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In this article, I present a firsthand account as an anaesthetist with substance use disorder who has been through rehabilitation and returned to clinical anaesthesia, followed by an overview of substance use disorder in anaesthesia. Substance use disorder is prevalent within the anaesthesia community and can result in tragic consequences, including death in many cases. The incidence is around one to two per 1000 anaesthetist years and this appears to be rising, perhaps mirroring the population-wide increase in substance use disorder as a result of the opioid epidemic. Recognising substance use disorder in a colleague and intervening to try and help them and protect patients can be immensely challenging. Carrying out a successful intervention requires careful planning and coordination in order to protect the affected individual, their colleagues and patients. Returning to clinical anaesthesia following a diagnosis of substance use disorder is also contentious, with the high abstinence rate (relative to the wider substance use disorder population) having to be balanced against the risk of death following relapse. Any return to practice must be well planned and supported, and include appropriate toxicology screening. With such measures, rehabilitation and a return to clinical anaesthesia is possible in certain cases. For the affected individual regaining, then maintaining, their professional identity can be a powerful motivator to remain abstinent. Drug diversion and substance use disorder in anaesthesia is unlikely ever to be fully preventable, but strategies such as biometric dispensing, analysis of unused drugs, random toxicology and ongoing education may help to keep it to a minimum.

ObjectiveTo evaluate abuse, misuse, and diversion of Xtampza ER, an extended-release (ER) abuse-deterrent formulation (ADF) of oxycodone.MethodsAbuse, misuse, and diversion of Xtampza ER were assessed using Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System data sources. Xtampza ER was compared with immediate-release (IR) oxycodone, other ADF ER products combined, and non-ADF ER products combined.ResultsXtampza ER prescriptions increased 50-fold during the study period. In contrast, cases from poison centers, substance abuse treatment centers, and diversion were infrequent and did not increase. Adjusted for prescriptions dispensed, poison center exposures were greater for IR oxycodone (rate ratio [RR] = 2.3, P = 0.008), other ADF ER opioids (RR = 5.2, P ConclusionXtampza ER abuse, misuse, and diversion and tampering are low relative to other prescription opioid analgesics. Abuse and diversion did not increase over the study period.

The Alabama Board of Nursing (ABN) administers the Voluntary Disciplinary Alternative Program (VDAP) and Probation, which are two monitoring programs related to substance use disorder. Based on national estimates of nurses with substance-related impairment, more than 8,000 nurses caring for patients in Alabama facilities may have a substance-related impairment. To better protect the public, identify nurses with substance abuse behaviors earlier, and improve communication, the ABN committed itself to create opportunities for early intervention and monitoring to support a safe return to professional practice. The ABN staff also developed educational programs for substance use diversion, initiated a continuous quality improvement team to enhance its VDAP and Probation programs, and created a promotional campaign for the VDAP. The program has produced clear and definable success, as demonstrated by a doubling of nurse substance abuse self-reports and peer reports.

The COVID-19 pandemic put an unprecedented strain on the nursing workforce. In response, many states issued executive orders waiving licensure requirements for their state if nurses have a license in good standing in another state. However, such efforts were not without risk. For example, a nurse who was working in a state under an executive order was terminated by the employer after the nurse was found diverting controlled substances and diluting vials of controlled substances with normal saline. This case study highlights the importance of the authority provisions granted in the Nurse Licensure Compact and the risk to public protection that can potentially result when executive orders waive the requirement for an in-state nursing license.

Drawing on a multisite sample of 40 persons who sell, share, or use diverted buprenorphine to manage opioid use disorder, in this study we describe why individuals seek to obtain buprenorphine outside of formal treatment contexts, and between-site variation regarding their motives and means. Findings indicate that both the provision and purchase of diverted buprenorphine support user-defined risk minimization strategies to avoid withdrawal, reduce heroin use, and satiate opioid cravings in periods of lowered tolerance. We also found that a subset of the sample used buprenorphine recreationally, and that it functioned to extend or augment illicit drug use careers. Implications of the findings are discussed in light of federal and state drug control and treatment policies.

Background To date, there is limited research on whether the various types of mandatory usage of prescription drug monitoring programs (PDMP) have any effects on prescribing patterns, drug usage, patient care, and drug diversion (8-10). Within the United States (US), there is wide variation in individual states' requirements for the usage of PDMPs. Objective The objective of this study was to determine whether mandatory prescriber review of a PDMP prior to each issuance of a controlled substance resulted in a reduction in the total number of controlled substance prescriptions dispensed. Study design A retrospective review of the State of Wisconsin's PDMP controlled substance database from April 2015 to March 2019 was performed. The evaluation compared the number of prescriptions among individual drug classes (opioids, benzodiazepines, stimulants) dispensed throughout the state before and after April 1st, 2017, when implementation of a state law mandating the review of the PDMP during each patient encounter prior to issuing a prescription for a controlled substance took effect. Setting Research was conducted using Wisconsin's PDMP controlled substance database from April 2015 to March 2019. During this time, controlled substance policy has come to the forefront of the nation due to issues with an opioid epidemic. Methods Descriptive analysis was used to express data as n and % for categorical data and average ± standard deviation for numerical data. Before- and after-prescription totals were analyzed using a paired t test and Levene's test for equality of variances. The P value was considered significant at a level of less than or equal to .05. Limitations Limitations to this study included its retrospective design, focus on a single US state, and possible unforeseen contributors to cause and effect. Results Prior to the enforcement of the state's mandatory PDMP legislation, an average of 844,314 controlled substance prescriptions were written monthly. Following the implementation of the law, the average monthly total prescriptions written within the state decreased to 708,063. This was an average monthly reduction of 136,251 prescriptions written or 16.1%. Statistically significant reductions were also seen in opioid and benzodiazepine subgroups (23.0%, 16.3%). Conclusion Our study suggests that state-enforced mandatory usage of a PDMP, which records all controlled substance prescriptions filled by a pharmacy such as opioids, benzodiazepines, amphetamines, etc. at every encounter prior to prescribing any controlled substance, can provide for a significant reduction in controlled substance prescriptions, specifically opioids and benzodiazepines. Key words Prescription drug monitoring program, opioids, mandatory usage, benzodiazepines, Wisconsin.

Doctors have two ethical duties: to cure disease or ease suffering and, also, to do no harm. The ethical duty to “Do No Harm” has been used to justify two sides of a pendulum swing in the philosophy of opioid prescribing for pain. In the 1990s, it was invoked to expand prescribing, and more recently to justify dramatic reductions in prescription opioid use. In this Article, we explore whether prescribing opioids for pain presents challenges that differ from the ordinary mandate physicians face as they balance the call for action with the imperative to do no harm [DNH].We argue that the treatment of pain differs in three important ways. First, the fact that pain is present and occurrent reduces uncertainty about the need for action, and thus strengthens the reasons to act. Second, while DNH applies to both physicians and policymakers, each has distinct duties: physicians have a duty to the individual patient; policymakers have a duty to society. As a result, harm from drug diversion should weigh little when clinicians decide how to treat individual patients. Public health officials, by contrast, rightly consider societal effects. However, in doing so, they must adopt policies that mitigate the ethical burdens placed on physicians, respect the testimony of patients in pain, and pay particular attention to how policy guidance is likely to be implemented by others. Finally, we address what duties are owed to patients who are currently taking opioid medication, given evidence that they are experiencing significant barriers in receiving healthcare. We argue that once treatment has been initiated, there are special duties to these patients.

The characteristics of opioid prescribing and administration in cancer centers include large quantities and less restrictive regulatory mandates governing cancer-related pain, which may increase the risk of drug diversion by staff members. The purpose of this article is to provide a framework for creating respectful investigative processes for staff suspected of drug diversion. Organizations, including cancer centers, need to engage in careful oversight of potential drug diversions while simultaneously promoting a psychologically safe work environment for individuals to successfully seek help.

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.

Purpose of review We consider a series of linked philosophical issues created by non-adherence to therapy in sleep medicine. Recent findings First, the difficulty of measuring rates of adherence creates an epistemic problem regarding the efficacy of prescribed treatments. Secondly, as diseases are often classified as refractory based on apparent failure of standard medicines, the validity of this classification faces a similar epistemic crisis. This in turn produces ethical issues when therapies are restricted to cases deemed refractory. It also calls into question, if the patient does not take the medicines as prescribed, what they do with them; and the prospect of potential drug diversion arises. Education of patients seems to be of limited help in addressing these issues; what may be needed is a revision of the patient-prescriber relationship to move away from blame when nonadherence occurs. We close by revisiting an ancient debate in the philosophy of action, which may shed light on what such a revised relationship would require. Summary More honest and trusting patient-physician relationships, and a much more accurate sense of when nonadherence is occurring and why, may result from a better practical and philosophical understanding of the patient's decision-making.

PURPOSE Recent reports suggest that buprenorphine is being diverted and used non-medically. However, no apparent studies have reported national-level data on buprenorphine diversion. METHODS Case report data were drawn from a quarterly survey of prescription drug diversion completed by a national sample of law enforcement and regulatory agencies who engage in drug diversion investigations. Quarterly rates of buprenorphine diversion per 100 000 population and 100 000 prescriptions dispensed were calculated for the period 2002 through 2019. Population-based diversion rates were also calculated by U.S. region. RESULTS In total, 9670 cases of diverted buprenorphine were reported across all 50 states and the District of Columbia during the study period. Buprenorphine diversion rates, per 100 000 population, were characterized by an accelerating increase over time; increases in diversion rates from 1st quarter 2002 through 4th quarter 2006 were not statistically significant, yet from 1st quarter 2007 through 4th quarter 2019, the rate of diversion cases increased by 0.0067 cases per 100 000 per quarter (p

Background: Over the past 20 years or so, the drug misuse scenario has seen the emergence of both prescription-only and over-the-counter (OTC) medications being reported as ingested for recreational purposes. OTC drugs such as antihistamines, cough/cold medications, and decongestants are reportedly the most popular in being diverted and misused.Objective: While the current related knowledge is limited, the aim here was to examine the published clinical data on OTC misuse, focusing on antihistamines (e.g., diphenhydramine, promethazine, chlorpheniramine, and dimenhydrinate), dextromethorphan (DXM)- and codeine-based cough medicines, and the nasal decongestant pseudoephedrine.Methods: A systematic literature review was carried out with the help of Scopus, Web of Science databases, and the related gray literature. For data gathering purposes, both the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and PROSPERO guidelines were followed (PROSPERO identification code CRD42020209261).Results: After completion of the selection, eligibility, and screening phases, some 92 articles were here taken into consideration; case reports, surveys, and retrospective case series analyses were included. Findings were organized according to the specific OTC recorded. Most articles focused here on DXM (n = 54) and diphenhydramine (n = 12). When specified, dosages, route(s) of administration, toxicity symptoms (including both physical and psychiatric ones), and outcomes were here reported.Conclusion: Results from the systematic review showed that the OTC misusing issues are both widespread worldwide and popular; vulnerable categories include adolescents and young adults, although real prevalence figures remain unknown, due to a lack of appropriate monitoring systems. Considering the potential, and at times serious, adverse effects associated with OTC misusing issues, healthcare professionals should be vigilant, and ad hoc preventative actions should be designed and implemented.

Outpatient palliative care programs are becoming a new source of ethics consults pertaining to suspected drug diversion and parameters for the safe prescribing of pain medications. While expanding ...

In the midst of a national opioid crisis, Americans have a heightened awareness of the potential for prescription drugs that can be abused. One drug—gabapentin—is frequently prescribed in long-term care facilities for seizures and postherpetic neuralgia, and its use is a growing concern globally. Approved for two uses, but used off-label for many others, gabapentin can induce euphoria at high doses. In older adults, clinicians prescribe it for seizures, pain, migraine, and aggression associated with dementia, among other things. Gabapentin's rapid onset of action, side effect profile, limited drug-drug interactions, and extensive pharmacokinetic data in renal impairment have made prescribers comfortable using it in older adults. This gabapentinoid—a cousin to the Schedule V drug pregabalin—has seen widespread recreational abuse and has led to its reclassification in the United Kingdom and in several U.S. states. Consultant pharmacists need to be aware that the evidence behind off-label use is scant; withdrawal is likely after as few as three weeks of treatment; and drug diversion is possible, even likely. In addition, it is the tenth-most prescribed medication in the United States.

Background The purpose of this study was to describe dentists’ training experiences relevant to pain management, addiction, and prescription opioid drug diversion and examine associations between these training experiences and dentists’ opioid prescribing practices. Methods A Web-based, cross-sectional survey was conducted among practicing dentist members of the National Dental Practice-Based Research Network (PBRN; N = 822). The survey assessed pain management prescribing practices and training experiences related to pain management and assessment for addiction and drug diversion. Survey data were linked with National Dental PBRN Enrollment Questionnaire data regarding practitioner demographics and practice characteristics. Results The majority of dentists (67%) reported prior training in pain management; however, a minority of dentists reported prior training regarding identification and assessment of drug abuse or addiction (48%) or identification of prescription drug diversion (25%). The majority of training experiences across all topics occurred through continuing dental education participation. Dental school training relevant to pain management, addiction, and identification of drug diversion was more prevalent among more recent dental school graduates. Training experiences were associated with prescribing practices. Conclusions Results suggest that across multiple levels of training, many dentists are not receiving training specific to addiction assessment and identification of drug diversion. Such training is associated with greater consistency of risk mitigation implementation in practice.

Purpose Drivers of excess controlled substance disposal behaviors are not well understood. A survey of patients who had received opioid-based medications was conducted to inform the design of future innovative drug take-back programs. Methods This was a cross-sectional survey study conducted in 152 participants who received treatment with an opioid within the previous 2 years and had possession of unused medication following either switching to a different opioid or discontinuation of pain. Results Approximately one-third of patients had disposed of their unused opioid medication. Education about the importance of and appropriate methods for drug disposal was associated with a significantly increased likelihood of patients disposing of unused medication, and it was observed that patients prescribed an immediate-release/short-acting opioid were twice as likely to keep their medication compared to those prescribed an extended-release/long-acting opioid. The most commonly reported methods for disposal were via drug return kiosks and flushing the medication down the toilet. Some of the most impactful drivers of unused opioid disposal were routine practice of disposing of all unused drugs and instruction from a health care provider, and the most common driver of keeping unused medication was the desire to have it on-hand should there be a need to treat pain in the future. Over 80 % of patients indicated that they would be more likely to use a drug take-back service if they were offered compensation or if the kiosk was in a location that they visited frequently, and approximately half of the patients indicated that they would be willing to request an initial partial fill of an opioid prescription to reduce the volume of unused medication. Conclusion There is a clear need to increase patient awareness about the importance and methods of proper medication disposal, and a great opportunity for health care providers to increase patient education efforts. These study findings also highlight key areas for improvement in drug take-back programs that may promote and incentivize more patients to utilize the services.

Over the last few years reports have indicated an increase in the number, type and availability of new psychoactive substances belonging to the benzodiazepine class. These molecules may pose high risks to users, since the majority have never undergone clinical trials or tests so their pharmacology and toxicology is largely unknown. However the new drug scenario emerging from the COVID-19 global pandemic seems to play a role in increasing the diversion of prescribed benzodiazepines and Z-drug. A brief presentation of this phenomenon is hereby presented. The awareness and response activities at national and international levels related to this issue should be enforced.

Imagine the following scenario. You are a thirty-year-old Army veteran. While in the service, you were the victim of a horrific sexual assault and diagnosed with post-traumatic stress disorder (PTSD). Your military health care provider (HCP) prescribes a low dose sedative “PRN” (take as needed) to mitigate your PTSD symptoms. Several years later, you are diagnosed with a painful and debilitating inflammatory bowel disorder (IBD), which significantly diminishes your daily functioning without treatment. Your military HCP prescribes you hydrocodone, which allows you to manage your IBD symptoms. As your condition deteriorates, you decide to retire from the military and seek treatment at a civilian clinic. At first, your new HCP continues your prescription drug treatment regimen. A few months later, however, that HCP informs you that (1) she is under U.S. Drug Enforcement Administration (DEA) investigation due to her state prescription drug monitoring program (PDMP) data, (2) you have been flagged by the PDMP as at risk for opioid misuse, and (3) she has no choice but to discontinue your medication. You try to no avail to find another HCP before you lapse into opioid withdrawal and are riddled with severe IBD symptoms. Within a week of your medication discontinuation, you are bedridden, unable to work or take care of your family, severely depressed, and experiencing suicidal ideation. This article exposes and critiques the laws and policies that collude to coerce this scenario and identifies and examines a regulatory oversight framework that can mitigate such needless pain and suffering. The American drug overdose crisis and generous funding by U.S. law enforcement agencies have provoked forty-nine states to implement PDMP surveillance programs. PDMP platforms rely on proprietary, predictive algorithmic tools designed and manufactured by a private company to determine a patient’s risk for drug misuse. Law enforcement conducts dragnet sweeps of PDMP data to target providers that the platform characterizes as “overprescribers” and patients that it deems as high risk of drug diversion, misuse, and overdose. Research demonstrates that PDMP risk scoring coerces clinicians to force taper, discontinue, and even abandon vulnerable patients without regard for the catastrophic collateral consequences that attend to those treatment decisions. The proxies that PDMPs utilize to generate patient risk scores are likely to produce artificially inflated risk scores for vulnerable patients. PDMPs, therefore, have the potential to exacerbate discrimination against vulnerable patients with stigmatized medical conditions by generating flawed, short-cut assessment tools that incentivize providers to deny these individuals indicated treatment. The Federal Food and Drug Administration (FDA) is authorized to regulate PDMP software platforms as medical devices and the agency has recently issued guidance that provides a robust framework for such oversight. This Article contends that FDA is obligated to exercise its regulatory authority over PDMP risk scoring software to ensure that such predictive diagnostic tools are safe and effective for patients.

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Introduction As the opioid epidemic continues, state legislatures and clinicians increasingly utilize Prescription Drug Monitoring Programs (PDMPs). These programs record dates prescribed and filled for all controlled substances, attempting to identify high-risk prescribing. The aims of this study were to (i) examine data from individuals who died of accidental opioid overdose and (ii) compare differences between those with prescriptions documented in Kentucky's PDMP with individuals without recorded prescriptions. Methods This was a retrospective, observational cohort study conducted in Jefferson County, Kentucky. We reviewed records for all opioid overdose death subjects from 2017 and 2018, cross-referencing with prescriptions in Kentucky's PDMP (Kentucky All Schedule Prescription Electronic Reporting System [KASPER]) back to 2014. We performed χ analyses for categorical variable comparisons and a separate univariate analysis for age. Results Of the 575 individuals who died of accidental opioid overdose in Jefferson County during the study period, 379 (65.9%) had prescriptions documented in KASPER. Individuals had a high prevalence of fentanyl on postmortem toxicology. Only one individual had postmortem toxicology positive for buprenorphine, a medication for opioid use disorder (MOUD). Several subjects experienced what we termed see-saw MOUD prescribing (prescriptions alternating between MOUD and other controlled substances including full agonists), and multiple prescriptions were apparently written and/or filled for deceased subjects. Conclusions Review of PDMP data in deceased patients can prevent unnecessary opioid prescribing and optimize clinical practice. Buprenorphine may have a protective effect in opioid dependence, but access must be consistent. Providers should be aware of see-saw MOUD prescribing and understand the effects on patient care. In response to the prescriptions filled for deceased individuals, legislators could enact a policy such as Void All Prescriptions or VAP alerts to cancel all prescriptions for individuals who have died, reducing drug diversion. It is vital that providers routinely use PDMP data along with counseling and other treatment strategies to optimize patient care.

Supplemental digital content is available in the text., Objectives Inpatient hospital pharmacies have a central role in managing controlled substances (CS) throughout the hospital medication use process (MUP). Our objectives were to identify vulnerabilities for diversion in the MUPs of 2 inpatient pharmacies, explore differences between the sites, and characterize the types of vulnerabilities identified. Methods We conducted clinical observations in 2 pharmacies to map their MUPs and performed a healthcare failure mode and effect analysis to proactively identify (1) the critical failure modes (CFMs) that make them vulnerable to diversion and (2) the controls that prevent, mitigate, or enhance the detectability of CFMs. Results We conducted 99 hours of observations between May–June and September–October 2018. We observed 36 pharmacy technicians, 4 pharmacists, and 1 clerk as they conducted tasks involving 4 processes common to both sites: procuring CS, receiving CS deliveries to the pharmacy, unit-dose packaging CS oral solids, and distributing CS to hospital units. The tasks and subtasks we mapped in the process flow diagrams led to the identification of 220 failure modes. Of these, 34 were deemed CFMs and were categorized as related to handling CS, data entry, or verification tasks. Three of the CFMs were unique to one site, given that the other site had a control for the CFM. Conclusions Multiple vulnerabilities for diversion exist in inpatient pharmacy processes. Our results provide some much needed detail about how specific vulnerabilities in MUP tasks and subtasks lead to an increased risk of diversion.

Human and veterinary pharmaceuticals offer many benefits, but they also pose risks to both the environment and public health. Life-cycle stewardship of medications offers multiple strategies for minimizing the risks posed by pharmaceuticals, and further insight is required for developing best practices for pharmaceutical management. The goal of this study was to clarify points of intervention for minimizing environmental and public health risks associated with pharmaceuticals. Specifically, our objectives were to provide insight on purchasing, use, and disposal behaviors associated with human and veterinary medications. This study used a state-wide representative sample of Vermont adults (n = 421) to survey both human and veterinary pharmaceuticals as potential sources of the unintended consequences of prescribed and over-the-counter (OTC) medications. The majority (93%) of respondents had purchased some form of medication within the past twelve months, including OTC (85%), prescription (74%), and veterinary (41%) drugs. Leftover drugs of any kind were reported by 59% of respondents. While 56% of people were aware of drug take-back programs, the majority reported never being told what to do with leftover medications by their physician (78%), pharmacist (76%), or veterinarian (53%). Among all respondents, take-back programs were the most common disposal method (22%), followed by trash (19%), and flushing (9%), while 26% of respondents reported keeping unused drugs. Awareness of pharmaceutical pollution in the environment and having received information about proper disposal were both significantly associated with participation in take-back programs. These findings indicate that a large volume of drugs are going unused annually, and that only a portion of leftover medications are returned to take-back programs where they can be appropriately disposed. Our results warrant further investigation of clinical interventions that support lower dose prescribing and dispensing practices in order to reduce the unintended environmental and public health consequences of pharmaceuticals within the consumer sphere. In addition, our findings suggest that directed efforts to raise awareness of proper disposal may be more effective than broad awareness campaigns, and we recommend research on the efficacy of providing disposal instructions on drug packaging.

Opioid use disorder (OUD) is a cause of significant morbidity and mortality in the United States. Although efforts are being made to limit access to prescription opioids, the use of heroin and synthetic opioids as well as death due to opioid overdose has increased. Medication-assisted treatment (MAT) is the pairing of psychosocial intervention with a Food and Drug Administration (FDA)–approved medication (methadone, buprenorphine plus naltrexone) to treat OUD. MAT has resulted in reductions in overdose deaths, criminal activity, and infectious disease transmission. Access to MAT in rural areas is limited by shortages of addiction medicine-trained providers, lack of access to comprehensive addiction programs, transportation, and cost-related issues. Rural physicians express concern about lack of mentorship and drug diversion as reasons to avoid MAT. The prescribing of MAT with buprenorphine requires a Drug Enforcement Agency (DEA) waiver that can easily be obtained by Family Medicine providers. MAT can be incorporated into the outpatient practice, where patient follow-up rates and number needed to treat to effect change are similar to that of other chronic medical conditions. We describe a case of opioid overdose and a suggested protocol for the induction of MAT with buprenorphine/naloxone (Suboxone) for OUD in a rural family medicine outpatient practice. Treatment access is facilitated by utilizing the protocol, allowing office staff work to the extent allowed by their licensure, promoting teamwork and minimizing physician time commitment. We conclude that improved access to MAT can be accomplished in a rural family medicine outpatient clinic by staff that support and mentor one another through use of a MAT protocol.

Background: Suicide and substance use disorder (SUD) pose serious public health challenges among young adults in the United States. Increasing social media use among these populations can be leveraged as an alternative method to detect characteristics of suicide-related topics and behavior among substance users.Objective: To detect and characterize suicide and self-harm related conversations co-occurring with SUD posts and comments on the popular social media platform Instagram.Methods: This study used big data and machine learning approaches to collect and classify Instagram posts containing 632 controlled substance-related hashtags. Posts were first classified for online drug diversion topics and then filtered to detect suicide and mental health discussions. Posts and comments were then manually annotated for SUD and mental health co-occurring themes. Associations between these characteristics were tested using the Chi-square test.Results: We detected 719 Instagram posts/comments that included user-generated discussions about suicide, substance use and/or mental health. Posts self-reporting SUD and mental health topics were also more likely to discuss suicide compared to those that did not discuss SUD and mental health topics, respectively (p < 0.001). Major themes observed included concurrent discussions of suicide ideation and attempts and low self-esteem.Conclusions: Our study results provide preliminary evidence of social media discussions about suicide and mental health among those with SUD. This co-occurrence represents a key health risk factor on a platform heavily utilized by young adults. Further studies are required to analyze specific patterns of suicide and self-harm ideations for the purposes of designing future suicide prevention campaigns through digital channels.

Malingering of ADHD symptoms is a potential means of nonmedical use of prescription stimulants (NMUPS). The Subtle ADHD Malingering Screener (SAMS) provides a potential avenue for identification of symptom malingering. However, no real world evidence of this scale has been published to date. The goal of this study was to examine patterns of use of stimulant prescriptions and to evaluate the ability of the SAMS to identify NMUPS. This study employed a cross-sectional observational design to administer an online, self-administered survey instrument in a convenience sample of college-enrolled young adults with a prescription for stimulant medications at a campus pharmacy. Respondents were asked about their prescription characteristics, nonmedical use and drug diversion behavior, along with ratings on the SAMS. Over 33% of respondents self-reported past-year NMUPS and 18% reported past-year drug diversion. Over 35% of respondents rated NMUPS as being slight or no risk and 55% were classified by the SAMS as likely to be malingering or exaggerating their symptoms. Individuals reporting past-year NMUPS or diversion consistently scored higher on the SAMS. The SAMS showed potential for future application in the pharmacy setting. Further research is needed to evaluate the relationship of SAMS to NMUPS or drug diversion. The results of this study also highlight several growing issues with the diagnosis and treatment of ADHD among young adults enrolled in college. Addressing perception of risk, social norms, and providing healthcare professionals with tools to prevent misdiagnosis is critical to the management of this issue.

Introduction Misuse of prescription medicines and the harms associated with such use are growing threats across the world. There is currently, however, limited data on the extent of prescription medicine misuse in Singapore and whether this is a current threat in the country. Methods An online survey, limited to 1,000 individuals (aged 21 years and over) who were residents in Singapore, was administered through a survey panel company in September 2015. The survey collected information on participant demographics, and their awareness, self-reported lifetime and past-year misuse of commonly available prescription medicines in Singapore as well as the use of a range of recreational drugs and novel psychoactive substances (NPS). Results Lifetime (6.7%) and past-year (4.8%) misuse of any prescription medicine was comparable to lifetime (6.0%) and past-year (3.0%) use of any recreational drugs/NPS. The top five prescription medicines for lifetime misuse were: diazepam (2.7%); codeine (2.3%); dhasedyl (promethazine, codeine and ephedrine; 1.6%); panadeine (paracetamol and codeine; 1.5%); and methylphenidate (1.2%). The top five drugs for past-year misuse were: diazepam (1.6%); codeine (0.9%); panadeine (0.7%); alprazolam (0.6%); baclofen (0.6%); and gabapentin (0.6%). Conclusion Misuse of prescription medicine in Singapore was common, with prevalence comparable to the use of recreational drugs/NPS. A common source for misused drugs was physicians. Further studies are required to determine whether this is more widespread in Singapore and establish the different forms of drug diversion, so that appropriate prevention strategies can be implemented.

Background Gabapentinoid drugs (gabapentin and pregabalin) are effective in neuropathic pain, which has a prevalence of ∼7%. Concerns about increased prescribing have implications for patient safety, misuse, and diversion. Drug-related deaths (DRDs) have increased and toxicology often implicates gabapentinoids. We studied national and regional prescribing rates (2006–2016) and identified associated sociodemographic factors, co-prescriptions and mortality, including DRDs. Methods National data from the Information Service Division, NHS Scotland were analysed for prescribing, sociodemographic, and mortality data from the Health Informatics Centre, University of Dundee. DRDs in which gabapentinoids were implicated were identified from National Records of Scotland and Tayside Drug Death Databases. Results From 2006 to 2016, the number of gabapentin prescriptions in Scotland increased 4-fold (164 630 to 694 293), and pregabalin 16-fold (27 094 to 435 490). In 2016 ‘recurrent users' (three or more prescriptions) had mean age 58.1 yr, were mostly females (62.5%), and were more likely to live in deprived areas. Of these, 60% were co-prescribed an opioid, benzodiazepine, or both (opioid 49.9%, benzodiazepine 26.8%, both 17.1%). The age-standardised death rate in those prescribed gabapentinoids was double that in the Scottish population (relative risk 2.16, 95% confidence interval 2.08–2.25). Increases in gabapentinoids contributing to cause of DRDs were reported regionally and nationally (gabapentin 23% vs 15%; pregabalin 21% vs 7%). In Tayside, gabapentinoids were implicated in 22 (39%) of DRDs, 17 (77%) of whom had not received a prescription. Conclusions Gabapentinoid prescribing has increased dramatically since 2006, as have dangerous co-prescribing and death (including DRDs). Older people, women, and those living in deprived areas were particularly likely to receive prescriptions. Their contribution to DRDs may be more related to illegal use with diversion of prescribed medication.

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 Oxy-Contin 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 Oxy-Contin 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.