Publications

NYC Health + Hospitals/Bellevue Hospital (Bellevue) conducts quarterly drills to test the readiness and preparedness of its special pathogen program. As a Regional Emerging Special Pathogen Treatment Center, Bellevue maintains a state of readiness to respond to patients infected with highly infectious pathogens. On March 29, 2024, Bellevue conducted a no-notice drill to simulate the arrival of a pediatric patient suspected of a viral hemorrhagic fever (VHF). Notification of the special pathogens unit (SPU) activation for a suspected VHF patient was communicated to Bellevue supervisors and leadership. Once responders arrived at their respective reporting stations, they were informed that this was a drill and instructed to read through their role-specific Roles & Responsibilities sheet. All respondents reported to assume their role in the SPU activation within the expected time frame. The cost savings of running this drill, as opposed to a full unit activation, was estimated to be nearly USD 2,000. Following the exercise, participants were offered to complete an anonymous survey assessing their perceptions of the drill and readiness for SPU activation. Key findings were that while most staff felt adequately prepared and understood their roles and responsibilities, suggestions for improvement included more frequent training sessions. This study underscores the importance of regular preparedness exercises to maintain SPU readiness. Insights gained from this drill can inform future training models, enhance the effectiveness of communication strategies during real-world activations, and can be replicated to improve the special pathogen preparedness of healthcare institutions across the United States, regardless of resource availability.

Despite the contribution of the µ-agonist fentanyl to the United States's opiate overdose epidemic, no human studies specifically address the ability of extended-release preparations of the opiate antagonist naltrexone (NTX) to block fentanyl's life-threatening µ-agonist-mediated respiratory depression. This paper presents three case histories of clinically necessary opiate challenges in opiate-abusing patients implanted with extended-release NTX (ER-NTX). It also reviews the sparse literature and is the first evidence that antagonist blood levels from ER-NTX preparations can completely block the lethal µ-agonist effects of at least 1,000 mcg of intravenous fentanyl.

Opioids are known to come with some relatively benign side effects, not including their addictive potential. This review will look at some of the side effects that occur when patients, especially chronic pain patients, take opioids chronically. These side effects include both hyperalgesia and allodynia caused by opioids. Overdose and factors, including hyperalgesia and allodynia, that make a patient more likely to overdose, is the other topic that will be covered. Not much research has been done with human subjects regarding treatment of opioid induced hyperalgesia or allodynia, but some of this research will also be briefly explored throughout this review.

OBJECTIVE: To report the rate of prescription opioid use rates over a 5-year period for the population of Newfoundland and Labrador (NL), Canada, and to highlight patient demographics within this cohort.

DESIGN: This retrospective cohort design used population-based pharmacy network prescription data from the province of NL to identify patients who were prescribed opioids from June 1, 2017, to June 1, 2022.

SETTING: A cohort of adult and pediatric patients who were being prescribed opioids from June 1, 2017, to June 1, 2022, in NL.

PARTICIPANTS: Patients who were prescribed opioids from June 1, 2017, to June 1, 2022. Prescriptions without complete data and medications taken for pain control that were not defined as opioids were excluded from the analysis. Buprenorphine, buprenorphine-naloxone, and methadone were also excluded from the analysis, as these are often prescribed as a treatment for opioid use disorder.

RESULTS: Between 27,344 (5.2 percent of NL population) and 57,562 (11 percent of NL population) opioid pain patients in NL were identified from 2017 to 2022, with 2018 having the highest number of opioid pain patients (11 percent). During this period, patients with opioid prescriptions averaged from 55 to 58 years of age. Data also showed more female users of prescription opioids than males, and there were no significant differences between urban and rural locations. The most prevalent type of prescriber during the period of observation was general practitioners (n = 1,131), followed by pharmacists (n = 476) and dentists (n = 237).

CONCLUSIONS: In comparison to national averages in Canada, NL had lower prescription opioid use rates. This study acts as a first step to better understand opioid use and prescribing practices in NL.

OBJECTIVE: Thoracic surgery is known to lead to post-operative opioid dependence in countries with high opioid consumption; however, there are limited reports from countries with moderate to low opioid consumption, such as Japan. This study aimed to investigate the prevalence and risk factors for persistent opioid use after thoracic surgery in Japan.

DESIGN: A retrospective cohort study using linked medical claims data from the National Health Insurance in Ibaraki Prefecture, Japan.

PATIENTS: Patients aged ≥18 who underwent thoracic (mediastinal or lung) surgery between October 2012 and September 2021 were included in this study.

MAIN OUTCOME MEASURES: Persistent opioid use was defined as prescription from 0 to 14 days after surgery and 91 to 180 days after surgery. We evaluated associated factors using multivariable logistic regressions.

RESULTS: Among the 6,041 patients who underwent thoracic surgery during the study period, 3,924 were included in the final analysis. The median age was 68 years (range, 64-71 years), and 2,316 (61.0 percent) were male. Persistent opioid use was recorded in 130 (3.3 percent). Multivariable analyses identified neoadjuvant therapy (chemotherapy or radiotherapy) (odds ratio [OR], 2.02; 95 percent confidence interval [CI], 1.09-3.77; p = 0.027) and thoracotomy (vs video-assisted thoracoscopic surgery) (OR, 1.50; 95 percent CI, 1.01-2.24; p = 0.046) as independent risk factors for persistent opioid use.

CONCLUSIONS: In a prefecture of Japan, 3.3 percent of patients who underwent thoracic surgery developed persistent opioid use. Neoadjuvant therapy (chemotherapy or radiotherapy) and thoracotomy were independent factors associated with persistent opioid use. Individualized perioperative pain management strategies should be considered for high-risk patients.

OBJECTIVE: The effects of opioid use disorder (OUD) are devastating and wide-ranging. Although the information in the >43,000 manuscripts on OUD are searchable, gaining a comprehensive grasp of this information is out of reach to most persons. We present a pilot study to use published data on OUD, repurpose it for rapid comprehension and distribution to the world.

DESIGN: Data from articles on OUD were entered into a data-tree and evaluated to achieve integration of information using the least number of notes.

SETTING: Literature on OUD. Experimental units: A total of 752 articles were selected from PubMed searches. Review articles, case reports, and short series with samples of less than ten were excluded.

OUTCOME MEASURES: The frequency of descriptive note types, and the total number of notes used with and without note sharing.

RESULTS: Four types of notes were found sufficient to describe extracted numeric data from an article; topic (20.1 percent), population (26.2 percent), description of numeric value (28.4 percent), and numeric value (25.3 percent). Notes were entered in parent-child relationships across hierarchical levels, descriptive analyses showed smooth expansion and reduction of notes across the database. Entry rules allowed sharing of parent notes across different numeric values, which reduced that total number of notes by 72.9 percent.

CONCLUSIONS: These results demonstrate a method of data extraction and integration that allows for readily understandable grouping of large amounts of data. This strategy yields a method to extract and make accessible all published data on OUD. We expect that common understanding will improve outcomes for patients and research objectives.

BACKGROUND: Opioid prescribing to post-operative patients in the acute hospital setting is well described; however, little is known about use of opioids in inpatient rehabilitation (IPR) settings. Understanding how opioids are prescribed across all inpatient settings is important to optimize opioid stewardship. The aim of this study was to determine the percentage of post-operative orthopedic patients prescribed opioids and prescribing patterns on discharge from an IPR ward.

DESIGN: Single-center retrospective audit.

SETTING: Tertiary metropolitan hospital.

PATIENTS: Patients who underwent an orthopedic surgical procedure between January and July 2020 and were subsequently transferred to an IPR center under the same health service.

MAIN OUTCOME MEASURES: Opioid prescribing data were obtained at three time points: on admission to the acute hospital, at the time of transfer from the acute hospital to IPR, and at the time of discharge from IPR. Doses were reported in oxycodone equivalent doses.

RESULTS: Of the 117 patients who were included in the audit (median age 84 years, median length of hospital stay 23 days), 115 (98 percent) were prescribed an opioid at the time of discharge from the acute hospital to IPR, and 69 patients (59 percent) were discharged from IPR with a prescription for an opioid.

CONCLUSIONS: A significant proportion of patients admitted to IPR were discharged with a prescription for an opioid. Further research is required to determine the appropriateness of continued opioid use in these patients, and ways to reduce the exposure of patients to opioids during and following IPR should be explored.

OBJECTIVE: To evaluate the effectiveness of an outpatient, interdisciplinary pain management (IPM) program offering individualized opioid tapering as part of flexible, patient-specific care plans, in achieving the dual goals of improved management of chronic nonmalignant pain (CNMP) and substantial reduction of opioid use.

DESIGN: A retrospective cohort study, comprising a cohort of patients who presented on opioid therapy and a cohort who did not.

SETTING: Community outpatient IPM program.

PARTICIPANTS: Patients presenting between April 1, 2016 and September 15, 2019. From an initial pool of 402 patients, inclusion and exclusion criteria identified 300 patients for analyses.

INTERVENTIONS: Engagement in a comprehensive and flexible IPM program with patient-specific care plans that included individualized opioid tapering.

MAIN OUTCOME MEASURE(S): Changes in pain intensity, pain interference, physical therapy (PT) metrics, patient retention, and follow-up of opioid use status at least 3 years after the end of each patient's study episode of care.

RESULTS: Changes in pain intensity and interference, and PT outcomes reflected notable improvements in pain management, with no significant overall differences between cohorts. During study episodes of care, all patients in the opioid cohort reduced opioid use and two-thirds discontinued opioids; patient retention was 90.9 percent. In follow-up of over 80 percent of the opioid cohort up to an average of 4.5 years, opioid use for CNMP decreased to 15.8 percent of patients.

CONCLUSIONS: A flexible, patient-centered IPM program can improve the management of CNMP, substantially reduce opioid use, and maintain a high rate of patient retention. During follow-up, patients further reduced their use of opioids for CNMP.

Pain and addiction are persistent public health issues that can lead to serious and fatal consequences on individuals, families, and communities. With the continued development of the opioid epidemic and the subsequent rise in opioid use and misuse, it is important to recognize the need for intervention at a public health level. Opioid stewardship programs (OSPs) are promising public health interventions that aim to coordinate safe and effective pain management through evidence-based intervention strategies. This narrative literature review examined the current evidence for implementation of OSPs in emergency departments and acute care hospitals to identify best practices and gaps in evidence. We reviewed publications found through PubMed and Embase, and articles were selected for inclusion after being evaluated through the inclusion criteria. One hundred and ninety-six articles were first found via the database search, and a final 24 articles were included in the sample for full review. The results indicated that all but two studies were published within the last 4 years, and one study mentioned a rural location. Most of the studies were pre- and post-OSP implementation studies. On average, the studies implemented four of the 11 total OSP strategies of interest. Twenty-two studies included information on care coordination, with the most prevalent effect being a decrease in total morphine milligram equivalents being prescribed at discharge. Nine studies included data on patient safety measures, including adverse events such as return emergency room visits, need for naloxone administration, and increase in post-operative clinic visits. This narrative review provides us with a preliminary understanding of OSP implementation in hospital settings and provides evidence that they are feasible and accepted with a wide variety of implementation interventions and strategies. It also demonstrates a gap in the literature regarding implementation in rural settings and with some specific implementation strategies.

Despite efforts to reduce abuse, opioids remain a societal concern. Coronavirus disease 2019 (COVID-19) brought new challenges, and research is needed to understand its impact on opioid abuse in the population. Three data sources were used to investigate trends in misuse and abuse of XTAMPZA® ER compared to extended-release (ER) and single-entity immediate-release (SE-IR) oxycodone from 2019Q3 through 2022. Changes in trends over 6-month intervals were investigated using linear spline models with a breakpoint at 2020Q3 to measure the impact of COVID-19. Poison center call rates for misuse or abuse of ER and SE-IR oxycodone showed significant changes during COVID-19 (both p < 0.001), reversing trends and significantly decreasing (201327.56 percent change and -12.91 percent change, respectively). In contrast, XTAMPZA ER trend rates showed no change during COVID-19, remaining fairly stable. The odds of abuse of ER oxycodone among those entering opioid use disorder treatment significantly changed during COVID-19 (p = 0.025), resulting in a stabilization of the trend. For SE-IR oxycodone, no change was observed in the decreasing trend (-12.88 percent change during COVID-19). XTAMPZA ER had no significant change during COVID-19 (p = 0.200) and appeared stable. Since 2021Q3, among the general adult population, the prevalence of past-year nonmedical use of XTAMPZA ER was rare (0.04 percent), as was the case for other oxycodone products (<1 percent). Overall, there is no evidence that oxycodone misuse and abuse worsened during COVID-19 in these populations, and XTAMPZA ER was consistently lower than other oxycodone products. Low rates and improving trends in oxycodone misuse and abuse may signify an ongoing reduction in prescription opioid contributions to the opioid crisis.