had tablets remaining at the time of the follow-up visit. Among those with tablets remaining, 52 received a home disposal kit, whereas 234 patients with tablets remaining did not. Patients who received the kit were more likely to dispose of opioid medications (54.9% versus 34.8%, relative risk = 1.8, 95% CI 1.3-2.5). No confounders were identified during multivariable analysis that increased a patient's likelihood of disposing excess medications. Conclusions The provision of a convenient home disposal kit postoperatively increased patient-reported opioid disposal.

INTRODUCTION: Pediatric postoperative opioid prescribing has come under scrutiny as a result of the ongoing opioid epidemic. Previous research has demonstrated that African American adults are less likely to receive analgesics, particularly opioids, after surgery, even after controlling for pain severity. We sought to examine racial disparities in the filling of opioid prescriptions by pediatric surgical patients after cholecystectomy. METHODS: We studied patients aged 1 to 18 years of age who were enrolled in Ohio Medicaid and underwent cholecystectomy. Procedures performed in January 2013 - July 2016 were included. The percentage of patients who filled a postoperative opioid prescription within 14 days of their procedure was compared between black and white patients using log binomial regression models fit using generalized estimating equations to account for patient clustering within hospitals. RESULTS: We identified 1277 patients who underwent a cholecystectomy. In unadjusted analyses, black children were significantly less likely than white children to fill an opioid prescription postoperatively (74.9% vs 85.7%, p

Impacts of the prescription opioid epidemic have not yet been examined in the context of heart transplantation. We examined a novel database in which national U.S. transplant registry records were linked to a large pharmaceutical claims warehouse (2007–2016) to characterize prescription opioid use before and after heart transplant, and associations (adjusted hazard ratio, (95% LCL)aHR(95% UCL)) with death and graft loss. Among 13 958 eligible patients, 40% filled opioids in the year before transplant. Use was more common among recipients who were female, white, or unemployed, or who underwent transplant in more recent years. Of those with the highest level of pretransplant opioid use, 71% continued opioid use posttransplant. Pretransplant use had graded associations with 1-year posttransplant outcomes; compared with no use, the highest-level use (>1000 mg morphine equivalents) predicted 33% increased risk of death (aHR (1.10)1.33(1.61)) in the year after transplant. Risk relationships with opioid use in the first year posttransplant were stronger, with highest level use predicting 70% higher mortality (aHR (1.46)1.70(1.98)) over the subsequent 4 years (from >1 to 5 years posttransplant). While associations may, in part, reflect underlying conditions or behaviors, opioid use history is relevant in assessing and providing care to transplant candidates and recipients.

Prescription monitoring programs (PMPs) house and monitor data about the prescribing practices of health care providers, as well as medications received by patients. PMPs aim to promote the appropriate use of prescription opioids by providing this information to prescribers and dispensers. Our objective in this systematic review was to comprehensively identify and assess the available evidence about the impact of PMPs on opioid prescribing and dispensing, multiple provider use for obtaining opioids, inappropriate opioid prescribing, and the extent of nonmedical prescription opioid use. We used a comprehensive search strategy and included study designs that could determine changes in outcomes with the implementation of a PMP. We included 24 studies; 75% of studies were conducted in the United States, and studies encompassed data years from 1993 to 2014. Overall, we did not find evidence to support an association between PMPs and decreased opioid prescribing and dispensing. We found limited, but inconsistent, evidence that PMPs were associated with reduced schedule II opioid prescribing and dispensing, as well as multiple provider use. Covariate adjustment was often inadequate in analyses, as was the timing of outcome and PMP measurement. Future studies should broaden their geographic scope to other countries and use more recent data with standard measurement. PERSPECTIVE: This systematic review aimed to determine the effectiveness of PMPs in changing prescribing practices and prescription opioid use. The findings from this review will inform policymakers and PMP administrators about the current state of the evidence on program effectiveness.

Surgeons have the opportunity to help offset the opioid epidemic by leading with practice changes. We sought to decrease the amount of opioid prescribed postoperatively through a multifaceted program.A multipronged program was introduced in our hospital system, which included resident education on prescribing for postoperative analgesia, a change in the default number of opioid pills in an electronic medication order entry system, and the distribution of a guideline card of recommended postoperative opioid prescription amounts. The amount of opioid prescribed postoperatively between January 2016 and August 2018 was collected for the 10 most common short-stay (48 hours) general surgery procedures. The 6 months prior to any intervention (pre-intervention) was compared to the last 6 months of data collection (post-intervention).In the study, 14,007 operations were captured, including 2,530 pre-intervention and 2,715 post-intervention. The average amount of postoperative opioid prescribed in the pre-intervention period was 207.1 morphine milligram equivalents; post-interventions, the average amount declined to 104.6 morphine milligram equivalents (P.01). The opioid refill rate remained the same (3.3% pre-intervention vs 3.1% post-intervention, P = .76).A comprehensive program to eliminate the over-prescription of opioids decreased the amount of opioid prescribed by half, without a concurrent increase in opioid refills, demonstrating that simple measures can be used to deliver sustained and reproducible improvements in offering source control in the opioid epidemic.

New persistent opioid use occurs in 3% to 14% of patients after elective surgery, but is poorly described after cardiothoracic surgery. We examined the association of prescription size with new persistent opioid use after cardiothoracic surgery.Opioid-naive Medicare patients undergoing cardiothoracic surgery between 2009 and 2015 were identified. Patients who filled an opioid prescription between 30 days before surgery and 14 days after discharge and with continuous Medicare enrollment 12 months before and 6 months after surgery were selected (n = 24,549). New persistent use was defined as continued prescription fills 91 to 180 days after surgery. Prescription size was reported in oral morphine equivalents. Multivariable regression was performed for risk adjustment, and new persistent use rate was estimated.Patient age was 71 ± 8 years, 9222 (38%) were female, and 20,898 (85%) were white. Overall new persistent use was 12.8% (3153 of 24,549), and declined yearly from 17% in 2009 to 7.1% in 2015 (P.001). Prescription size, preoperative prescription fills, black race, gastrointestinal complications, disability status, open lung resection, dual eligibility (Medicare and Medicaid), drug and substance abuse, female sex, tobacco use, high comorbidity, pain disorders, longer hospital stay, and younger age were associated with new persistent use. Adjusted new persistent use was 19.6% (95% confidence interval, 18.7% to 20.4%) among patients prescribed more than 450 oral morphine equivalents, compared with 10.4% (95% confidence interval, 9.9% to 10.8%) among those prescribed 200 oral morphine equivalents or less (P.001).Size and timing of perioperative opioid prescriptions were the strongest predictors of new persistent opioid use after cardiothoracic surgery. Modifiable risk factors such as prescription size should be targeted to reduce new persistent use.

Purpose To examine opioid prescription practices, patient use of opioids after laparoscopic cholecystectomy, and patient knowledge about disposal of unused medication. Design Mixed methods design with a chart review and structured phone interview. Methods Thirty-four patients were interviewed by phone and asked how many opioids were prescribed, how many excess pills they had 6 to 10 days postoperatively, and if they knew how to dispose of them. Findings Average number of excess pills ranged from 0 to 42 (mean = 14; SD = 11.7). Nearly half of patients (47%) perceived the prescribed quantity as “too many.” Seventy-one percent of patients using opioids for 5 days or less and 88% did not recall any instruction about medication disposal. Conclusions Patients often have excess prescribed opioids after laparoscopic cholecystectomy, and they do not understand proper disposal of unused medications. Education about proper disposal of unused opioids medications is a key role of perianesthesia.

Dentists and physicians alike often prescribe opioids for dental pain management. The purpose of this study was to identify the common practices among United States endodontists for prescribing opioids to their patients. A descriptive, cross-sectional survey was developed to query 1000 American Association of Endodontists members from all 7 districts in the United States. The 20-question survey addressed provider demographics, types and frequency of medications prescribed, and clinical scenarios that compelled prescription-writing habits. The anonymous survey was electronically mailed. There was a preference to prescribe nonsteroidal anti-inflammatory drugs and/or acetaminophen followed by hydrocodone to manage endodontic pain. The majority of respondents limited an opioid prescription to ≤4 days. Different demographics played a role in the response to direct questions if they ever felt or succumbed to pressure toward prescribing opioids. Opioids are the second most prescribed medication to manage endodontic postoperative pain. Practice background was a significant factor in feeling pressure to prescribe an opioid.

Background Few studies have assessed prescription opioid supply preceding death in individuals dying from unintentional prescription opioid overdoses, or described the characteristics of these individuals, particularly among Veterans. Objectives To describe the history of prescription opioid supply preceding prescription opioid overdose death among Veterans. Methods In a national cohort of Veterans who filled ≥1 opioid prescriptions from the Veterans Health Administration (VA) or Medicare Part D during 2008–2013, we identified deaths from unintentional or undetermined-intent prescription opioid overdoses in 2012–2013. We captured opioid prescriptions using both linked VA and Part D data, and VA data only. Results Among 1181 decedents, 643 (54.4%) had prescription opioid supply on the day of death, and 735 (62.2%) within 30 days based on linked data, compared to 40.1% and 46.7%, respectively, using VA data alone. Decedents with prescription opioid supply were significantly older and less likely to have alcohol or illicit drugs as co-occurring substances involved in the overdose. Using linked data, 241 (20.4%) decedents lacked prescription opioid supply within a year of death. Conclusions Many VA patients who die from prescription opioid overdose receive opioid prescriptions outside VA or not at all. It is important to supplement VA with non-VA data to more accurately measure prescription opioid exposure and improve opioid medication safety.

Misuse of prescription opioids and associated negative health outcomes is a leading public health crisis among adolescents in the US. Opioid prescription rates, misuse, and overdose deaths have increased among adolescents in the last twenty years. This commentary highlights trends in prescribing opioids and medication misuse among adolescents in the US and sheds light on reasons and motives for misuse of prescription opioids among adolescents. It discusses recent educational initiatives which promote medication safety, describes current practices, and recommends effective strategies to enhance prescription opioid safety among adolescents. Opportunities to enhance opioid medication safety among adolescents are frequently overlooked. A critical strategy to combat opioid misuse and overdose deaths among adolescents involves increasing awareness and knowledge about safe medication use.

This review presents updated recommendations, based on existing clinical research, for anesthetic management of strabismus surgery in children. In children, unlike adults, eye surgery nearly always requires general anesthesia, even for brief procedures. Recommendations for preoperative anxiolysis, fasting guidelines, and management of upper respiratory infections are discussed. Airway considerations and the oculocardiac reflex are highlighted. The prevention of postoperative complications, including those related to opioid prescription therapy, is also addressed. Finally, given the 2016 warning from the Food and Drug Administration about anesthesia neurotoxicity in children, we discuss recent studies on anesthetic neurotoxicity in children undergoing general anesthesia.

Background Postoperative opioid prescribing is often excessive, but the differences in opioid prescribing between teaching hospitals and nonteaching hospitals is not well understood. Given the workload of surgical training and frequent turnover of prescribers on surgical services, we hypothesized that postoperative opioid prescribing would be higher among teaching compared with nonteaching hospitals. Study design We used insurance claims from a statewide quality collaborative in Michigan to identify 17,075 opioid-naive patients who underwent 22 surgical procedures across 76 hospitals from 2012 to 2016. Our outcomes included the following: (1) the amount of opioid prescribed for the initial postoperative prescription in oral morphine equivalents and (2) high-risk prescribing in the 30 days after surgery (high daily dose [≥ 100 oral morphine equivalents], new long-acting/extended-release opioid, overlapping prescriptions, or concurrent benzodiazepine prescription). Teaching hospital status was obtained from the 2014 American Hospital Association survey. Multilevel regression was used to adjust for patient and procedural factors and to perform reliability adjustment. Results The amount of opioid prescribed per initial opioid prescription varied 4.7-fold across all hospitals from 130 oral morphine equivalents to 616 oral morphine equivalents. Patients discharged from teaching hospitals filled larger initial opioid prescriptions overall compared with nonteaching hospitals (251 oral morphine equivalents versus 232 oral morphine equivalents; P = .026). Teaching hospitals had higher risk-adjusted rates of high-risk prescribing compared with nonteaching hospitals (13.7% vs 10.3%; P = .034). Conclusion In Michigan, surgical patients discharged from teaching hospitals received significantly larger postoperative opioid prescriptions and had higher rates of high-risk prescribing compared with nonteaching hospitals. All hospitals, and particularly teaching institutions, should ensure that adequate resources are devoted to facilitating safe postoperative opioid prescribing.

Background Non-medical use (NMU) of prescription opioids is a public health concern and sex differences in prevalence of NMU have been observed previously. Little is known about how youth are obtaining and using these drugs. While any regular use could be problematic, NMU is particularly concerning. More information is needed on NMU patterns among youth and how these patterns might differ by sex. Methods The National Monitoring of Adolescent Prescription Stimulants Study (N-MAPSS) recruited youth 10–18 years of age from 10 US metropolitan areas from 2008 to 2011 with a final sample of 11,048 youth. The cross-sectional survey included questions on past 30 day use of prescription opioids (10,965 provided responses), with NMU defined as non-oral use and/or use of someone else's opioids. NMU through use of a patient's own prescription orally for a reason other than prescribed could not be identified, though this is usually contained within the standard definition of NMU. Results Among the 10,965 youth, past 30 day prevalence of NMU of prescription opioids was 3.1% (n = 345) with 59.7% (n = 206) using someone else's opioids only, 5.2% (n = 18) having non-oral use only and 35.1% (n = 121) having both. In total, seven sources and three routes of administration were assessed. The most common source among males was someone from school (n = 111, 60.0%), with no highly prevalent second source. Among females, there were two prevalent sources of prescription opioids; a parent (n = 59,41.6%) and someone from school (n = 53,37.3%). For non-oral use, snorting prescription opioids was more frequent among males compared to females (n = 85, 31.8% and n = 44, 17.1%; p Conclusions Based on these findings, to combat the current opioid crisis, implementation of strategies to prevent youth from sharing opioids, especially with friends from school, should be considered and tested.

In this paper, we consider the problem of asymptotic exit control for a prescription opioid epidemic that describes the interaction between the regular prescription or addictive use of opioid drugs, and the process of rehabilitation and that of relapsing into the opioid drug use. In particular, our interest is in the situation, when the optimal control effort appearing linearly in the opioid epidemic model is interpreted as the rate at which the susceptible individuals are effectively removed from the population due to an opioid-related intervention policy, while a small perturbing noise enters through the dynamics of the susceptible group in the population compartmental model. To this end, we introduce a mathematical apparatus that minimizes the asymptotic exit-rate with which the solution for such stochastically perturbed prescription opioid epidemics exits from a given bounded open domain. Moreover, under certain conditions, we provide an admissible optimal control for the corresponding optimal control problem that optimally effected removal of the susceptible or recovered individuals from the population dynamics.

Persons living with HIV/AIDS (PLWHA) report high rates of clinically significant pain that is associated with several negative outcomes, including higher CD4 T-cell count, poor medication adherence, and substance use and misuse. Importantly, PLWHA also report elevated rates of both opioid and tobacco use, and these elevated rates have often been associated with increased pain experience. Although research suggests that negative affective responses to pain may be uniquely associated with substance misuse among individuals in the general population, little work has examined these relations among PLWHA. The current study examined negative emotions in response to pain as a predictor of current opioid misuse, future opioid misuse, and perceived smoking-pain relationships among 66 ( M age = 51.26, SD = 8.00, 60.6% male) HIV+ adults with co-occurring pain. Results indicated that negative emotions in response to pain uniquely predicted each of the substance use outcomes, with clinically significant effect sizes that may be characterized as medium in magnitude. Overall, these findings suggest that negative affective responses to pain may play a role in prescription opioid misuse and smoking among PLWHA. These findings may inform the development of tailored interventions for PLWHA smokers who are prescribed opioid pain medications.

We examine how two interventions designed to curtail prescription opioid misuse, the reformulation of OxyContin and the implementation of must‐access prescription drug monitoring programs (PDMPs), affected child abuse and neglect. Our results suggest that counties with greater initial rates of prescription opioid usage experienced relatively larger increases in substantiated child abuse and neglect subsequent to OxyContin’s reformulation. We also find larger increases in child abuse and neglect after must‐access PDMP implementation in counties with higher pre‐intervention exposure to opioids. Our results uncover unintended consequences of reducing the supply of an addictive good without adequate support (or alternatives) for dependent users.

This study investigates the role of retail pharmacy ownership in the opioid epidemic in the United States by comparing independently owned pharmacies' and chain pharmacies' prescription opioid dispensing practices. Using data of prescription opioid orders at the pharmacy level between 2006 and 2012, we find that compared to chain pharmacies within the same ZIP code area, independent pharmacies on average dispense 40.9% more opioids and 61.7% more OxyContin. We further confirm that after being acquired by a chain, a previously independent pharmacy reduces dispensing of opioids by 31.7% and OxyContin by 43%. Using the OxyContin reformulation in 2010, which reduced the demand for diversion for illegal recreational use but not the demand for medical use, we show that half of the difference in dispensed OxyContin doses between independent and chain pharmacies can be attributed to drug diversion. In addition, we find that independent pharmacies' OxyContin dispensing is higher in areas with greater competition. Furthermore, a larger county-level recreational demand is correlated with a larger difference between independent and chain pharmacies' prescription opioid dispensing. We discuss two reasons that may explain why independent pharmacies are more likely to be linked to drug diversion. First, they have stronger financial incentives due to lower expected costs of misdoing. Second, they may have less information on patients' prescription drug use history. Prescription drug monitoring programs help to reduce the information gap between independent and chain pharmacies to some extent, but monitoring of small independent pharmacies needs to be strengthened.

Background Inability to access opioid agonist therapy (OAT) in correctional settings has previously been reported in Vancouver, Canada, and is associated with harms among people with opioid use disorder (OUD), including overdose death. We investigated the prevalence and correlates of OAT utilization within correctional settings among incarcerated persons with OUD in Vancouver. Methods Data were derived from three prospective cohorts of people who use drugs in Vancouver between 2005 and 2016. Using multivariable generalized estimating equations, we examined factors associated with OAT utilization among participants with OUD reporting incarceration in the past six months. Results Among 597 eligible participants, 207 (34.7%) contributed 325 reports of having utilized OAT while incarcerated. Of those, 295 (90.8%) were continuations and 30 (9.2%) were new initiations of OAT while incarcerated. For those currently on OAT (at the time of interview), in multivariable analyses, non-fatal overdose (adjusted odds ratio [AOR] = 0.49, 95% confidence interval [CI]: 0.29-0.82) and daily prescription opioid use (AOR = 0.42, 95% CI: 0.20-0.85) remained independently and negatively associated with having utilized OAT while incarcerated. For those not currently on OAT, none of the variables considered had significant associations with utilization of OAT while incarcerated. Conclusions Utilization of OAT in correctional settings was low in our sample. Utilization of OAT was significantly and negatively associated with overdose and ongoing prescription opioid misuse if OAT was continued upon release from correctional settings. Findings underscore the urgent need for improved utilization of OAT in correctional settings, and linkage to community care to prevent harms such as overdose.

Evolving literature suggests that the epidemic of prescription opioid use affects the transplant population. We examined a novel database wherein national U.S. transplant registry records were linked to a large pharmaceutical claims warehouse (2007 to 2015) to characterize prescription opioid use before and after kidney transplant, and associations (adjusted hazard ratio, (95% LCL)aHR(95% UCL)) with death and graft loss. Among 75,430 eligible patients, 43.1% filled opioids in the year before transplant. Use was more common among recipients who were women, white, unemployed, publicly insured, and with longer pre-transplant dialysis. Of those with the highest level of pre-transplant opioid use, 60% continued high-level use post-transplant. Pre-transplant opioid use had graded associations with 1-year post-transplant outcomes; the highest-level use predicted 46% increased risk of death (aHR (1.28)1.46(1.66)) and 28% increased risk of all-cause graft failure (aHR (1.17)1.28(1.41)). Effects of high-level opioid use in the first year after transplant were stronger, predicting twice the risk of death (aHR (1.93)2.24(2.60)) and 68% higher all-cause graft loss risk (aHR (1.50)1.68(1.89)) over the subsequent year; increased risk persisted over 5 years. While associations may, in part, reflect underlying conditions or behaviors, opioid use history is relevant in assessing and providing care to transplant candidates and recipients.

Background One in five adolescents and emerging adults have reported prescription opioid misuse (POM), posing significant risks for opioid-related adverse outcomes. Devising prevention strategies requires a better understanding of the decisional factors underlying risky misuse behavior. This research examined the associations between past opioid use behavior, opioid risk knowledge and perceptions, and intentional POM decisions. Methods Participants aged 15–23years completed surveys assessing past prescription opioid use and misuse, opioid risk knowledge, opioid risk perceptions, and pain relief preferences (i.e., analgesic benefit vs. risk aversion preference). The outcome, Willingness to Misuse (i.e., intentional decisions to use a prescription opioid in a non–compliant manner) was measured using hypothetical pain decision scenarios. Results Surveys were completed by 972 adolescents and young adults. In total, 44% had taken a prescription opioid and 32% of these reported past POM. Willingness to Misuse was significantly associated with lower opioid misuse risk perceptions (β = .75 [95% CI .66–.86]) and past opioid misuse (β = 1.81 [95% CI 1.13–2.91]) but not simple risk knowledge (β = .81 [95% CI .58–1.11]. The probability of future misuse was highest for those who reported past opioid misuse and had low risk perceptions (58.7% [95% CI 51.3–65.8]) and high pain relief preferences (53.4% [95% CI 45.3%–61.3%]). Conclusions Findings suggest that simple knowledge of prescription opioid risks is insufficient to curtail misuse among adolescents and emerging adults. Rather, it may be important to heighten opioid risk perceptions and strengthen opioid risk aversion values when prescribing opioid analgesics to better prevent future misuse in this high risk population.