Prescription Opioid Injection among HIV-Positive People Who Inject Drugs in a Canadian Setting

Prescription opioids (POs) are commonly prescribed to patients living with HIV/AIDS, while the illicit use of POs remains a major public health concern throughout Canada and the United States. 

We sought to identify the prevalence and correlates of PO injection among HIV-positive people who inject drugs (PWID) in Vancouver, Canada, where HIV/AIDS treatment and care is offered at no cost. We examined data from 634 individuals from an ongoing prospective cohort of HIV-positive PWID. 

Between December 2005 and November 2013, the median prevalence of recent PO injection was 24.2% [interquartile range (IQR): 21.5-25.8 %]. 

In a multivariable generalized estimating equation model, 

• Caucasian ethnicity, 
• heroin injection, 
• and drug dealing were positively associated with PO injection, 

While older age and methadone maintenance treatment were negatively associated with PO injection (all p < 0.05). Engagement on antiretroviral therapy was inversely associated with PO injection in a bivariable analysis, but did not remain significant after adjusting for heroin injection. 

These findings describe a particularly vulnerable sub-group of PWID who may benefit from targeted efforts to both minimize drug-related risk behaviors and support HIV/AIDS treatment.

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By:  Lake S^1,2, Kerr T^1,3, Buxton J², Guillemi S¹, Parashar S¹, Montaner J^1,3, Wood E^1,3, Milloy MJ^4,5.

¹British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.

²School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, V6T 1Z3, Canada.

³Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.

⁴British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. uhri-mjsm@cfenet.ubc.ca.

⁵Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. uhri-mjsm@cfenet.ubc.ca.

AIDS Behav. 2016 May 5. [Epub ahead of print] 

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The Relationship Between Non-Medical Use of Prescription Opioids and Sex Work Among Adults in Residential Substance Use Treatment

Highlights

• Sex work (SW) is common among patients in residential substance use treatment.
• SW among individuals in addictions treatment is associated with more extensive substance use and greater psychiatric severity.
• Non-medical use of prescription opioids is widespread among individuals involved in SW.

High rates of substance use (e.g., alcohol, cocaine, heroin) have been documented among individuals who engage in sex work (SW), and adults seeking substance use disorder (SUD) treatment frequently report prior engagement in SW. Non-medical use of prescription opioids (NMUPO) has increased over the last decade, but little is known about the relationship between NMUPO with sex exchange. 

The purpose of this study was to describe the prevalence of recent SW among patients at a large residential SUD treatment center and examine the association between NMUPO and SW. Approximately 14% of 588 adults reported involvement in SW in the month prior to treatment. NMUPO was more common among those with a history of SW (95% of sex workers vs. 74% of non-sex-workers), and this association remained statistically significant after controlling for demographic factors, other substance use and psychiatric symptom severity (odds ratio=3.38). SW is relatively common among patients in residential SUD treatment, and is associated with greater psychiatric severity and more extensive substance use, including alarming rates of NMUPO. 

Addiction treatment for individuals involved in SW may benefit from the addition of content related to NMUPO.

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By:  Matusiewicz AK1, Ilgen MA2, Bonar EE3, Price A3, Bohnert AS2.

• VA Center for Clinical Management Research (CCMR), 2800 Plymouth Rd. Building 16, Ann Arbor MI 48109 USA; Department of Psychiatry, University of Michigan, 2800 Plymouth Rd. Building 16, Ann Arbor MI 48109 USA; VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor MI 48109 USA. Electronic address: amatusie@uvm.edu.
• 2VA Center for Clinical Management Research (CCMR), 2800 Plymouth Rd. Building 16, Ann Arbor MI 48109 USA; Department of Psychiatry, University of Michigan, 2800 Plymouth Rd. Building 16, Ann Arbor MI 48109 USA.
• 3Department of Psychiatry, University of Michigan, 2800 Plymouth Rd. Building 16, Ann Arbor MI 48109 USA. 
• J Subst Abuse Treat. 2016 May;64:24-8. doi: 10.1016/j.jsat.2016.01.010. Epub 2016 Feb 13.

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Treatment of Prescription Opioid Disorders in Canada: Looking at the 'Other Epidemic'?

The magnitude and consequences of prescription opioid (PO) misuse and harms (including rising demand for PO disorder treatment) in Canada have been well-documented. 

Despite a limited evidence-base for PO dependence treatment, opioid maintenance therapy (OMT) - mostly by means of methadone maintenance treatment (MMT) - has become the de facto first-line treatment for PO-disorders. For example in the most populous province of Ontario, some 50,000 patients - large proportions of them young adults - are enrolled in MMT, resulting in a MMT-rate that is 3-4 times higher than that of the United States. 

MMT in Ontario has widely proliferated towards a quasi-treatment industry within a system context of the public fee-payer offering generous incentives for community-based MMT providers. Contrary to the proliferation of MMT, there has been no commensurate increase in availability of alternative (e.g., detox, tapering, behavioral), and less intrusive and/or costly, treatments which may provide therapeutic benefits at least for sub-sets of PO-dependent patients. 

Given the extensive PO-dependence burden combined with its distinct socio-demographic and clinical profile (e.g., involving many young people, less intensive or risky opioid use), an evidence-based 'stepped-care' model for PO dependence treatment ought to be developed in Canada where MMT constitutes one, but likely a last resort or option, for treatment. Other, less intrusive treatment options as well as the best mix of treatment options should be systematically investigated and implemented. 

This case study has relevance and implications for evidence-based treatment also for the increasing number of other jurisdictions where PO misuse and disorders have been rising.

Full article at:   http://goo.gl/EPWqtR

By:  Fischer B1,2,3,4, Kurdyak P5,6,7, Goldner E8, Tyndall M9,10, Rehm J11,12,13,14.

• 1Social and Epidemiological Research Department, Centre for Addiction & Mental Health (CAMH), Toronto, ON, M5S 2S1, Canada. bfischer@sfu.ca.
• 2Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada. bfischer@sfu.ca.
• 3Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, M5T 1R8, Canada. bfischer@sfu.ca.
• 4Centre for Applied Research in Mental Health & Addiction (CARMHA), Simon Fraser University, Vancouver, V6B 5K3, Canada. bfischer@sfu.ca.
• 5Social and Epidemiological Research Department, Centre for Addiction & Mental Health (CAMH), Toronto, ON, M5S 2S1, Canada. paul.kurdyak@camh.ca.
• 6Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada. paul.kurdyak@camh.ca.
• 7Mental Health and Addictions Program, Institute for Clinical Evaluative Science (ICES), Toronto, ON, M4N 3M5, Canada. paul.kurdyak@camh.ca.
• 8Centre for Applied Research in Mental Health & Addiction (CARMHA), Simon Fraser University, Vancouver, V6B 5K3, Canada. egoldner@sfu.ca.
• 9B.C. Centre for Disease Control (BCCDC), Vancouver, BC, V5Z 4R4, Canada. mtyndall@bccdc.ca.
• 10Department of Medicine, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada. mtyndall@bccdc.ca.
• 11Social and Epidemiological Research Department, Centre for Addiction & Mental Health (CAMH), Toronto, ON, M5S 2S1, Canada. jtrehm@gmail.com.
• 12Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada. jtrehm@gmail.com.
• 13Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, M5T 1R8, Canada. jtrehm@gmail.com.
• 14Dalla Lana School of Public Health, University of Toronto, Toronto, ON, M5T 3M7, Canada. jtrehm@gmail.com.
• Subst Abuse Treat Prev Policy. 2016 Mar 8;11(1):12. doi: 10.1186/s13011-016-0055-4. 

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"Prescription Thugs" Official Trailer - Video

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Review: http://www.nytimes.com/2016/01/22/movies/prescription-thugs-review.html?_r=0

Risk Factors of Prescription Opioid Overdose among Colorado Medicaid Beneficiaries

Highlights

• This article presents the risk factors of opioid overdose among the Colorado Medicaid population.
• Six factors were associated with opioid overdose including mean morphine dose equivalent (>50 mg/day), methadone use, drug/alcohol abuse, psychiatric illness, benzodiazepine use, and the number of different pharmacies used by the beneficiary.
• States and communities should ensure the availability of at-home intra-nasal naloxone for overdose rescue based on the presence of risk factors.

This study aims to determine risk factors of opioid overdose among the Colorado Medicaid population. A retrospective nested case-control study was undertaken. Medicaid beneficiaries who had a medical claim(s) for an emergency department visit or a hospitalization associated with an opioid overdose from July 2009 to June 2014 were defined as cases. Controls were selected using a nearest neighbor matching without replacement. The matched controls were selected based on age, gender, and opioid prescription. One case was matched with three controls. Multivariate conditional logistic regression was used to compare risk factors. 

A total of 816 cases with 2,448 controls were included. Six factors were associated with opioid overdose: mean morphine dose equivalent (>50 mg/day), methadone use (switching opioid to methadone vs. no methadone use), drug/alcohol abuse, other psychiatric illness, benzodiazepine use, and the number of pharmacies utilized by the beneficiary (≥4 pharmacies vs. 1 pharmacy). 

In conclusion, several factors are associated with opioid overdose. States and communities should ensure the availability of at-home intra-nasal naloxone for overdose rescue based on the presence of risk factors.

PERSPECTIVES:

This article presents the risk factors of opioid overdose among Colorado Medicaid population. Based on study findings, Colorado Medicaid is currently working with physicians, hospitals, and other health-system stakeholders to continue develop policies to identify and assist this subset of our population. One such policy will be to provide intranasal naloxone for overdose rescue.

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By:   Dilokthornsakul P1, Moore G2, Campbell JD2, Lodge R3, Traugott C3, Zerzan J3, Allen R4, Page RL 2nd2.

• 1Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences (http://www.ucdenver.edu/academics/colleges/pharmacy/Pages/SchoolofPharmacy.aspx), University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand. Electronic address: piyamethd@gmail.com.
• 2Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
• 3Department of Health Care Policy and Financing, State of Colorado.
• 4Peak Statistical Services, Evergreen, CO, USA.
• J Pain. 2015 Dec 22. pii: S1526-5900(15)00985-2. doi: 10.1016/j.jpain.2015.12.006.
• 
  
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Racial And Ethnic Trends & Correlates of Non-Medical Use of Prescription Opioids among Adolescents in the United States 2004-2013

PURPOSE:

Our objective was to elucidate the trends in non-medical use of prescription opioids (NMUPO) among whites, African-Americans, and Hispanic adolescents in the United States. An additional aim was to examine the sociodemographic, behavioral, and psychosocial correlates of NMUPO across each of these aforementioned racial and ethnic groups.

METHODS:

Data was derived from the National Survey on Drug Use and Health (NSDUH) involving non-Hispanic white, African American, and Hispanic respondents ages 12-17 (n = 164,028) and spanning the years 2004-2013. Consistent with prior NSDUH-based studies, respondents reporting use within the previous 12 months were classified as nonmedical prescription opioid users. Logistic regression was used to examine significance of trend year and correlates of NMUPO.

RESULTS:

Non-Hispanic white youth consistently reported higher levels of NMUPO as did older adolescents (ages 15-17) and females. However, there was a decrease in the prevalence of NMUPO overall driven largely by a significant decline (p < 0.001) in NMUPO among non-Hispanic whites of approximately 35% over the study period such that by 2013 no statistically significant differences across race/ethnicity remained. Further, logistic regression models found that externalizing behaviors such as comorbid drug use and fighting was associated with NMUPO and religiosity and parental involvement were identified as protective correlates.

CONCLUSIONS:

To our knowledge, this is the first study to identify a declining trend in NMUPO among adolescents. Although the present study findings provide a source for optimism, there is still a relatively high prevalence of NMUPO and it remains to be seen whether our findings portend a long-term decline. Given the harm done by NMUPO, continued awareness and targeted prevention efforts should be implemented.

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By:   Vaughn MG1, Nelson EJ2, Salas-Wright CP3, Qian Z4, Schootman M4.

• 1School of Social Work, College for Public Health and Social Justice, Saint Louis University, Tegeler Hall, 3550 Lindell Blvd, St. Louis, MO 63103, United States. Electronic address: mvaughn9@slu.edu.
• 2College for Public Health and Social Justice, 3545 Lafayette Avenue, St. Louis, MO 63104, United States. Electronic address: nelsonej@slu.edu.
• 3School of Social Work, The University of Texas at Austin, 1925 San Jacinto Blvd D3500, Austin, TX 78712-0358, United States. Electronic address: salaswright@utexas.edu.
• 4College for Public Health and Social Justice, 3545 Lafayette Avenue, St. Louis, MO 63104, United States. 

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Economic Burden of Prescription Opioid Misuse and Abuse: A Systematic Review

A 2009 systematic review found that the total cost of prescription opioid abuse in 2001 in the United States was approximately $8.6 billion and medical expenses were estimated to be $15,884 for opioid abusers and $1,830 for nonabusers. 

A search was conducted for English publications on the cost of prescription opioid abuse and misuse from 2009 to 2014. The initial literature search identified 5,412 citations. Title and abstract review selected 59 for further review. The final review process resulted in 16 publications for inclusion that examined cost from the payer perspective. 

Mean costs to the payer for abusers were $23,000-$25,000 per year and excess costs approximately $15,000 per patient. 

Three papers were identified that presented societal costs, including direct and indirect costs such as criminal justice costs and costs associated with lost productivity. The strongest evidence suggests that societal cost is in excess of $50 billion per year in the United States. 

Prescription opioid abuse and misuse is a common and important problem throughout the world that has significant associated societal costs and excess medical costs.

...Rossiter et al.²¹ examined a population of patients who were continuous users of extended release opioids. Overall costs were highest in commercially insured patients, $37,846, with Medicare eligible, $34,965, and Medicaid, $34,607, being lower and similar. Excess costs in each of the cohorts ranged from $9,456 to $11,501. Tkacz et al.²² compared chronic pain patients with potentially problematic opioid use (PPOU) with patients taking buprenorphine/naloxone and controls. That study found that the PPOU patients had the highest overall costs, $38,553. Buprenorphine/naloxone patients had health care costs of $28,583 and controls $26,193. Xie et al.²⁴ evaluated patients who had been hospitalized or treated in an ED and had no prior opioid prescription in the prior 12 months and compared those who received opioids during the hospitalization or ED visit and those that did not. Patients who received an opioid during the visit had much higher overall costs than patients who did not receive an opioid ($49,766 vs. $19,875). A summary of the cost per diagnosed opioid abuse patient per year, cost per control patient, and excess cost (cost for abusers –cost for controls) is shown in Table 3...

Full article at:   http://goo.gl/roAvma

By:   Oderda GM, Lake J, Rüdell K, Roland CL, Masters ET.

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Descriptive Epidemiology & High Risk Behavior of Male Prescription Opioid Abusers: Cross-Sectional Study from Sikkim, North East India

Background:

Sikkim is emerging as an important area for prescription opioid abuse with frequent news of seizures and arrests due to possession of prescription opioids. However, till date there is a little information on descriptive epidemiology and high risk behavior of prescription opioid abusers from Sikkim.

Aims:

The aim was to describe demographic (age, sex, religion, marital status, community, occupation, etc.); socioeconomic (income, education, family information etc.); and high risk behavior (e.g., injection sharing, visit to commercial sex workers [CSWs], homosexuality etc.) among treatment-seeking prescription opioid abusers in Sikkim.

Materials and Methods:

Epidemiological data were collected by administering predevised questionnaires from n = 223 prescription opioid abusers (main problem prescription opioids) reporting for treatment at five different drug abuse treatment centers across Sikkim.

Results:

The mean age of prescription opioid abusers in Sikkim was 27 years; all were male, of Nepalese ethnicity and single/never married, school dropout and/or illiterate, earning < Rs. 10,000/month with most spending almost Rs. 5000 a month on prescription opioids. Most (57.4%) prescription opioid abusers belonged to the urban community. Commonly abused prescription opioids were dextropropoxyphene and codeine. Injection sharing was more in urban areas whereas syringe exchange was observed equally among rural and urban prescription opioid abusers. Among urban injectors visits to CSWs, and multiple sex partners were also common in spite of knowledge about AIDS. Limited condom use was observed among rural respondents. Incidences of arrests, public intoxication, and violence under the influence of prescription opioids were also reported.

Conclusion:

Both the rural and urban areas of Sikkim show increasing rates of prescription opioid abuse among males. It is more prevalent among school dropouts and unemployed youth. Trends of injection drug use, unsafe injection, high risk behavior have also been observed.

Below:  Socioeconomic profile of prescription opioid abusers

Below:  Sexual behavior among prescription opioid abusers

Below:  Risk behavior pattern of prescription opioid abusers, past month 

Full article at:  http://goo.gl/WuFc60

By:  D. Datta, S. Pandey, S. Dutta, Y. Verma,1 and Amit Chakrabarti2

Department of Pharmacology and Psychiatry, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India

¹Department of Pathology, STNM Hospital, Government of Sikkim, Gangtok, Sikkim, India

²Department of Toxicology, Regional Occupational Health Centre (Eastern), National Institute of Occupational Health, Indian Council of Medical Research, Kolkata, West Bengal, India

Address for correspondence: Dr. Amit Chakrabarti, Regional Occupational Health Centre (Eastern), National Institute of Occupational Health, Indian Council of Medical Research, Sector V, Salt Lake, Kolkata - 700 091, West Bengal, India. E-mail: ni.gro.rmci@ctima

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The Effect of Prescription Opioid Injection on the Risk of Non-Fatal Overdose among People Who Inject Drugs

Prescription opioid (PO) use by people who inject drugs (PWID) is a growing public health concern. Non-fatal overdose remains a leading source of morbidity among PWID, however, little is known about the relationship between PO injection and non-fatal overdose in this population. In this study we sought to examine the impact of PO injection on non-fatal overdose among PWID from Vancouver, Canada.

Data were derived from two open prospective cohorts of PWID for the period of December, 2005 to May, 2014. Multivariable generalized estimating equations were used to examine the odds of overdose among those who injected: POs; heroin; and POs and heroin.

In total, 1660 PWID (33.7% women) participated in this study. In multivariable analyses, in comparison to those who were injecting non-opioid drugs, exclusive PO injection was not significantly associated with non-fatal overdose. The odds of non-fatal overdose were elevated for heroin injection, but were greatest for those who injected both heroin and POs.

Compared to injecting non-opioids, injecting POs exclusively did not increase risk of non-fatal overdose; however, injecting both POs and heroin doubled the risk. This may reflect consistencies in drug potency and composition when POs are used, as well as unique characteristics of exclusive PO injectors. Our findings call for the continued scale-up of evidence-based overdose prevention interventions for people who inject opioids, including POs.

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By: Lake S1, Hayashi K2, Buxton J3, Milloy MJ2, Dong H4, Wood E2, Montaner J2, Kerr T5.

• 1British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada.
• 2British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
• 3School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada.
• 4British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
• 5British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. Electronic address: uhri-tk@cfenet.ubc.ca.  

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Estimating the Health Care Burden of Prescription Opioid Abuse in Five European Countries

Opioid abuse, including abuse of prescription opioids (“RxOs”) and illicit substances like heroin, is a serious public health issue in Europe. Currently, there is limited data on the magnitude of RxO abuse in Europe, despite increasing public and scientific interest in the issue. The purpose of this study was to use the best-available data to derive comparable estimates of the health care burden of RxO abuse in France, Germany, Italy, Spain, and the United Kingdom (EU5).

Published data on the prevalence of problem opioid use and the share of opioid abuse patients reporting misuse of non-heroin opioids were used to estimate the prevalence of RxO abuse in the EU5 countries. The costs of RxO abuse were calculated by applying published estimates of the incremental health care costs of opioid abuse to country-specific estimates of the costs of chronic pain conditions. These estimates were input into an economic model that quantified the health care burden of RxO abuse in each of the EU5 countries. Sensitivity analyses examined key assumptions.

Based on best-available current data, prevalence estimates of RxO abuse ranged from 0.7 to 13.7 per 10,000 individuals across the EU5 countries. Estimates of the incremental health care costs of RxO abuse ranged from €900 to €2,551 per patient per year. The annual health care cost burden of RxO abuse ranged from €6,264 to €279,927 per 100,000 individuals across the EU5 countries.

This study suggests that RxO abuse imposes a cost burden on health systems in the five largest European countries. The extent of RxO abuse in Europe should be monitored given the potential for change over time. Continued efforts should be made to collect reliable data on the prevalence and costs of RxO abuse in Europe to facilitate an accurate characterization of the extent of this potentially growing problem.

Below:  Per patient annual incremental health care costs of RxO abuse.

Note: All costs are reported in 2013 euros.

Abbreviation: RxO, prescription opioid.

Below:  Population-adjusted annual health care burden of RxO abuse.

Note: All costs are reported in 2013 euros.

Abbreviation: RxO, prescription opioid.

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By: Amie Shei,1 Matthew Hirst,2 Noam Y Kirson,1 Caroline J Enloe,1 Howard G Birnbaum,1 and William C N Dunlop2

²

²

1Analysis Group, Inc., Boston, MA, USA

2Mundipharma International Limited, Cambridge, UK

1Analysis Group, Inc., Boston, MA, USA

1Analysis Group, Inc., Boston, MA, USA

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