OBJECTIVEThe purpose of this retrospective, observational pilot study was to explore change in route of administration (RoA) and motivation for changing RoA during the course of opioid abuse.DESIGNThis retrospective pilot study involved collecting and analyzing semistructured interview data.SETTINGInterviews were conducted with patients undergoing outpatient substance abuse treatment at a buprenorphine clinic.PARTICIPANTSTwenty adult patients (50 percent male) participated in the interviews.MAIN OUTCOME MEASURESInterview data were qualitatively and quantitatively analyzed to evaluate trends and motivations for changing RoA.RESULTSIn this sample, RoA varied over time. Most patients (75.0 percent) began abusing prescription opioids by swallowing intact pills, and 53.3 percent of patients eventually progressed to chewing. All patients who initiated abuse through chewing or insufflation (ie, intranasal use) progressed to injection. However, several patients (20.0 percent) did not exhibit a linear progression from RoAs with lesser to greater risk for serious adverse events. Of the eight motivations for changing RoA identified in the current study, the most frequently cited (38.2 percent) motivation was to achieve a desired effect (eg, euphoria).CONCLUSIONSThis pilot study is one of the first to investigate natural history of RoA in prescription opioid abuse and motivations for changing RoA. Results suggest that a defined pathway of RoA progression may not exist, and that achieving a desired effect is a common motivation for changing RoA. Although these findings need to be replicated in a larger sample, this research may help support the development of opioid risk mitigation strategies.

PURPOSE:Prescriptions for hydrocodone immediate-release (IR) combination products have recently decreased, yet they represent the majority of opioid prescriptions dispensed and are commonly abused analgesics among both adults and adolescents. Little data exist to understand the contribution of IR products to the problem of prescription opioid abuse. This study aimed to better understand abuse patterns for hydrocodone IR combination products among adult and adolescent substance abusers.METHODS:This cross-sectional study examines abuse prevalence (including abuse adjusted for prescription volume and morphine milligram equivalents) and abuse characteristics for hydrocodone IR combination products and other prescription opioids among separate samples of adults and adolescents assessed for substance abuse problems or entering treatment from January 2012 through June 2015.RESULTS:Results indicate higher abuse for hydrocodone IR combination products than other opioid categories per 100 assessments but lower per prescriptions dispensed. Hydrocodone IR combination products had similar abuse prevalence to all extended-release and long-acting opioids when considering abuse measured per morphine milligram equivalents dispensed. An upward trend in hydrocodone IR combination product abuse was observed among adult substance abusers comparing the period prior to and after Drug Enforcement Administration rescheduling of these products in October 2014. Most individuals reported oral abuse of hydrocodone IR combination products, but snorting, reported by 23% of hydrocodone IR combination product abusers, also appears to be a route of abuse that may have public health relevance.CONCLUSIONS:Given their high prescription volume, hydrocodone IR combination products, even at a relatively low prevalence of abuse, may contribute substantially to the overall problem of prescription opioid abuse. Additional public health interventions, including development of abuse-deterrent formulations for these types of opioid products may aid in reducing their abuse.

In this work, surface magnetic molecularly imprinted polymers (SMMIPs) were synthesized and used as artificial receptors in the dispersive magnetic solid phase extraction (DMSPE) for capturing potential neuronal nitric oxide synthase–post synaptic density protein-95 (nNOS–PSD-95) uncouplers, which is known as neuroprotection against stroke. Factors that affected selective separation and adsorption of the artificial receptors, such as the amount of template, the types of functional monomer and porogen solvents, and the molar ratio of template/functional monomer/cross-linker were optimized. The artificial receptors were also characterized using fourier transformed infrared, scanning electron microscope, thermal gravimetric analysis and physical property measurement systems. Multiple interactions between template and SMMIPs led to larger binding capacities, faster binding kinetics, quicker separation abilities and more efficient selectivity than the surface magnetic nonimprinted polymers (SMNIPs). The SMMIPs were successfully applied to capture potential nNOS–PSD-95 uncouplers from complex samples, and eight compounds were seized and confirmed rapidly when combined with HPLC and MS. The detection of the new nNOS–PSD-95 uncouplers ranged from 0.001 to 1.500 mg/mL with correlation coefficients of 0.9990–0.9995. The LOD and LOQ were 0.10–0.68 μg/mL and 0.47–2.11 μg/mL, respectively. The neuroprotective effect and co-immunoprecipitation test in vitro revealed that Emodin-1-O-β-d-glucoside, Rhaponticin, Gnetol and 2,3,5,4′-Tetrahydroxystilbene-2-O-β-d-glucoside have neuroprotective and uncoupling activities, and that they may be the new uncouplers of nNOS–PSD-95

OBJECTIVE:Evaluate nonmedical use (NMU) of ADHD prescription stimulants (Ritalin(®), Adderall(®), Adderall(®) XR, Concerta(®), and Vyvanse(®)) in a U.S. adult general population sample.METHOD:In all, 10,000 adults (aged 18-49) from an online, opt-in panel, proximity matched to U.S. Census demographics, were surveyed to assess NMU prevalence, routes of administration (ROA), reasons for NMU, and diversion source.RESULTS:Lifetime NMU of any prescription drug was 35.1%, pain medications (24.6%), sedatives/tranquilizers (15.6%), sleep medications (9.9%), and prescription stimulants (8.1%). Within the prescription stimulants, rates of NMU (per 100,000 prescriptions dispensed) were 1.62 for Ritalin and 1.61 for Adderall followed by Adderall XR (0.62), Concerta (0.19), and Vyvanse (0.13). Respondents used stimulants mostly for wakefulness and performance enhancement, obtained the drugs from family/friends, and used oral ROA.CONCLUSION:NMU of ADHD prescription stimulants were low compared with other prescription medications. While prevalence of NMU was higher for immediate-release than extended-release ADHD medications, absolute rates for prescription stimulants were low.

Monitoring use of tobacco products among pregnant women is a public health priority, yet few studies in U.S. national samples have been reported on this topic. We examined prevalence and correlates of using cigarettes, e-cigarettes, and other tobacco/nicotine delivery products in a U.S. national sample of pregnant women. Data were obtained from all pregnant women (≥ 18 years) in the first wave of the Population Assessment of Tobacco and Health (PATH, 2013–2014) Study (N = 388). Prevalence of current and prior use of tobacco/nicotine products was examined overall and among current cigarette smokers. Multiple logistic regression was used to examine correlates of use of cigarettes, e-cigarettes, hookah and cigars. Overall prevalence was highest for cigarettes (13.8%), followed by e-cigarettes (4.9%), hookah (2.5%) and cigars (2.3%), and below 1% for all other products. Prevalence of using other tobacco products is much higher among current smokers than the general population, with e-cigarettes (28.5%) most prevalent followed by cigars (14.0%), hookah (12.4%), smokeless (4.7%), snus (4.6%), and pipes (2.1%). Sociodemographic characteristics (poverty, low educational attainment, White race) and past-year externalizing psychiatric symptoms were correlated with current cigarette smoking. In turn, current cigarette smoking and past year illicit drug use were correlated with using e-cigarettes, hookah, and cigars. These results underscore that tobacco/nicotine use during pregnancy extends beyond cigarettes. The results also suggest that use of these other products should be included in routine clinical screening on tobacco use, and the need for more intensive tobacco control and regulatory strategies targeting pregnant women.

Aims: Screening, briefmotivational counseling interventionand referral to treatment (SBIRT) has shown to be effective in reducing substance use and related harms among adolescents in clinical settings but it had not been adapted for use in schools. This translational research study aimed to (a) develop a proof of concept, (b) test the feasibility of conducting SBIRT in two urban New York schools, and (c) examine the economic sustainability. Methods: With the cooperation of the New York OSAS, licensed “health clinics” were createdwithin these schools, equippedwith a computer screening program and a trained substance abuse counselor. The computer presented a standard substance screening; provided tailored prevention information to the student and provided counselor guidance for an immediate, private Motivational Interviewing counseling session. Results: In Spring 2012, 248 students were randomly approached to participate; 100% accepted the screening; 42% of them (n=105) reported substance use (vs. 28% reported in schoolwide, anonymous survey). Importantly, 99% of positively screened students voluntarily accepted onemotivational counseling session and68% returned for additional counseling sessions. The SBIRTprocedure did not interfere with academic activities. Conclusions: The SBIRT was feasible to implement and attractive to students, teachers and administration. We believe the acceptance and participation was due the use of non-school personnel and the private, professional and confidential procedures employed. The data offer clear indication that further effectiveness testing is warranted and potentially valuable. SBIRT, as implemented, has been approved for Medicaid (and some private insurance) reimbursement without co-payment to the parents or students. Economicmodeling demonstrates the current national SBIRT reimbursement rates to be adequate to broadly implement and sustain school-based SBIRT in most mid to largesized schools. Financial support: Phoenix House and Treatment Research Institute.

A survey of 1220 street-recruited crack cocaine smokers revealed that crack smokers may turn to drug injection to ease crack withdrawal. Crack smokers who later injected tended to smoke crack more heavily and for longer periods than those who did not inject. The initiation of injection was significantly associated with ever snorting heroin (prevalence ratio [PR] = 3.4, 95% confidence interval [CI] = 2.0–5.9) or snorting heroin specifically while smoking crack (PR = 2.3, 95% CI = 1.3–4.0), suggesting that snorted heroin use may mediate the transition to injection among crack smokers. Programs to prevent and treat crack dependence may prevent later injection and injection-related infections including HIV.

OBJECTIVE:To determine what, if any, public health and societal impacts are associated specifically with injection of prescription opioids.DESIGN:Cross-sectional observational study.SETTING:Five hundred forty treatment facilities in 35 states across the United States performing Addiction Severity Index-Multimedia Version (ASI-MV) assessments.PARTICIPANTS:Adult patients (29,459) who reported past 30-day abuse of any prescription opioid on the ASI-MV assessment between January 2007 and January 2011.MAIN OUTCOME MEASURES:The public health indicators selected for this study were liver disease, HIV/AIDS status, recent visit to an emergency room, treatment for pain, treatment for overdosing, homelessness, residence with alcohol/substance abuser, and unemployment.RESULTS:Prescription opioid injection was significantly associated with health problems, psychosocial problems, and utilization of medical services.CONCLUSIONS:This study demonstrates an approach to measure the potential impact of injecting prescription opioids on public health indicators. Findings indicate a positive association between injection of prescription opioids and public health indicators suggesting a need for prescription opioid formulations that may inhibit injection of these medications.

Dear Editor, We commend Butler et al. for their Spanish translation of the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) [1]. This linguistic translation is an important first step in widening the clinical reach of a tool that makes opioid prescribing safer. As the authors of this newly translated tool clearly recognize, Hispanics/Latinos are the largest minority group in the United States. The high prevalence of illiteracy and low literacy among Hispanic groups represent a barrier to the appropriate understanding of chronic pain, its management, and the specific risk of opioid analgesics. Often, non-English-speaking patients and those with limited education are specifically excluded from clinical research. As a consequence, the risks of these therapies are …

Oxycodone hydrochloride controlled-release, also known as extended-release oxycodone (ER oxycodone), was reformulated with physicochemical barriers to crushing and dissolving intended to reduce abuse through nonoral routes of administration (ROAs) that require tampering (eg, injecting and snorting). Manufacturer shipments of original ER oxycodone (OC) stopped on August 5, 2010, and reformulated ER oxycodone (ORF) shipments started August 9, 2010. A sentinel surveillance sample of 140,496 individuals assessed for substance abuse treatment at 357 U.S. centers between June 1, 2009, and March 31, 2012, was examined for prevalence and prescription-adjusted prevalence rates of past-30-day abuse via any route, as well as abuse through oral, nonoral, and specific ROAs for ER oxycodone and comparators (ER morphine and ER oxymorphone) before and after ORF introduction. Significant reductions occurred for 8 outcome measures of ORF versus OC historically. Abuse of ORF was 41% lower (95% Cl: 44 to 37) than historical abuse for OC, with oral abuse 17% lower (95% Cl: 23 to 10) and nonoral abuse 66% lower (95% Cl: 69 to 63). Significant reductions were not observed for comparators. Observations were consistent with the goals of a tamper resistant formulation for an opioid. Further research is needed to determine the persistence and generalizability of these findings.Perspective: This article presents preliminary findings indicating that 8 outcome measures of abuse of a reformulated ER oxycodone were lower than that for original ER oxycodone historically, particularly through nonoral ROAs that require tampering (le, injection, snorting, smoking), in a sentinel sample of individuals assessed for substance use problems for treatment planning. (C) 2013 by the American Pain Society

ABSTRACT Purpose The ability to track prescription opioid abusers' endorsement of compounds may be valuable in forecasting abuser's preferences. We developed a metric, referred to as the Endorsement Ratio (ERo), to explore the feasibility of quantifying the sentiment expressed by opioid abusers who post online about prescription opioid products. Methods Internet posts written between April 1, 2010 and March 31, 2011 and related to six prescription opioid compounds (oxycodone ER, hydrocodone, hydromorphone, oxymorphone, morphine ER, and tramadol) were identified and qualitatively coded. A mixed effects multinomial logistic regression was employed to model the probability of observing endorsing, discouraging, mixed, or unclear messages per compound. Endorsement‐to‐discouragement ratio (ERo) and ratio of endorsement‐to‐discouragement ratios (RERo) were estimated for each compound. Results In the study sample of 12 838 Internet posts, a ranking of endorsement could be established, with oxymorphone as most endorsed (ERo = 7.39), followed by hydromorphone (ERo = 5.02), hydrocodone (ERo = 3.53), oxycodone ER (ERo = 3.23), morphine ER (ERo = 2.71), and tramadol (ERo = 1.76). Relative rankings of products required that route of administration be considered. Conclusions This study expands existing Internet monitoring approaches by developing a metric to estimate the endorsement of specific prescription opioid compounds as viewed through the lens of Internet communities. Route of administration must be taken into account when examining preferences of drug abusers for various products. This study did not assess whether the novel metric is valid with respect to classification of abuse rates of different drugs. Further studies examining external validation studies are warranted. Copyright © 2012 John Wiley & Sons, Ltd.

BACKGROUND:Evaluation of tamper resistant formulations (TRFs) and classwide Risk Evaluation and Mitigation Strategies (REMS) for prescription opioid analgesics will require baseline descriptions of abuse patterns of existing opioid analgesics, including the relative risk of abuse of existing prescription opioids and characteristic patterns of abuse by alternate routes of administration (ROAs). This article presents, for one population at high risk for abuse of prescription opioids, the unadjusted relative risk of abuse of hydrocodone, immediate release (IR) and extended release (ER) oxycodone, methadone, IR and ER morphine, hydromorphone, IR and ER fentanyl, IR and ER oxymorphone. How relative risks change when adjusted for prescription volume of the products was examined along with patterns of abuse via ROAs for the products.METHODS:Using data on prescription opioid abuse and ROAs used from 2009 Addiction Severity Index-Multimedia Version (ASI-MV®) Connect assessments of 59,792 patients entering treatment for substance use disorders at 464 treatment facilities in 34 states and prescription volume data from SDI Health LLC, unadjusted and adjusted risk for abuse were estimated using log-binomial regression models. A random effects binary logistic regression model estimated the predicted probabilities of abusing a product by one of five ROAs, intended ROA (i.e., swallowing whole), snorting, injection, chewing, and other.RESULTS:Unadjusted relative risk of abuse for the 11 compound/formulations determined hydrocodone and IR oxycodone to be most highly abused while IR oxymorphone and IR fentanyl were least often abused. Adjusting for prescription volume suggested hydrocodone and IR oxycodone were least often abused on a prescription-by-prescription basis. Methadone and morphine, especially IR morphine, showed increases in relative risk of abuse. Examination of the data without methadone revealed ER oxycodone as the drug with greatest risk after adjusting for prescription volume. Specific ROA patterns were identified for the compounds/formulations, with morphine and hydromorphone most likely to be injected.CONCLUSIONS:Unadjusted risks observed here were consistent with rankings of prescription opioid abuse obtained by others using different populations/methods. Adjusted risk estimates suggest that some, less widely prescribed analgesics are more often abused than prescription volume would predict. The compounds/formulations investigated evidenced unique ROA patterns. Baseline abuse patterns will be important for future evaluations of TRFs and REMS.

Background As a population, non-medical prescription opioid users are not well-defined. We aimed to derive and describe typologies of prescription opioid use and nonmedical use using latent class analysis in an adult population being assessed for substance abuse treatment. Methods Latent class analysis was applied to data from 26,314 unique respondents, aged 18-70, self-reporting past month use of a prescription opioid out of a total of 138,928 cases (18.9%) collected by the Addiction Severity Index-Multimedia Version (ASI-MV®), a national database for near real-time prescription opioid abuse surveillance. Data were obtained from November 2005 through December 2009. Substance abuse treatment, criminal justice, and public assistance programs in the United States submitted data to the ASI-MV database (n = 538). Six indicators of the latent classes derived from responses to the ASI-MV, a version of the ASI modified to collect prescription opioid abuse and chronic pain experience. The latent class analysis included respondent home ZIP code random effects to account for nesting of respondents within ZIP code. Results A four-class adjusted latent class model fit best and defined clinically interpretable and relevant subgroups: Use as prescribed, Prescribed misusers, Medically healthy abusers, and Illicit users. Classes varied on key variables, including race/ethnicity, gender, concurrent substance abuse, duration of prescription opioid abuse, mental health problems, and ASI composite scores. Three of the four classes (81% of respondents) exhibited high potential risk for fatal opioid overdose; 18.4% exhibited risk factors for blood-borne infections. Conclusions Multiple and distinct profiles of prescription opioid use were detected, suggesting a range of use typologies at differing risk for adverse events. Results may help clinicians and policy makers better focus overdose and blood-borne infection prevention efforts and intervention strategies for prescription opioid abuse reduction.