Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management

While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.

When Innovation Goes Wrong: Technological Regress and the Opioid Epidemic

The fourfold increase in opioid deaths between 2000 and 2017 rivals even the COVID-19 pandemic as a health crisis for America. Why did it happen? Measures of demand for pain relief – physical pain and despair – are high and in many cases rising, but their increase was nowhere near as large as the increase in deaths. The primary shift is in supply, primarily of new forms of allegedly safer narcotics. These new pain relievers flowed in greater volume to areas with more physical pain and mental health impairment, but since their apparent safety was an illusion, opioid deaths followed. By the end of the 2000s, restrictions on legal opioids led to further supply-side innovations, which created the burgeoning illegal market that accounts for the bulk of opioid deaths today. Because opioid use is easier to start than end, America's opioid epidemicis likely to persist for some time.

Use of Naloxone in 9-1-1 Patients without Respiratory Depression in Los Angeles County, California (USA)

Introduction:Along with an increase in opioid deaths, there has been a desire to increase the accessibility of naloxone. However, in the absence of respiratory depression, naloxone is unlikely to be beneficial and may be deleterious if it precipitates withdrawal in individuals with central nervous system (CNS) depression due to non-opioid etiologies.Objective:The aim of this study was to evaluate how effective prehospital providers were in administering naloxone.Methods:This is a retrospective study of naloxone administration in two large urban Emergency Medical Service (EMS) systems. The proportion of patients who had a respiratory rate of at least 12 breaths per minute at the time of naloxone administration by prehospital providers was determined.Results:During the two-year study period, 2,580 patients who received naloxone by prehospital providers were identified. The median (interquartile range) respiratory rate prior to naloxone administration was 12 (6-16) breaths per minute. Using an a priori respiratory rate of under 12 breaths per minute to define respiratory depression, only 1,232 (47.8%; 95% CI, 50.3%-54.2%) subjects who received naloxone by prehospital providers had respiratory depression.Conclusion:This study showed that EMS providers in Los Angeles County, California (USA) frequently administered naloxone to individuals without respiratory depression.

Correlations between Changes in Medical Opioid Dispensing and Contributions of Fentanyl to Opioid-Related Overdose Fatalities: Exploratory Analyses from Canada

Canada is experiencing an epidemic of opioid-related mortality, with increasing yet heterogeneous fatality patterns from illicit/synthetic (e.g., fentanyl) opioids. The present study examined whether differential provincial reductions in medical opioid dispensing following restrictive regulations (post-2010) were associated with differential contributions of fentanyl to opioid mortality. Annual provincial opioid dispensing totals in defined daily doses/1000 population/day, and change rates in opioid dispensing for the 10 provinces for (1) 2011–2018 and (2) “peak-year” to 2018 were derived from a pan-Canadian pharmacy-based dispensing panel. Provincial contribution rates of fentanyl to opioid-related mortality (2016–2019) were averaged. Correlation values (Pearson’s R) between provincial changes in opioid dispensing and the relative fentanyl contributions to mortality were computed for the two scenarios. The correlation between province-based changes in opioid dispensing (2011–2018) and the relative contribution of fentanyl to total opioid deaths (2016–2019) was −0.70 (t = 2.75; df = 8; p = 0.03); the corresponding correlation for opioid dispensing changes (“peak-year” to 2018) was −0.59 (t = −2.06; df = 8; p = 0.07). Provincial reductions in medical opioid dispensing indicated (near-)significant correlations with fentanyl contribution rates to opioid-related death totals. Differential reductions in pharmaceutical opioid availability may have created supply voids for nonmedical use, substituted with synthetic/toxic (e.g., fentanyl) opioids and leading to accelerated opioid mortality. Implications of these possible unintended adverse consequences warrant consideration for public health policy.

Opioid Prescribing Mediating State Policy Intervention Effects on Drug Overdose Mortality

The Centers for Disease Control and Prevention reported 70 630 drug overdose deaths for 2019 in the United States, 70.5% of which were opioid-related. Preliminary estimates now warn that drug overdose deaths likely surpassed 86 000 during 2020. Despite a 57.4% decrease in opioid prescribing since a peak in 2012, the opioid death rate has increased 105.8% through 2019, as the share of those deaths involving fentanyl increased from 16.4% to 72.9%. This letter seeks to determine whether the opioid prescribing and mortality paradox is robust to accepted methods of causal policy analysis and if prescribing rates mediate the effects of policy interventions on overdose deaths. Using loge-loge ordinary least squares with three different specifications as sensitivity analyses for all 50 states and Washington, DC for the period 2001-2019, the elasticities from the regressions with all control variables report operational prescription drug monitoring programs (PDMPs) reduce prescribing rates 8.7%, while mandatory PDMPs increase death rates from opioids 16.6%, heroin and fentanyl 19.0%, cocaine 17.3% and all drugs 10.5%. There is also weak evidence that recreational marijuana laws reduce prescribing, increases in prescribing increase pain reliever deaths, pill mill laws increase cocaine deaths, and medical marijuana laws increase total overdose deaths, with demographic variables suggesting states with more male, less non-Hispanic white, and older citizens experience more overdoses. Weak mediation effects were observed for pain reliever, cocaine, and illicit opioid deaths, while broad reductions in prescribing have failed to reduce opioid overdoses.

Trends in Fentanyl and Fentanyl Derivative Utilization in the United States

ObjectiveThe primary objective of this study was to explore fentanyl and fentanyl derivative distribution patterns from 2010 and 2019 across the United States (US). This study builds upon previous literature that has analyzed the trends in opioid distribution and assesses changes in opioid prescription preferences.MethodsThe amount of fentanyl base distributed in the US from 2010-2019 was obtained from the Drug Enforcement Administration’s Automated Reports and Consolidated Ordering System (ARCOS). Fentanyl derivatives (sufentanil, alfentanil, remifentanil) were also analyzed using ARCOS from 2010-2017, the most recent date reported. Census data from the American Community Survey was used to correct for population. Prescriptions, units, and reimbursement of fentanyl and fentanyl citrate formulations for 2010 and 2019 were obtained from Medicaid and prescriber specialty in Medicare Part D.ResultsTotal grams of fentanyl distributed in the US from 2010 to 2019 decreased by 63%. Correspondingly, there was a 65% decrease in the milligrams per person distributed when correcting for population. From a regional perspective, Ohio had the greatest decrease (−79.3%) while Mississippi saw the smallest (−44.5%). Medicaid reimbursement in 2019 was $165 million for over eight hundred-thousand prescriptions with the majority to generic (99.7%) and injectable (77.6%) formulations. Interventional pain management and anesthesia were over-represented, and hematology/oncology under-represented for fentanyl in Medicare.ConclusionThe production and distribution of fentanyl-based substances has decreased, although not uniformly, in the US over the last decade. Additionally, the most prescribed formulations of fentanyl have transitioned away from transdermal, potentially in an effort to regulate its availability. Although impactful, the overdose deaths attributed to synthetic opioid deaths continue to increase highlighting the need for public health interventions beyond the pharmaceutical and medical communities.

White Health Benefits of Histories of Enslavement: The Case of Opioid Deaths

Popular media and researchers have given increasing attention to the perceived growing alienation and despair of white Americans. The narrative of white decline has been particularly robust in light of the recent uptick in premature deaths of whites from opioid use, but this national conversation has lacked consideration of potential associations between opioid mortality among whites and durable legacies of white advantage that were established through historical racial violence. We provide an initial analysis of how contemporary patterns of white opioid mortality in the counties of southern states relate to the presence of slavery and postbellum institutions of racial social control in those counties. We find that areas in the South with higher rates of past enslavement are associated with contemporary reductions of white vulnerability, in this case, opioid mortality. This finding supports the thesis that historical institutions of racial control offer a protective benefit within the modern white population.

Wooden Chest Syndrome: A Case Report of Fentanyl-Induced Chest Wall Rigidity

Wooden chest syndrome (WCS) describes a finding of fentanyl-induced skeletal muscle rigidity causing ventilatory failure. Known primarily to anesthesiology, pulmonary, and critical care fields, WCS is a rare complication that may affect patients of all ages if exposed to intravenous fentanyl, characterized by a patient’s inability to properly ventilate. Given the rise of synthetic opioid deaths across the United States in the past decade, an understanding of all of fentanyl’s effects on the body is necessary. In this article, we present a case of WCS in a patient with acute respiratory distress syndrome in a 61-year-old female.