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Background and Objectives Prescription Drug Monitoring Programs (PDMPs) can serve as screening tools and support the clinical decision-making process in patients receiving opioids. The objective of the study was to utilize 2014 INSPECT (Indiana's PDMP) data to identify factors that increase patients’ likelihood to engage in opioid-related risk behaviors. Methods Based on a literature review, four risk behaviors were identified: Receiving >90 morphine milligram equivalents (MME), having >4 opioid prescribers, obtaining opioids from >4 pharmacies, and concurrent use of opioids and benzodiazepines. Two binary logistic regression analyses (engaging in at least one risk behaviors; engaging in all four risk behaviors) and an ordinal regression analysis (engaging in 0–4 risk behaviors) were conducted to identify factors associated with these opioid-related risk behaviors. Results Of the 1,538,120 unique opioid patients included in the study, 18.4% engaged in one, 5.3% in two, 1.6% in three, and .4% in all four risk behaviors. Depending on the model, prescribing a second monthly opioid increased patients’ odds to engage in risk behaviors by a factor of 10 or more and prescribing two or more benzodiazepines annually increased the odds at least 13-fold. Conclusions and Scientific Significance About one-fourth of all patients consuming opioids engaged in one or more risk behaviors; higher number of opioid prescriptions and addition of even a small number of benzodiazepine prescriptions dramatically increased these odds. PDMPs can be helpful in identifying opioid users at high-risk for misuse. This information could be used to target efforts to reduce the prescription drug epidemic. (Am J Addict 2017;XX:1–8)

INTRODUCTION: Chronic liver diseases (CLDs) and substance use disorders (SUDs) are increasingly prevalent and often coexist. Contemporary studies describing the characteristics and hospitalization trends of those with comorbid CLD-SUD are lacking. We aimed to characterize a population-based cohort with comorbid CLD-SUD and describe trends in these hospitalizations over time by individual-level characteristics. METHODS: We performed a cross-sectional analysis of the National Inpatient Sample from 2005 through 2017. Diagnosis codes were used to identify adult hospitalizations with CLD, SUD, or both. Bivariate and multivariate analyses were used to make comparisons between diagnosis categories. Unadjusted and age-adjusted trends in these hospitalizations were described over time. RESULTS: Of 401,867,749 adult hospital discharges, 3.2% had CLD-only and 1.7% had comorbid CLD-SUD. Compared with CLD-only, comorbid CLD-SUD hospitalizations resulted in higher inpatient mortality (3.1% vs 2.4%, P < 0.001) and were associated with younger age, male sex, Native American race, and urban and Western US location. Over time, comorbid hospitalizations grew 34%, and the demographics shifted with larger increases in hospitalization rates seen in younger individuals, women, Native Americans, and those publicly insured. In comorbid hospitalizations, alcoholic SUD and CLD decreased, but drug SUDs and nonalcoholic fatty liver diseases are fast-growing contributors. DISCUSSION: In this comprehensive analysis of US hospitalizations, comorbid CLD-SUD hospitalizations are increasing over time and lead to higher inpatient mortality than CLD alone. We further characterize the changing demographics of these hospitalizations, providing a contemporary yet inclusive look at comorbid CLD-SUD hospitalizations. These data can guide interventions needed to improve the poor outcomes suffered by this growing population.

Background and Objectives Fourfold increases in opioid prescribing and dispensations over 2 decades in the U.S. has paralleled increases in opioid addictions and overdoses, requiring new preventative, diagnostic, and treatment strategies. This study examines Prescription Drug Monitoring Program (PDMP) tracking as a novel measure of opioid addiction treatment outcomes in a university-affiliated integrated mental health-addiction treatment clinic. Methods Repeated measure parametrics examined PDMP and urine drug screening (UDS) data before and after first injection for all patients (N = 68) who received at least one long-acting naltrexone injection (380 mg/IM) according to diagnostic groupings of having either (i) alcohol (control); (ii) opioid; or (iii) combined alcohol and opioid use disorders. Results There were no group differences post-injection in treatment days, injections delivered, or treatment service encounters. UDS and PDMP measures of opioid exposures were greater in opioid compared to alcohol-only patients. Post-first injection, UDS's positive for opioids declined (p

Introduction The opioid epidemic has been largely attributed to changes in prescribing practices over the past 20 years. Although current overdose trends appear driven by the opioid fentanyl, heroin has remained the focus of overdose fatality assessments. We obtained full toxicology screens on lethal overdose cases in a major US city, allowing more accurate assessment of the time-course of fentanyl-related deaths. Methods We used coroner data from Marion County, Indiana comprising 1583 overdose deaths recorded between January 1, 2010 and April 30, 2017. Bayesian multilevel models were fitted to predict likelihood of lethal fentanyl-related overdose using information about the victim's age, race, sex, zip code, and date of death. Results Three hundred and seventy-seven (23.8%) overdose deaths contained fentanyl across the seven-year period. Rates rose exponentially over time, beginning well below 15% from 2010 through 2013 before rising to approximately 50% by 2017. At the beginning of the study period, rates of fentanyl overdose were lowest among Black persons but increased more rapidly, eventually surpassing Whites. Currently, White females are at particularly low risk of fentanyl overdose whereas Black females are at high risk. Rates were highest for younger and middle-aged groups. Over time, fentanyl was more likely detected without the presence of other opioids. Conclusions Fentanyl has increasingly been detected in fatal overdose deaths in Marion County. Policy and program responses must focus on education for those at highest risk of fentanyl exposure and death. These responses should also be tailored to meet the unique needs of high-risk demographics.

Prescribing of controlled substances, particularly opioids, has grown dramatically over the past 2 decades in the United States, along with prescription drug addictions and lethal overdoses.1–3 One type of opioid, hydrocodone, is now the most commonly prescribed drug in the United States,4 and Americans are now more likely to die from a prescription drug overdose than from a car accident or suicide.1,2,5 Since 2000, 5-fold increases in lethal overdoses involving opioids have paralleled increases in their legal prescriptions by primary care doctors, emergency room physicians, dentists, and other specialists.1,5,6 As prescription drug deaths have surpassed those from illicit drugs,5 health and justice officials have become increasingly motivated to better educate the public and health professionals about the dangers of opioid medications and to develop new tools that can reduce adverse prescribing practices.3,7,8 State-supported prescription drug monitoring programs (PDMPs) allow practitioners to rapidly visualize records of controlled substance dispensations to their patients, enhancing identification of prescription drug abuse patterns.9,10 PDMPs may be particularly useful in behavioral health treatment settings: addictions, including those involving prescription drugs, are highly concentrated in populations with mental illness.11–19 Given “adverse selection,” where patients most vulnerable to addiction are the ones most likely to be prescribed opioids in large quantities,13,20 and biological vulnerability to addiction in mental illness,21,22 the regular use of PDMPs by psychiatric physicians could enhance the detection, interdiction, and treatment of prescription drug addictions. To our knowledge, there are no published studies demonstrating the use of PDMPs as either clinical or research tools in psychiatry, although a 2012 Ohio survey suggests few psychiatrists use them routinely.23 The present study addresses this evidence gap while gauging the scope and penetrance of controlled substance prescribing in a community mental health outpatient population, with exploration of how controlled prescription patterns might correlate with specific diagnoses or differences in health insurance coverage.

Background: Opioid use and abuse in the United States continues to expand at an alarming rate. In this study, we examine the county-level determinants of the availability and abuse of prescription opioids to better understand the socio-ecological context, and in particular the role of the healthcare delivery system, on the prescription drug abuse epidemic. Methods: We use community-level information, data from Indiana’s prescription drug monitoring program in 2011, and geospatial regression methods to identify county-level correlates of the availability and abuse of prescription opioids among Indiana’s 92 counties. Results: The findings suggest that access to healthcare generally, and to dentists and pharmacists in particular, increases the availability of prescription opioids in communities, which, in turn, is associated with higher rates of opioid abuse. Conclusions: The results suggest that the structure of the local healthcare system is a major determinant of community-level access to opioids adding to a growing body of evidence that the problem of prescription opioid abuse is, at least in part, an “iatrogenic epidemic.”

Tremendous growth in opioid prescribing over two decades in the USA has correlated with proportional increases in diversion, addiction, and overdose deaths. Pseudoaddiction, a concept coined in 1989, has frequently been cited to indicate that under-treatment of pain, rather than addiction, is the more pressing and authentic clinical problem in opioid-seeking patients. This investigative review searched Medline articles containing the term "pseudoaddiction" to determine its footprint in the literature with a focus on how it has been characterized and empirically validated. By 2014, pseudoaddiction was discussed in 224 articles. Only 18 of these articles contributed to or questioned pseudoaddiction from an anecdotal or theoretical standpoint, and none empirically tested or confirmed its existence. Twelve of these articles, including all four that acknowledged pharmaceutical funding, were proponents of pseudoaddiction. These papers described pseudoaddiction as an iatrogenic disease resulting from withholding opioids for pain that can be diagnosed, prevented, and treated with more aggressive opioid treatment. In contrast, six articles, none with pharmaceutical support, questioned pseudoaddiction as a clinical construct. Empirical evidence supporting pseudoaddiction as a diagnosis distinct from addiction has not emerged. Nevertheless, the term has been accepted and proliferated in the literature as a justification for opioid therapy for non-terminal pain in patients who may appear to be addicted but should not, from the perspective of pseudoaddiction, be diagnosed with addiction. Future studies should examine whether acceptance of pseudoaddiction has complicated accurate pain assessment and treatment, and whether it has contributed to or reflected medical-cultural shifts that produced the iatrogenic opioid addiction epidemic.